Billing and Coding Guidance for the Minuteman® Device in 2025
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1. What is the Minuteman® Procedure?
The Minuteman® G5 is a minimally invasive spinal fusion device provided by Spinal Simplicity, LLC. It’s specifically used to stabilize and fuse segments of the lumbar spine (T1 to S1), addressing conditions such as spinal stenosis, degenerative disc disease, and spondylolisthesis.

Unlike traditional spinal fusion surgeries, which often require larger incisions and extensive tissue disruption, the Minuteman® procedure employs a minimally invasive lateral or posterior approach. By doing so, it reduces the surgical footprint, preserving critical ligamentous structures and musculature, ultimately facilitating quicker patient recovery and reducing postoperative complications.

2. Appropriate CPT Codes for Billing
Billing accurately requires identifying appropriate CPT codes. According to the Spinal Simplicity 2025 billing guidelines, the following codes apply specifically to the Minuteman® implantation:

Key CPT Codes:

CPT CodeProcedure Description
22612
Posterior or posterolateral arthrodesis (fusion), single interspace; lumbar (with lateral transverse technique when performed).

22840
Posterior non-segmental instrumentation (attachment of fixation devices, e.g., rods or plates).
20930
Allograft placement or osteopromotive material for spinal surgery (This code is typically bundled and not reimbursed separately).

Explanation of the Codes:

• CPT 22612 (Arthrodesis, Lumbar):
  This CPT code is used when performing a posterior lumbar fusion at a single intervertebral space. It involves stabilizing and fusing two adjacent vertebrae to treat conditions like spinal stenosis or spondylolisthesis.
  Medicare Physician Fee Schedule (2025):
  • Work RVU: 47.79
  • Medicare Reimbursement: $1,553.60
• 22840 (Posterior Non-segmental Instrumentation):
  This code covers non-segmental fixation techniques such as placement of devices like the Minuteman®, where instrumentation attaches to adjacent spinal segments but does not extend across multiple levels. This CPT is billed separately from the arthrodesis code.
  Medicare Physician Fee Schedule (2025): Included separately with an additional reimbursement of approximately $400–$800 depending on payer-specific rules.
• 20930 (20931):
  These codes relate to the use of allograft materials (bone grafts), typically bundled into the primary fusion procedure and not reimbursed separately by Medicare.

3. Medical Necessity Documentation for the Minuteman® Device
For proper reimbursement, payers, including Medicare, require comprehensive documentation to justify medical necessity:

• Patient History & Symptoms:
  Clearly document persistent back pain, radiculopathy, neurological symptoms, functional impairment, and reduced quality of life despite conservative therapy.
• Imaging Studies:
  Include MRI, CT, or X-ray reports confirming conditions such as spinal stenosis, spondylolisthesis, degenerative disc disease, or segmental instability.
• Failed Conservative Therapy:
  Detail conservative management previously attempted—such as physical therapy, pharmacotherapy, chiropractic care, injections, or lifestyle modifications—that did not provide sustained improvement.
• Clinical Indications:
  Clearly state why the Minuteman® procedure is medically necessary, emphasizing failed conservative management, confirmed instability, or ongoing neurological compromise.

4. Clinical Guidelines and Insurance Utilization Policies
Insurance guidelines and utilization policies can vary significantly. Here's a detailed breakdown:
Medicare (CMS):

• CMS typically does not publish specific national coverage decisions for individual branded devices like the Minuteman®. Instead, Medicare coverage is determined at the local level by individual Medicare Administrative Contractors (MACs) through Local Coverage Determinations (LCDs).
• Coverage generally requires documented evidence of instability, neurological compromise, or progressive degenerative changes unresponsive to conservative treatment.
• Unlisted CPT code (22899) requires detailed narrative and supporting documentation to justify medical necessity.

