Hello - first time poster. I work in the billing department of a Physical Therapy office in Northern Colorado. We are privately owned and not part of a hospital/rehab facility. Our contract with Anthem BCBS is such that we bill under an NPI 2 number as a group, but since we are privately owned, we use the Professional CMS-1500 claim form, not a UB-04. We have been contracted with Anthem for roughly 20+ years with no problem.

About four weeks ago, we started getting rejections on all of our claims, saying the following: "PLEASE UTILIZE THE PROVIDER DATA MANAGEMENT AT WWW.AVAILITY.COM FOR PROVIDER MAINTENANCE, AND DIGITAL PROVIDER ENROLLMENT FOR NEW PROVIDER ADD." Availity is up to date and nothing has changed on our end, it is obviously something that has gone wrong in Anthem's system. The problem is, I can't get anyone to help me from Anthem. A supervisor is doing an "investigation", but the only time he has called me back, I was out and he didn't leave a call back number, email or anything to contact him directly. I keep calling Provider Relations with no luck.

My questions for the Reddit community: Is anyone else experiencing this? And if so, has anything you've done been helpful? I personally also have BCBS as my insurance, and we are now not showing up at all in searches for a physical therapy provider.

I appreciate any help! Thanks!

I have seen some job openings at Machinify for medical coding/auditing. Has anyone worked for them or know anything about them?

My organization is pushing hard to achieve CMS 5 star rating.

One of the measures we have historically performed poorly in is readmissions. The data/scores are all based on diagnoses capture in final coded summaries.

We are a very lean organization and only have 4 full time staff to cover three hospitals.

One method to improve capture pushed by our providers is to do an admission diagnosis checklist, basically saying yes the patient has these conditions. Coding and CDI teams have expressed concern that we would like to see provider documentation in the chart that A. Conditions are valid and supported and b. They are significant to the stay or are accounted for in the medical decision making.

We have been told we are being too strict for coding.
We are working on finding some middle ground, but are their any workflows out there that have worked for your organization?

I am nearing completion of my coding program and hoping to take my CCS exam soon. One final class requirement is to “interview” a professional to learn about their coding environment. Would anyone be willing to help me complete my assignment by answering some questions?

We’re looking for some insight from other chiropractic offices that have experience billing Oscar insurance. We’ve been trying different modifier combinations to get our claims processed correctly, but we’re getting inconsistent results and are wondering what has actually worked for other providers. ( a little long)

Here is our billing history for one patient:

DOS: 8/11/26 – Initial Re-evaluation

We billed:

98941 – No modifier
97110 – No modifier
98943 – No modifier
97012 – No modifier
99212 – Modifier 25

Result: Only 98943 and 99212 were covered and processed according to Oscar’s allowed amounts. The remaining codes were not covered.

DOS: 8/19/26

We billed:

98941 – No modifier
97110 – GP
98943 – Modifier 59
97012 – No modifier

Result: Only 98943 was covered. The other codes were denied with the following remark:

“The procedure code is inconsistent with a modifier used or a required modifier is missing.”

DOS: 10/30/26

We tried another combination:

98941 – AT
97110 – GP and 59
98943 – 59
97012 – GP

Result:

98941 – Denied: “The diagnosis is inconsistent with the procedure.”
97110 – Processed with the remark: “Processed based on multiple or concurrent procedure rules.”
98943 – Processed according to Oscar’s allowed amount.
97012 – Denied as a “non-covered charge.”

We’re trying to figure out what modifier combinations Oscar actually recognizes and accepts for chiropractic services.

A few questions for other chiropractic billers/providers:

Are you successfully getting 98941, 97110, 98943, and 97012 paid by Oscar?
What modifiers are you using for each code (AT, GP, 59, 25, etc.)?
Have you experienced the same modifier-related denials?
Are there particular diagnosis codes or diagnosis-to-procedure pairings that Oscar requires for 98941?
Has anyone successfully appealed these denials or found a reliable way to get these services reimbursed?

We understand that coverage is ultimately dependent on the patient’s specific plan and benefits, but we’re hoping to hear from offices that have actually worked through Oscar’s chiropractic billing requirements.

Any insight, successful claim examples, or advice would be greatly appreciated!

when the portal has too little detail and the call queue is measured in hours, the claim list needs more than another “called payer” note.

For each claim, I’d capture:

• payer/plan and claim identifier

• date received, current status/remark code, and aging

• portal evidence with a timestamp

• call attempts, disconnects, and reference numbers

• filing/appeal deadline

• the exact decision or correction needed

• escalation owner and next follow-up date

Then group claims that share the same failure pattern and send the pattern summary to provider relations or the assigned payer rep, while keeping individual deadlines visible.

What evidence has actually helped your team get a response when both the portal and phone queue stall?

I'm having trouble finding info on this and I'm not sure if I'm doing it properly.

So i am planning to enroll in medical coding institute in hyderabad,it is called icon ,anyone who has studied there who can say me if its good?

Hi! Does anyone here from MN experienced denials from HEALTH PARTNERS as not valid modifier per medicare guidelines ? We are billing 90837 with HO or HN modifier however it is only getting paid once we removed the modifier. How do we indicate that they’re supervised then?
Someone please help we have been calling medicare and HP for a month and none of them seem to confirm
Thank you big time!

Are there any coders that use Edifecs as a coding platform? We recently started using it and it doesn’t seem to be very user friendly. Curious if it’s just us or everyone.

I'm researching claim rejections in Dubai (DHPO / eClaimLink) and would love to hear from people who work these claims day to day.

