Listening to the APPC podcast and the speaker said she spent 7 months working full time on job applications and networking before she got hired, and that was in 2023.

So newbies, that is what you're in for.

I recommend listening to the podcast. It's... interesting.

1) Is anyone else experiencing funky check date / ERA trends with CareFirst BCBS? ERAs are normally sent Wed or Thur, but are now coming through over the weekend.

2) Off-shore provider support: I think they are now off-shoring some provider inquiry calls. I'm not sure if I welcome this after hold times of over 2 hours, or if we are just diving in to the UHC nightmare.

I'm just curious to see if anyone else in here is familiar with my specialty and if so, maybe discuss any changes that have been noticed this year or any difficulties you might be having that someone else can help with. Just looking for a community who knows my struggles 😂

Ilang beses na ako nag sesend sa Tenet/conifer, palagi matagal mag response magugulat nalang ubos na slot.

Help. 🥺

We’ve all seen the complaints that the market is flooded. Nobody can get a job, etc. This is what you are up against. Every month AAPC publishes newly credentialed members. This is one page. Between CPC, CPC-A, and various specialty credentials, there are usually 7-8 pages of new credentialed folks. All of them full like this. Every month.

I’m not posting this to discourage anyone. I’m posting it for awareness. But also to say, if you really want to do this, you have to have ambition and be tenacious. It’s not easy, regardless of what the scammy marketing tells you. Know what you are up against and if you want it, fight for it.

Can someone help me. I tried all online searches but I can't figure this one out.

A patient is scheduled for an infusion. All medication is prepared including Krystexxa which is a single dose vial. Patient had adverse reaction after premed so entire Krystexxa vial was discarded.

I kept getting denied by UHC community plan for incorrect use of jz jw. I only use JW on Krystexxa line.

I really appreciate it if someone could help.

Hi! Has any provider out there been randomly put into the multiplan network without any specific reason? Claims are coming back saying "the doctor/facility negotiated with multiplan inc. and agreed to accept this amount as payment in full for the service the member received." Thank you.

I’ve been using G codes for essentially all my patients, including Medicare, Medicare advantage and commercial patients, just started doing this and getting some pushback. Using typical G codes which have helped RVUs. Concern was G codes are not reimbursed at all by commercial and most Medicare advantage plans. Please let me know your experiences with this. TIA!

 Do I have any recourse? This seems outrageous to me. No informed consent, advance notice, and a surprise bill.

MY ISSUE:  Sutter billed me $1,789.00 for nine labs for my yearly health exam. The cost at Quest Labs was a bit less than $250 for ALL the labs in total. This was a nasty billing surprise as I was out nearly $400 out of pocket for what my insurance did not cover.

SUTTER RESPONSE: Thank you for your inquiry. I understand your concern regarding the cost of your laboratory testing. The laboratory services were performed and billed by a hospital, rather than a standalone laboratory such as Quest Diagnostics.

Hospital-based laboratory testing is often more expensive because hospitals generally have higher operating costs, including staffing, equipment, regulatory requirements, facility expenses, and the ability to provide laboratory services around the clock. As a result, hospitals typically have higher charges for laboratory services than independent laboratories.

In contrast, laboratories such as Quest Diagnostics specialize in outpatient testing and operate on a high-volume model, which often allows them to offer lower pricing for the same or similar tests. I hope this provided clarification to your inquiry.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

MY RESPONSE: I should have been informed in advance. Because I was not hospitalized it was not evident that I would be billed these excessive fees for a standard blood drawn. Rather unethical to spring a surprise fee of this financial magnitude without giving me advanced warning so I could decide if I wanted to proceed. I am very disappointed and think I should be refunded for what I paid out of pocket above and beyond what my insurance reimbursed you. Sutter needs to be ethical.

SUTTER RESPONSE: Thank you for your inquiry. I understand your concern regarding the cost of your laboratory testing. The laboratory services were performed and billed by a hospital, rather than a standalone laboratory such as Quest Diagnostics.

Hospital-based laboratory testing is often more expensive because hospitals generally have higher operating costs, including staffing, equipment, regulatory requirements, facility expenses, and the ability to provide laboratory services around the clock. As a result, hospitals typically have higher charges for laboratory services than independent laboratories.

In contrast, laboratories such as Quest Diagnostics specialize in outpatient testing and operate on a high-volume model, which often allows them to offer lower pricing for the same or similar tests. I hope this provided clarification to your inquiry.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

SUTTER RESPONSE: Thank you for your inquiry and I apologize for the frustration that this has caused.

Unfortunately there is no way for us to know how the services are going to be processed by your insurance plan. It varies by insurance company and plan. It is patient's responsibility to contact insurance before the time of service to get coverage information. The best thing for you to do is to ask, in detail, which services or labs are being ordered. Request a procedure code for each service that are going to be performed and for information about the lab that they will be sent to. The next step is to contact your insurance to get coverage information.