Relevant LCD Example:

Novitas Solutions Local Coverage Determination (LCD): Lumbar Spinal Fusion (L35094).
URL: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35094 


Commercial Insurers (UnitedHealthcare, Anthem BCBS, Aetna, Cigna):

• UnitedHealthcare considers interspinous fusion devices, including Minuteman®, as investigational or experimental for certain conditions. Prior authorization is critical, with clear clinical justifications, detailed imaging, and previous treatment documentation.
• Anthem BCBS and Premera BCBS typically classify interspinous fixation devices as investigational, requiring thorough justification and appeals for coverage.
• Credence BCBS states clearly to utilize CPT 22899 for this procedure, as no dedicated CPT exists yet.

Sample Policies:

• UnitedHealthcare Interspinous Fusion Devices Policy:
  https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/interspinous-fusion-decompression-devices.pdf
• Credence BCBS Medical Policy:
  https://policies.credenceblue.com

5. Example of a Billing & Coding ScenarioClinical Scenario:
A 65-year-old patient presents with lumbar spinal stenosis and Grade 1 spondylolisthesis at L4-L5, causing severe neurogenic claudication and significant functional limitation. Conservative treatments (physical therapy, medications, and epidural injections) over six months have provided inadequate relief. A decision is made for spinal stabilization using the Minuteman® device.

Coding & Billing Example:

• CPT Codes:
  • 22612 (Arthrodesis, posterior lumbar)
  • 22840 (Posterior instrumentation, non-segmental)
  • 22899 (If specifically requested by payer)
• ICD-10 Diagnosis Codes:
  • M48.061 – Lumbar spinal stenosis with neurogenic claudication
  • M43.16 – Lumbar spondylolisthesis

Claim Submission Example:

• Include operative notes detailing the surgical procedure, clearly describing implant insertion, stabilization, and any additional instrumentation.
• Provide comprehensive patient clinical records, imaging reports, and previous conservative therapy notes.

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Reference: ​https://spinalsimplicity.com/wp-content/uploads/2025/02/L250-Minuteman-Billing-Guidance-2025-Rev1.pdf

Healthcare organizations are facing significant financial pressure due to various factors such as wage inflation, rising costs, declining patient and service volume, and the lingering uncertainty caused by the pandemic. These challenges are further compounded by the prevalence of unresolved claims denials, which lead to substantial annual losses for hospitals and healthcare facilities. In order to alleviate this financial burden, it is essential for organizations to adopt a strategic approach that focuses on preventing denials and effectively managing the claims process.
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The Rising Denial Rates: Over the past five years, denial rates have been on the rise, with an average increase of over 20 percent. Currently, the average claims denial rate exceeds 10 percent. A recent survey conducted by the Medical Group Management Association (MGMA) reveals that medical practices experienced an average increase in denials of 17 percent in 2021 alone. Industry data indicates that nearly 20 percent of all claims are denied, and a significant portion of returned claims are never resubmitted. The cost of reworking or appealing denials further exacerbates the financial impact, with practices spending an average of $25 per claim, and hospitals facing a staggering $181 per claim.

Preventing denied claims begins with understanding the most common reasons for claim rejections. 

1. Prior authorization: Failure to obtain prior authorization prior to providing a service may result in claim denials.
2. Missing or incorrect information: Inaccurate or incomplete data, such as blank fields or incorrect plan codes, can lead to claim rejections.
3. Failure to meet medical necessity requirements: If a healthcare service is deemed medically unnecessary by the payer, it may not be covered under the policy.
4. Non-covered procedures: Claims may be denied if the performed procedure is not covered by the payer, emphasizing the importance of reviewing patients' plans in advance.
5. Out-of-network providers: If services are provided by out-of-network providers, payers may deny all or part of the claim.
6. Duplicate claims: Submitting multiple claims for the same patient, service, and provider on the same day can lead to denials.
7. Coordination of benefits: Claims for patients with multiple health plans may experience delays or denials until coordination of benefits is updated.
8. Bundling: Payers may group separate services together and pay a reduced fee instead of individual fees.
9. Services already included in payment: If a service is already covered by another service or procedure, payment may be adjusted accordingly.
10. Exceeded timely filing limit: Claims filed beyond the payer's required timeframe may be denied, necessitating consideration of processing time for resubmissions.

