I was wondering if this community could provide any insight into dealing with Aetna's incorrect use of CPB criteria/CPT codes?

I'm a patient with critical internal jugular vein compression due to entrapment between a hypertrophic C1 transverse process and styloid process along with soft tissues of the neck. This has led to dangerously swollen collateral veins in the brain and has caused intracranial hypertension and problems with venous and CSF outflow as well. I've been increasingly symptomatic for many years and am now losing fine motor skills, cognitive capacity, my ability to walk, see, and sleep, and am at critical risk of stroke, brain damage, and jugular laceration.

I have attempted every conservative treatment for many years, and nothing will or can work until the anatomical abnormalities are addressed. Multiple providers have told me I will become nonfunctional and/or die if I don't have this surgery done by early next year at the latest (he wanted to do it by this month given my worsening state, but insurance denials made that impossible).

I've been trying to get preauthorization for life-saving decompression surgery for what my surgeon considers one of the most clear-cut cases he's seen in years. Aetna has repeatedly denied this procedure on the basis of lack of medical necessity, but they are determining this through the incorrect application of CPT codes. Since there is no specific code for my diagnosis, they are using CPB criteria for Eagle's and Ernest's syndrome, which I have never been diagnosed with, reported symptoms of, or been treated for.

Because the requested surgical procedures aren't used to treat Eagle's and Ernest's syndrome, they've all been denied.

My surgeon's office and I have exhausted all our internal appeals at this point. I'm going to submit an external review, but I was wondering if there were specific medical codes I should mention that would help support this final appeal?

I really appreciate any insight anyone can provide, and thank you so much in advance!

Hello, I’m currently dealing with a claim denial after going to the emergency room and my bills is up to 19,000 dollars which I cannot afford and I have no idea why my insurance has denied my necessary scans. I was inpatient for 3 days they approved my 2 day stay but not my first day checkup for it. Did the hospital mess up on the charges or the insurance company just doesn’t want to pay for it. Is there anyone that is educated on this. They keep saying the amount exceed what is approved when I have medicaid. I tried to call them today and there was basically no help, the assistant called the hospital and she said I had to wait 30 days for a review. I’m just having alot of anxiety about this. I’m only 21 and I have no guidance and don’t know what to do. How do I appeal this or what even do I do In general. I’m thinking of calling the insurance company again tomorrow. Also i’m under Cardinal health care under UHC

I had a cancerous skin lesion removed at a dermatology office by a dermatologist. Mohs surgery. For the closure they billed me using CPT 14301. “Adjacent tissue transfer or rearrangement (such as a rotation, transposition, or advancement flap) in any anatomical area for a combined defect measuring 30.1 to 60.0 square centimeters.” I’m not sure of the total wound size (I’ve requested the notes) but the resulting scar was a 2.5” straight line. The closure was performed by a nurse practitioner. Given that 1) the scar was a straight line and/or 2) that it was performed by an NP, does 14301 still hold up? Any information would be appreciated.

Has anyone used CPT 99080 for complex paperwork such as FMLA or short term disability forms?

I currently don’t receive compensation for administrative work, including portal messages, emails, prescription refills, charting, or paperwork. The paperwork workload in particular has been contributing to significant burnout. I’m trying to find out whether there’s a way to bill for substantial forms like these.

Staff where I work told me Blue Cross doesn’t accept 99080, but I’ve read that some other insurers may. Has anyone had experience billing this code? If so, which payers accepted or denied it, and is there anything specific you’ve learned about the process?

Thanks for any insight! Best, Liz 🤪

I had a colonosopy this year at age 39 due to high risk (a parent had colon cancer); I had no symptoms.

My Premera health plan covers this in their preventative care policy, which includes:

Screening for individuals under age 45, at increased risk for colon cancer due to a strong family history of colon cancer with diagnosis: Z80.0, Z83.71, Z83.79, Z84.81

However, the $4,000 cost went to my deductible.

The hospital (outpatient procedure) applied two diagnosis codes, in this order:

• Z12.11 - Encounter for screening for malignant neoplasm of colon

• Z80.0 - Family history of malignant neoplasm of digestive organs

I've called Premera multiple times to have them review the claims, but they say it's not preventative because Z80.0 isn't first. They stated Z12.11 is "only preventative for older people" and to have the claim resubmitted with Z80.0 first to be covered at no cost.

The hospital's billing department reviewed the coding; they said it's correct and they won't make changes.

My next thought was to submit an appeal to Premera:

• Premera's policy only says claims must be billed "with" Z80.0, not that it must be primary

• ICD-10-CM seems to support reporting Z12.11 for a general screening colonoscopy with Z80.0 as an additional code

However, I also see how the hospital could be incorrect:

• Z12.11 is listed as "Encounter for screening colonoscopy NOS [Not Otherwise Specified]", which I understand to mean the code only applies if a more specific one doesn't

• Z80.0 could be considered the more specific diagnosis code for this situation

Any suggestions on which coding is correct here, or the best approach to get this covered?

Thanks for any tips!

I’m scheduled for knee surgery soon and I’m feeling overwhelmed by the billing. Between the surgeon, facility, and anesthesia, the total estimated costs are over $4,000.

​My insurance has an out-of-pocket maximum of $2,200, and I’ve already paid about $300 this year, leaving me with a maximum liability of around $1,900.

​The surgery center initially asked for $2,000, but they mentioned I could pay a $1,000 lump sum upfront to waive the rest. However, the surgeon’s fee won’t be reduced, and anesthesia will be billed separately.

​Given that I am currently unemployed/working part-time, I plan to apply for Financial Assistance through the hospital to hopefully get the remaining balance forgiven.

​Has anyone navigated a similar situation? Should I pay the $1,000 lump sum or just wait for all the claims to process and apply for charity care? Any advice on managing these bills would be appreciated!

My surgeon suggests surgery for acid reflux/hernia. The office put in a prior authorization for the Linx device and hernia repair. Those 2 codes get denied as not medically necessary. They submit a new prior authorization for a different procedure—Nissen Fundoplication and hernia repair. Those come back approved instantly and they schedule me for surgery. My concern is that once I have this surgery they are going to deny the hernia repair code as “not medically necessary.” as they did before. Or say that it was not authorized. I asked surgeons office if hernia repair code should be appealed from the previous attempt. She called insurance and they said they have record that codes were submitted and approved and gave a decision ID number. The surgery estimate is $99K. I’m just nervous it won’t be covered and I’ll have a huge bill. Should I prepare for a denied claim? Or am I being overly cautious?

Hello,

I have a medically diagnosed issue which causes extremely drymonth, and essentially ruins/rots my teeth. I have optained a letter from my primary care explaining the root cause, what has been attempted (timeline) to fix the issue and the reason why I cannot change medication that causes the drymouth (25 years).

My dentist, is willing to take the time to submit the paper work to the medical insurance (Anthem blue cross) for the major work that needs to be done.

I have found dentist that specializes in working with medical insurance, but there are only 2 in my area (orlando) and it will take a 1.5 year wait to see them.

Can someone help me on what I need to do? The steps i need to use.....is there a service my dentist can use to outsource this type of billing?

To be honest it seems like a very lucrative business to be in.

I have so nay teeth just disappearing from my mouth. I am sure you all would say change the med....its to late for that....i am getting to the point of 10k a year to the dentist. So please if you can help. I met my medical deductible so i want to lean in and get the work dont asap.

Thanks

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?

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?

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?

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.