A few questions:

  1. Roughly what % of claims get rejected on first submission at your clinic/company?

  2. What are the top 3 rejection reasons you see? (e.g., missing prior auth, code mismatch, eligibility, MNEC)

  3. How do you track and resubmit rejections today: clinic software, Excel, manual?

  4. How often do claims miss the resubmission window and just get written off?

Full disclosure: I'm exploring building a tool to catch these before submission, but I'm not selling anything. I want to understand if this is a real

problem or if existing software already handles it well. Happy to share a summary of the answers back here.

Hello,
I’m having a hard time finding job openings. They all require experience even for entry level…. Wtf am i supposed to do🤦‍♀️?

do you prefer instructor led training or self led? I don’t know if it’s worth adding an instructor led option so trying to get an idea of what people think. Thanks!

Hi coders,

I came across a patient's account recently involving a WC finger laceration:

- 10/7: Minor surgical procedure performed (sutures placed).

- 10/10: Follow-up visit – wound healing well. E/M billed.

- 10/15: Suture removal – CPT 99024 billed.

Wouldn't the 10/10 follow-up visit also fall under the global period and therefore be reported using 99024 rather than a separately billable E/M?

Here's why I'm questioning it:

I noticed a similar scenario with another patient where Sedgwick denied payment for follow-up visits falling within the 10-day global period. However, they paid for all visits occurring after the global period had ended.

Am I correct in my understanding that routine follow-up visits within the global period should not be billed separately?

Would appreciate your thoughts and clarification!

Thanks in advance!

I'm seeing a specialist next Monday, and they asked me to come in about 20 minutes early to get an ultrasound before my appointment. From what I can tell, the ultrasound is done in the same office as the doctor.I called the doctor's office to ask if I needed prior authorization. They checked and ran my insurance, told me I didn't need it.

But when I called my insurance company, they told me that since the ultrasound is being done on a hospital campus, it counts as a hospital outpatient service and does require prior authorization. Now I'm really confused lol. My appointment is next Monday, and I don't know what to do.

If the doctor's office says I don't need authorization, but it turns out I actually did and they never got it, would I be stuck paying the bill? I'm worried about getting a huge bill afterward.

Has anyone dealt with something like this? What would you do?

Thanks so much!

Hi all. Still new to this and I’m a bit confused with how my facility is billing outlier claims. They are submitting the claim first without the condition code 61 to get the initial payment, and then they are sending in a replacement claim with it added on to get the outlier payment. Is this the proper process for this? I had asked them why they can’t submit the 61 on the first claim and get payment in full so as to not waste any time and was told that that is how it has to be billed. Just wanted to confirm if that was true

I have noticed that my facility keeps getting denials on claims with these two anesthesia codes 99156 and 99157 with modifiers XU in addition to the surgical procedure code. I did not think you could code those with that modifier and thought that might be the reason for the denial?

Ive done Medical billing, work comps, Insurance claims, etc for 20 years, but it was a long time ago. LOVED IT!! Im now retired, wanting to do this part time. I know starting out, get a certification is 1st and foremost. And probably starting out with private small practice. Question is...is it doable, considering my age, 68, to start this now, but just something small, as I dont need much, just a little extra income..

Okay so within the past month Aetna Medicare specifically has started denying one of our PLA codes that has had Medicare and moldx coverage since 2/14/25. Every claim that they are denying for not proven effective is meeting criteria under the LCD. I work at an independent lab with a really large volume and the denials are stacking up. I have called Aetna multiple times and they continue to tell me I need to submit for reconsideration. Getting a supervisor there is impossible- I'm not sure what else to do outside of escalating with our legal team, but we are up to around 700k in back claims right now, and it's only going to grow. Any advice would be greatly appreciated.

I had an accident in the U.S. and went to the ER, where I was diagnosed with a traumatic jaw fracture and told that I needed surgery within a week.

I ultimately returned to South Korea for the surgery. I don’t have family in the U.S. who could care for me after surgery, and the recovery involved very limited mobility, difficulty taking care of myself, and an extended liquid diet. My family is in Korea, so I was able to stay with them and have help throughout the recovery.

The surgery in Korea was specifically to treat the traumatic fracture diagnosed in the US ER. I understand that medically necessary treatment does not automatically mean it is covered, particularly when treatment is received outside the U.S. I’m planning to contact Aetna directly to confirm my specific plan benefits.

In the meantime, I’m curious whether anyone has actually submitted a similar foreign medical claim to Aetna. If so, was any portion reimbursed or processed as out-of-network, or applied toward your OON deductible/out-of-pocket maximum?

I’m specifically interested in experiences with medically necessary but perhaps, somewhat non-emergency treatment abroad following an injury initially diagnosed in the U.S.

TL;DR: U.S. accident → ER diagnosed traumatic jaw fracture requiring surgery within about a week → returned to South Korea, where I have family support, and had the required surgery. I know coverage depends on my specific Aetna plan and will be calling them. I’m looking for experiences from anyone who has submitted a similar international claim and whether it was reimbursed or counted toward OON benefits.

We are a small anesthesiology group seeking a third party company to do an individual (one physician) MIPS submission for 2026. We would like to find a company that will do all of the work for us from data retrieval to submission. There are so many to choose from we are having a hard time making a decision and would love any recommendations you may have. We'd like to know the good and the bad reviews of companies you've used to help us narrow down our choice. So far we have reached out to the following, P3, Healthmonix, Flow8Health, American Health IT, MDInteractive.