To mitigate the financial impact of denied claims, healthcare organizations should prioritize prevention efforts while also implementing effective denial management strategies. This involves:

1. Prevention: Establishing a zero-tolerance mindset toward preventable denials by implementing comprehensive audit systems to ensure clean claims are submitted.
2. Understanding denial codes: Categorizing denial codes into contractual obligations, other adjustments, payer-initiated reductions, and patient responsibility, and responding accordingly.
3. Correcting and appealing denials: Timely correction of errors, appeals, and understanding payer requirements, involving coding professionals and providers as necessary.
4. Continuous improvement: Regularly evaluating internal workflows, analyzing denial patterns, and conducting staff training to enhance efficiency and identify areas for improvement.
5. Collaboration with payers: Engaging in collaborative efforts with payers to address denial issues more efficiently and improve system-wide effectiveness.
6. Utilizing outsourced services: Considering the use of outsourced medical billing and coding operations to access specialized expertise and support in managing denials, allowing internal teams to focus on other critical aspects of healthcare operations and patient experience.

Implementing the following best practices can significantly enhance denials management and improve overall outcomes:

1. Know the statistics: Gain a deep understanding of initial denial, dollar, and claims rates to identify root causes and develop targeted process improvements.
2. Maintain an organized process: Utilize HIPAA-accredited tools and technologies to track and manage denied claims effectively, minimizing revenue loss and administrative challenges.
3. Identify trends: Quantify and categorize denials, leverage data analytics to uncover patterns, and proactively address underlying issues with the assistance of physicians and payers.
4. Act in a very timely manner, do not delay: Establish a well-defined workflow to address denials promptly, aiming for corrections within a week to optimize revenue flow.
5. Establish a dedicated team: Assemble a cross-functional team consisting of key stakeholders from various departments to collaborate, strategize, and implement solutions, while continuously monitoring progress and identifying root causes.
6. Collaborate with payers: Foster collaboration with payers to streamline the resolution of denials and improve overall system efficiency.
7. Prioritize quality over quantity: Focus on thorough follow-up and resolution of already-addressed claims to maximize revenue generation and quality outcomes.
8. Monitor progress: Regularly track and analyze performance, conduct audits, and leverage automation to streamline denial management processes and reduce rejections.
9. Verify patient information: Utilize patient portals for accurate and updated patient information, ensuring data quality and proper insurance coverage verification.
10. Learn from historical claims rejections: Analyze rejection trends, leverage available resources such as electronic health records, and continuously improve data quality to avoid claim rejections.
11. Meet deadlines: Adhere to insurance company policies and deadlines to avoid claim filing delays that could lead to denials.
12. Foster a strong relationship with clearinghouses: Maintain a solid partnership with clearinghouses to facilitate smoother interactions with insurance companies and gain insights into rejection explanations.
13. Understand claim formats: Familiarize yourself with standardized claim formats such as ANSI837, enabling efficient identification and resolution of problems associated with denied claims.
14. Conduct regular follow-ups: Track each claim, promptly correct and resubmit denials within scheduled appeal timelines to minimize revenue losses.
15. Follow a decision tree approach: Train staff to utilize decision trees, systematically considering all possible outcomes and tracing each path to resolution, enhancing the effectiveness of denial resolution efforts.