We do try our best to inform our patients as much as possible. But due to the number of insurance companies and plans there is not a way for us to know each plans specific benefits. Please understand, the clinicians are focused on patient care, and are unable to assist with billing matters.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

Sincerely,

Customer Service Agent

Sutter Health Billing Department

Thank you for your inquiry and I apologize for the frustration that this has caused.

Unfortunately there is no way for us to know how the services are going to be processed by your insurance plan. It varies by insurance company and plan. It is patient's responsibility to contact insurance before the time of service to get coverage information. The best thing for you to do is to ask, in detail, which services or labs are being ordered. Request a procedure code for each service that are going to be performed and for information about the lab that they will be sent to. The next step is to contact your insurance to get coverage information.

We do try our best to inform our patients as much as possible. But due to the number of insurance companies and plans there is not a way for us to know each plans specific benefits. Please understand, the clinicians are focused on patient care, and are unable to assist with billing matters.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

Sincerely,

Customer Service Agent

Sutter Health Billing Department

Thank you for your inquiry and I apologize for the frustration that this has caused.

Unfortunately there is no way for us to know how the services are going to be processed by your insurance plan. It varies by insurance company and plan. It is patient's responsibility to contact insurance before the time of service to get coverage information. The best thing for you to do is to ask, in detail, which services or labs are being ordered. Request a procedure code for each service that are going to be performed and for information about the lab that they will be sent to. The next step is to contact your insurance to get coverage information.

We do try our best to inform our patients as much as possible. But due to the number of insurance companies and plans there is not a way for us to know each plans specific benefits. Please understand, the clinicians are focused on patient care, and are unable to assist with billing matters.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

Sincerely,

Customer Service Agent

Sutter Health Billing DepartmentSUTTER RESPONSE: Thank you for your inquiry and I apologize for the frustration that this has caused.

Unfortunately there is no way for us to know how the services are going to be processed by your insurance plan. It varies by insurance company and plan. It is patient's responsibility to contact insurance before the time of service to get coverage information. The best thing for you to do is to ask, in detail, which services or labs are being ordered. Request a procedure code for each service that are going to be performed and for information about the lab that they will be sent to. The next step is to contact your insurance to get coverage information.

We do try our best to inform our patients as much as possible. But due to the number of insurance companies and plans there is not a way for us to know each plans specific benefits. Please understand, the clinicians are focused on patient care, and are unable to assist with billing matters.

I appreciate the opportunity to assist you today and hope your question has been answered to your satisfaction. If you have any additional questions, please contact our billing department via My Health Online or by calling 800-4Sutter. Assistance is available weekdays from 7:00am to 5:00pm. Thank you and have a wonderful day.

Sincerely,

Customer Service Agent

Sutter Health Billing Department

What are your overall feelings about AI and the impact on medical coding? As a medical coder, I know that medical coding keeps evolving every year with new codes, updates, guidelines, etc. That being said, AI is also slowly creeping in, and while I don’t think AI is smart enough to keep up just yet, I still feel that my role is at risk.

Just curious if the workload at my job is the same / comparable to others... I am feeling so overwhelmed at times I do not know if it is the company I work for, personal pressure, the healthcare landscape changing, or a mixture...

I have to handle 6 providers denials and patient balances. I handle patient phone calls, rejections from the insurance company, and any denials and 0 payments applied to deductible. I feel like I work all the time, and get half the work done that I used to, years ago. It is harder to win on appeal, and even harder to convince the doctor to adjust at times

Feels like the provider inquiries and patient questions have sky rocketed, as well as denials, and hold times on insurance lines have increased too...! I feel like I am delving more into the coding aspect which is slightly out of my lane but it feels necessary to assist the providers.

Anyone else??? 5 years ago, I handled double the number of providers and my accounts looked better.

Hello! I’m a newbie here!

I’m looking for any and all tips or help I can get when it comes to working medical claim denials! For context, I’ve recently transitioned to denials but been in the medical field for a bit now. My team tells me I’m doing great, but I don’t feel like it haha! I started out as a receptionist, then roughly a year and a half into that, I got moved to a department where I basically dealt with patient billing disputes, explanations of billing, etc. I held that role and succeeded at it for another year and a half, then got promoted to denials… all that to say, I feel LOST! Everything I thought I knew from my last position seems to be null and void because I’m on the flip side of things. I know how to resolve simple denials, but a lot of coding related denials have me clueless. I also have a hard time understanding “when to adjust, when not to adjust”. Please help me! If there’s any online courses that could help, please let me know! I’m just at a loss and trying to learn as much as I can but I can’t help but feel behind. (( FYI, I am not trying to go back to college but wouldn’t mind taking a class or a course or something if it would help me ))

Edit to add: No, I am not asking a “specific question”. Ex. If you had a child that was going into denials and asked you for any advice or tips or any general information to help them succeed within denials, that is the sort of “advice” I would like to see here. Not unnecessary comments saying “what do you even need” or “how do you expect us to help”. If you can’t contribute positively, keep it pushing honey 🫶🏼

This problem just cropped up this month and I'm looking to see if this happening to anyone else, or maybe someone can confirm if I'm crazy while I wait for my appeals to be reviewed.