Leveraging Technology Solutions: Implementing the right technology resources can significantly enhance denial management efforts. Claim editor or "claim scrubber" software can help identify coding errors, medical necessity issues, and technical errors before claims are submitted. Medical claim scrubber solutions automate the matching of diagnosis and procedure codes, ensuring compliance with coding guidelines. Code check software and encoders validate and improve coding accuracy, saving time and improving efficiency.
Mitigating Losses and Protecting the Bottom Line: While it may not be possible to eliminate denials entirely, a strategic and proactive approach, backed by data analysis, automation, and technology tools, can mitigate their impact on the financial bottom line. By continuously monitoring, identifying trends, collaborating with payers, and adhering to best practices, healthcare organizations can reduce write-offs and safeguard their revenues.
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Efficient denial management requires a comprehensive approach that includes prevention, understanding denial codes, effective correction and appeals, continuous improvement, collaboration with payers, and leveraging technology solutions. By implementing these strategies and practices, healthcare organizations can minimize the financial impact of denied claims, optimize revenue generation, and maintain a stable bottom line while providing quality care to patients.

The Role of Staff Training: Investing in staff training is crucial for effective denial management. By equipping employees with the necessary knowledge and skills, organizations can reduce errors and improve the accuracy of claims submissions. Training should cover topics such as coding guidelines, payer requirements, documentation best practices, and effective communication with payers.
Continuous Monitoring and Analysis: To stay ahead of denials, it's essential to continuously monitor and analyze denial data. Regularly running reports to identify denial patterns and trends can provide valuable insights into the root causes of denials. By identifying these patterns, organizations can take proactive measures to prevent future denials, implement process improvements, and enhance overall revenue cycle management.
Utilizing Outsourced Services: For healthcare organizations that lack the resources or expertise to handle denial management internally, outsourcing services can be a viable solution. Outsourced medical billing and coding companies specialize in managing denials, ensuring efficient claims processing, and optimizing revenue collection. By leveraging the expertise of these external partners, organizations can alleviate the burden on their internal teams and achieve better denial management outcomes. Our company, the GoHealthcare Practice Solutions can easily help you with this! 
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Denial management is a critical component of revenue cycle management in healthcare organizations. By focusing on prevention, utilizing effective denial management strategies, leveraging technology solutions, and investing in staff training, organizations can mitigate the financial impact of denied claims and protect their bottom line. Continuous monitoring, analysis of denial patterns, and collaboration with payers are essential to identify opportunities for improvement and implement proactive measures. By adopting these best practices, healthcare organizations can optimize revenue generation, enhance operational efficiency, and provide quality care to their patients.

1. "Strategies for Reducing Claim Denials and Improving Revenue Cycle Performance" by Healthcare Financial Management Association (HFMA)
   • This resource provides insights into strategies for reducing claim denials and improving overall revenue cycle performance in healthcare organizations.
   • Source: https://www.hfma.org/topics/revenue-cycle/article/strategies-for-reducing-claim-denials-and-improving-revenue-cycle-performance.html
2. "Effective Denial Management: A Proactive Approach to Revenue Cycle Optimization" by American Health Information Management Association (AHIMA)
   • This article highlights the importance of proactive denial management and provides recommendations for optimizing the revenue cycle through effective denial management practices.
   • Source: https://library.ahima.org/doc?oid=301233#.YzLbIegzaUk
3. "The Role of Technology in Denial Management" by Healthcare Information and Management Systems Society (HIMSS)
   • This resource discusses the role of technology solutions in streamlining denial management processes, improving efficiency, and reducing claim denials in healthcare organizations.
   • Source: https://www.himss.org/resources/role-technology-denial-management
4. "Best Practices in Denial Management: Strategies for Success" by Medical Group Management Association (MGMA)
   • This MGMA resource provides best practices and practical strategies for successful denial management in medical group practices, including prevention, analysis, and resolution of denials.
   • Source: https://www.mgma.com/resources/revenue-cycle/denials-management/best-practices-in-denial-management
5. "Effective Strategies for Preventing and Managing Claim Denials" by Becker's Hospital Review
   • This article offers insights into effective strategies for preventing and managing claim denials, including process improvements, staff training, and technology utilization.
   • Source: https://www.beckershospitalreview.com/finance/effective-strategies-for-preventing-and-managing-claim-denials.html

Please note that availability and access to these sources may vary, and some of them may require a subscription or purchase.

The HHS through HRSA (Health Resources and Services Administration) had announced the $20 billion New Phase 3 Relief Funding which began yesterday, October 5, 2020. 

Source of Information: ​https://www.hhs.gov/about/news/2020/10/1/trump-administration-announces-20-billion-in-new-phase-3-provider-relief-funding.html

​Patients Access and a Successful Revenue Cycle Management
The Patients Access plays a very important role in capturing and collection of patient service revenue.

There are 3 parts of Revenue Cycle where the Patient Access Management is very important and the Patient Access Team plays a very valuable role.

1. Pre-service Phase

• Scheduling patients
• Pre-registering patients
• Verifying insurance coverage and eligibility
• Verifying pre-certification and referral requirement
• Discussing patient costs and providing financial counseling services if required

2. Time of Service 

• Activate the patients record in the Electronic Medical Record and or Practice Management system
• Attached copy of insurance card front and back on the patient's chart
• Attached copy of government issued identifications on the patient's chart
• Patient reviews and sign the consent forms
• Completed the positive patient identification
• Financial Clearance
• Patient Arrival
• Patient Care Delivery

3. Post-service Phase

• Claims Submission
• Patients Responsibility
• Claims follow up

​Access is a significant concern in the United States and all over the world when it comes to patient care. We all know that the patients have to wait for months to get the physician they want, and a good doctor has more patients than they can manage. The patients waiting for months to get the physician surely lead to delayed treatment and also can jeopardize their health and their life. On the other hand, it will certainly reduce the patient satisfaction scores for the doctors and the medical service providers.

As these scores have to be shared with third parties such as pharmaceuticals and drug companies as well as the insurance companies, managing the scores is extremely significant for the doctors.

So here are a few ways that you can make sure your patients are not sitting and waiting for you to give them an appointment for half a year. 

Step 1:  Learn how to Measure
The first appointment available is a valuable commodity. So make sure that you have a good system to call people who are on the waiting list. Not just the first appointment available, but the second and third appointments available can also be prescheduled. You should inform the patients that are on the waiting list that they can be called in for a consult at short notice. When a person is coming up for the next available appointment, you can inform them that they are next on the list. That will allow individuals to prepare for showing up without feeling like it was impractical to ask on such short notice. 

Call people up or have a reminder system in place that will inform people on the list when they are next on the list of first appointment available. There are many openings happening every day, and placing then effectively can reduce overextended waiting lists considerably.

Step 2: Denied Appointment Requests
The patients who were denied an appointment is also a crucial list that needs to be monitored closely. There are many reasons that a patient is denied care, and those reasons should be listed clearly. If there is no appointment available or the appointment is not given for another reason, the reasons should be listed. That process will allow the nurses and administration to solve the problem and will allow them to develop a system that reduces denied appointments. 

Step 3: Implementation of the Data
The main focus of all of the points mentioned above is to have a system that focuses on developing data sheets on appointment schedules so that you can decide how to have a more productive appointment culture.

​Guideline:
The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days



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WHEN IT IS APPROPRIATE:

• Treatment of problem requiring a return to operating/procedure room
• More extensive than original procedure
• Unanticipated clinical condition
• Therapy following a diagnostic, surgical procedure                                
• Each case requires surgical documentation and evaluation

Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in same specialty, same group are to bill and are reimbursed as a single physician

Key to Remember!  Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

It is NOT APPROPRIATE WHEN:

• Not appropriate for E/M - Evaluation and Management! or assistant surgery services

References:
CMS Medicare Website
Coding Books
​Payers Websites

Definition: Bilateral Procedure; procedures/services that occur on identical, opposing structures (such as for example - "LEFT" and "RIGHT" Side)
Many Billers are still really confused on how Modifier 50 really works. 

APPROPRIATE:

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule BILAT SURG indicator is 1: 
• Report codes with a BILAT SURG indicator of 1 on one line, appending modifier 50 and submit one unit of service. 