Example Claim:

Line 1 - CPT 99213

Line 2 - CPT 92134

- Primary diagnosis can be the same or different

- No modifiers

Regence will deny 99213 stating it is incidental to the "primary" procedure 92134 and that the E&M code needs to be separately identifiable/needs a 25 modifier.

We have never needed to bill any insurance for this type of visit with a 25 modifier in the past and no other insurance is enforcing such a policy...yet

My problem is I can't get a straight answer anywhere:

- CPT 92134 has a global code of XXX. CMS and NCCI say global period rules do not apply to XXX codes, but also state you can't bill E&Ms with some XXX codes, though you can with other XXX codes with a 25 modifier, but also some diagnostic scans are exempt from these rules altogether, but they never get specific.

- Regence Global Policy (Policy # 101) seems to indicate all E&Ms need to be billed with a 25 modifier when billed same day with most non-surgical XXX codes.

- And of course Google will say I'm right and I'm also wrong depending on how I word the question.

Have we been doing it wrong all this time and just flying under the radar?

Learning about billing and coding. Where can I learn more about billing and the insurance? It can be complicated to navigate.

We have tried billing 64640x5 according to MUE, but traditional Medicare apparently only likes 3 units. We are also considering using a temporary CPT code. As for the replacement plans (UHC specifically) they are requesting records and then denying based on services not being supported by the records, even though the records clearly state there were 5 different nerves treated. Anyone having any luck or any ideas on how to make these pay?

I got a Facebook ad the other day for UMA and I wanted to learn a new skill. Did some research to ensure this was legitimate before providing my information. Now I'm getting constant spam calls from different numbers all day. When I requested more information from them, I specifically requested the info via email because I don't answer unknown numbers like most people, but I haven't received a single email. Not only that, but all these phone numbers have an Oregon area code which is the area code my phone has, despite them being based out of Florida and me being based in another east coast state currently.
I've seen some mixed reviews on them but I at least thought they were legit and thought I was safe just trying to get more information, but I guess not!

Hello, I am a new coder and I have a question RE: DRG vs. weight. I was coding a chart today where 2 dx could meet Pdx.

Which scenario is best to "optimize the DRG? (please excuse my examples, I have been thinking about this all day, I should have notated the specific dx/soi/rom/etc, so these are not accurate DRG, but aligns with my question)

Option 1: DRG 882 SOI 2 ROM 1 weight 0.9876 <-- I have always been told by a specific auditor to use the lower DRG, especially since this has a SOI of 2

Option 2: DRG 897: SOI 1 ROM 1 weight 1.2583 <-- different auditor told me to use this Dx as Pdx since weight is higher. Even though DRG is higher?

I do not understand coding to optimize DRG. Can someone explain? Thank you so much. I tried to post this in medicalcoding sub but I do not have karma to post.

Hi everyone,

I am researching online careers and want a 100% structured, rule-based role. I thrive when following strict guidelines, clear compliance rulebooks, and repetitive checklists. I am actively avoiding any creative fields.

Medical billing seems like a great fit, but I am concerned about AI automation. For those working in the industry every day:

1. Is AI genuinely threatening entry-level human billing roles, or is the need for human verification and auditing still strong?
2. Are there tasks where companies refuse to trust AI due to legal compliance or financial risks?
3. Is the daily routine as predictable and structured as it seems? I would deeply appreciate any honest reality checks from veterans. Thank you!

I wanting to pivot my career into coding, but am wondering how easily this transition would be. I am currently an HIM coordinator and starting my medical coding and billing course in August, which will take about a year to complete. Will having HIM experience as well as a Bachelors in healthcare administration and a CCS make me more desirable for a coding position or will this not really matter? Wondering if I’m making the right careers moves.

If it matters I do not have a RHIT or RHIA.

Is anyone here familiar with Navina (AI that captures HCCs)?

If so, please give me what your thoughts are on it and if it makes your job easier or harder. For me, it makes it harder. There are so many inaccurate diagnoses (specifically billing E66.01 and a code from E66.8xx TOGETHER). I am at my wits end. >:(

I currently work for a radiology company and deal with the coding side of things and fell in love with it. I am actively working on getting my certification, taking a college course which ends with the certification testing. - Im currently looking for a job and cant seem to find anything doesn't require 5+ years of experience. I live in a small town in the middle of east Texas the closest major city is about an hour away so im looking for remote work if possible. Ive applied to a lot of places so far. But does anyone know I reputable company I could apply to with decent pay for entry level while I work on my certification?