For example: 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 

Billed as 64490 -50  1 unit

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule (MPFS) BILAT SURG indicator is 3: 
• Submit codes with a BILAT SURG 3 on one line appending either modifier 50 using one unit of service (UOS); or 
• Submit codes on one line with two UOS (the use of the RT/LT modifiers would be optional); or 
• Submit on two lines of service using RT on one line and LT on the other with one UOS each.

INAPPROPRIATE:

• Reporting this modifier when performing the service on different areas of the same side of the body. 
• The BILAT SURG indicator is 0, 2, or 9. 
• When removing a lesion on the right arm and one on the left arm - use the RT and LT modifiers. 
• Do not use modifier 50 for multiple procedures on one organ, such as the skin. 
• On a procedure code that is described as bilateral or unilateral or bilateral in its CPT description. 
• Do not report a bilateral procedure on two lines of service appending modifier 50 to the second line of service.

Coding Tip:
Generally speaking, the above information applies when two of the same procedure codes are performed on the same day for the same patient by the same provider. However, there could be instances where two separate procedure codes are used. If so, Medicare's payment or denial would depend on any other type of rules or regulations concerning the individual services in question. This could include the National Correct Coding Initiative (NCCI) that could necessitate additional modifiers, duplicate edits, and global surgery edits.

Remember, the Modifier 50 is used as a payment, rather than informational, modifier. The addition of this modifier could affect payment depending on the procedure code and the BILAT SURG indicator. The BILAT SURG indicator for each procedure code can be found on the Medicare Physician Fee Schedule Relative Value File. Following are the indicators and their descriptions.

BILAT SURG indicator "0" =150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

Reference Manual:
The CMS Internet-Only Manual, Publication 100-04, Chapter 12 , Section 40.7.B, indicates "If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physician must report the procedure with modifier "-50". They report such procedure as a single line item."

BILAT SURG Indicator "2" =150% payment adjustment does not apply. Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.

BILAT SURG Indicator "3" = the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.

BILAT SURG Indicator "9" = The bilateral payment adjustment concept does not apply.

Ambulatory Surgical Centers (ASCs) and Modifier 50

Bilateral surgical procedures furnished by certified ASCs may be covered under Part B. While use of the 50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs.

Bilateral procedures should be reported as a single unit on two separate lines or a single unit with "2" in the unit field on one line, in order for both procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting.

Read more examples for appropriate billing procedures in the MLN Matters article,

"Revised Payment System for Ambulatory Surgical Centers (ASC) in Calendar Year (CY) 2008"  (Revised SE 0742).

References:
CMS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Noridian: https://med.noridianmedicare.com/web/jeb/specialties/surgery/bilateral-surgery
American Medical Association Coding Guidelines

So, meaning, when you bill for $2000.00 and the insurance made their determination at 100% of your charges… you bill $2,000, they allowed $2,000 – would you be happy?
Honestly, if I see EOB like this, I will be very very nervous! Your provider could have been paid more than the practice submitted charges, isn’t it?

Interestingly, most of my readers said they’ll be happy if they were paid at 100% of their charges… now, would you?

What if the allowed amount could have been $2,500? – how much is the difference? Yep, $500! How can the payer allow $2,500 if you have only submitted a charged amount of $2,000?!
Make sense?

Ok, now, here’s the deal! — if you got paid at 100% based on your charged amount you should find out about your fee schedule or contracted rate or what is usual and customary if you are out of network provider. Make sure you know you are not under-charging the insurance payer.
But what if you have realized that you did under-charge the insurance payer? what will you do? can you recover the money that you could have been paid for? The answer is YES! you can recover that money!
Now, don’t wait too long! Take action immediately!

Based on my experience, you can go back as far as 3 years from the date the claims were paid. I haven’t tried more than 3 years of claim to recover due to undercharges! After all, just like the insurance payer, they can always go back as far as more than 3 years I think to recover overpayments. Or depending on where state you are located.
Pay attention on your EOBs! I think that’s the key. As soon as you discover there is an undercharging and you were paid 100% on your charged amount. Pick up the phone and call that insurance payer immediately.
Connect with us today, we will show you better strategies on how to run an effective revenue cycle management!

​Can you bill a Medicare Patient for Missed Appointment or No-Show?

When patients missed their appointments, it does cost you your time and your staff. In this article, you are wondering if you can bill Medicare when their beneficiaries missed and appointment or has no-show. Below you will find clarifications.

​According to Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge nonMedicare patients for missed appointments and the charges for Medicare and non-Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.
The other key points of CR5613 are:

• The provider may bill the Medicare beneficiary directly. • Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.
• Claims for missed appointments sent to Medicare will be denied with the reason code 204 (This service/equipment/drug is not covered under the patient’s current benefit plan.).
• In most instances, a hospital outpatient department can charge a beneficiary a missed appointment charge.
• In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee. 

According to Medicare guideline; "make certain that your billing staff is aware that you may bill the beneficiary directly, that Medicare itself does not make any payments for missed appointments, and that Medicare should not be billed for these charges".
"The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare."
"Providers may not charge ONLY Medicare beneficiaries for missed appointments; they must also charge non-Medicare patients. The amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients.​"

Source: MLN: MM5613 Related Change Request Number: 5613

(1) Incorrect demographic information (insurance ID , date of birth, even the gender!)
Always scan a copy of your patient's primary and secondary insurance card. Make sure to get a copy of their new card (if there is a change)
(2) Patient's non-coverage or terminated coverage at the time of service may also be the reason of denial. That is why, it is very important that you check on your patient's benefits and eligibility before seeing the patient (unfortunately, I have seen practices who does not check benefits and eligibility on their patients so they end up being not paid for the service they have rendered for the patient
(3) Coding Issues (requires 5th digit, outdated codes)--- be careful also with your secondary/additional codes! Claims may be denied even if the problem was just because of the secondary codes!Again as I previously pointed out with my other articles on tracking your claims, with this problem, discuss solving the coding error rather than how much you want to get reimbursed. Most of the insurance companies will help you with codes (in fairness!!) and they also inform you on outdated codes, or codes that requires a 5th digit. You can also clarify by asking them more information on their reimbursement and utilization guidelines
(4) Improper use of modifiers (be careful with bilateral procedures!, modifiers for professional and technical component, modifiers for multiple procedures, postoperative period, etc.)
(5) No precertification or preauthorization obtained. It is so hard to file an appeal when the claim or service was non-precertified. Avoid this from happening! So be careful with your Surgical Procedures, Therapy Services and DME Services. 
(6) No referral on file. HMOs or the Managed Care normally requires a referral! (remember that!). Most Therapy Services would require a an order or script from the referring provider. Make sure the referring provider's NPI appears on Box 17 on your HCFA 1500 Claim Form
(7) The patient has other primary insurance, the patient turn out to be a Workman's Comp case or an MVA case. Call our office, we can give you an example of our template of benefits eligibility verification. Remember, WC/MVA cases services are normally always require Prior Auth so make sure you have the claim information, connect with the Adjustor and the Nurse Case Manager
(8) Claim requires documentation, require additional notes to support medical necessity. A well documented medical records is a good practice!
(9) Claim requires referring physician's information (very common for Therapy Services and DME Billing requirements)
(10) Untimely filing. So how can you prove that you did submit the claims in a timely manner? When unfortunately, most of the insurances does not accept your billing records on your practice management software that shows that date(s) you billed the insurance! They want a receipt from your electronic receipt or for postal mail, obviously they want a receipt too! a tracking number maybe? certified letter receipt? If you are submitting claims by electronic, make sure you generate transmission reports/receipts. Your reports must read "accepted" or "in process" and not "rejected". If you are sending claims by paper or postal mail, it is a good idea to send your claims as certified mail with tracking number, keep your transmission receipts!

Need our professional consulting advise to run a more efficient Revenue Cycle Management? - call and talk to us at 609-481-3494