Just got back the bill from an ENT visit. I went there for having issues smelling/loss of sense of smell.

They charge my insurance for the nasal endoscopy and then $455 for this new mod that I’m on the hook for $300

From what I read looking through the sub this is only charged if we talked about something besides my initial visit?

The visit was like 30 minutes with the main doctor and all he did was the endoscopy and tell me they can’t do anything but maybe a smell test kit on Amazon might help. We didn’t discuss any other issues I have.

Is this care still correct or should I call someone. Thanks

Has anyone here used Ritten for behavioral health billing? Like their RCM?

I’ve always been told (and verified myself) that POS 19 is not on the PA Medicaid fee schedule so we won’t get paid if we use it. I’ve wondered how other practices are submitting their claims but that a rabbit hole for another day. Anyway, I’m now looking at claims that we submitted, with POS 19, that have been paid by Medicaid. I’m confused. Anyone have any insight?

I'm working with healthcare EDI data (837 and 835 transactions) and trying to better understand how claim resubmissions work in practice.

I've noticed cases where the same claim appears in multiple 837 submissions, but each submission has a claim frequency code of 1 (Original) instead of using:

• 7 – Replacement/Corrected Claim
• 8 – Void/Cancel Claim

For example:

• 837 #1: Patient Control Number ABC123, frequency code 1
• 837 #2: Patient Control Number ABC123, frequency code 1, submitted a few days later

Sometimes the claim information is identical, while other times certain details have changed.

A few questions:

1. Why would a provider or clearinghouse submit the same claim multiple times using frequency code 1?
2. Is this common when the original claim was rejected before adjudication?

Hello,

I am wondering if $400 is a normal billing price for an appointment to tell me that I am being referred to a specialist. The appointment was virtual and lasted 5 minutes (I understand that it takes 5 minutes to glance at my lab results and make a decision too...) and it was in response to an email I sent to my primary care doctor containing lab results which the office ordered.

Irrespective of high/low deductible, I think this is absurd. The "insurance negotiated rate" cut $200 off of it, but there is still $200 remaining to be covered by me (don't focus on whether or not this applies to deductible).

I think this is insane. The medical center is owned by private equity if that makes a difference.

Hi folks! I’m currently using the 2026 AAPC Icd-10-Cm book and am planning to take it to the exam. I know I’m allowed to bring it BUT idk if that will hurt my exam scores. Does the edition of the book matter that much for test content?

I was pregnant starting in September 2025. Under my Avmed insurance at the time, I was told I only had to pay a $30 copay for my first prenatal visit, with no copays for the remaining visits.
In January 2026, my employer changed insurance plans to Aetna. I was again told I only had to pay a $30 copay for my first visit under the new plan and nothing for the rest of my pregnancy.
After giving birth, in June 2026, I received a bill for my October, November, and December 2025 visits because Avmed had not paid them. I paid the bill and opened a case with Avmed. They eventually paid for only one visit.
Now, my gynecologist says prenatal visits are billed at the end of the pregnancy, and because my insurance changed, they cannot bill those visits as prenatal care without it being considered double-dipping. They are billing Avmed as regular office visits instead, which means Aetna pays less, and they want me to pay the difference PLUS a $30 copay for each visit.
I’ve been going back and forth between Avmed and my gynecologist with no resolution.

My questions are:
Is it standard practice to bill prenatal visits at the end of pregnancy?
Shouldn’t the three visits with Avmed be billed as pregnancy visits?
Can my gynecologist retroactively change them to regular office visits and charge me additional copays and balances when I was originally told I wouldn’t owe anything beyond my first copay?
Has anyone experienced this with Avmed or dealt with a similar situation? I’d really appreciate any advice!

​

I work at a gynecology clinic that sees many patients with Medicaid plans. We recently started administering the Abrysvo vaccine in accordance with TMHP requirements for pregnant patients. We are receiving claim denials—supposedly due to the patients' age—even though we are only administering it to patients over 18 who are between 32 and 36 weeks pregnant. Any ideas on what needs to be done to stop these denials?

I’m really interested in getting my CPC certification (if there’s another coding certification I should do instead of with this please let me know!!) and starting a career in medical coding, but I’m honestly scared to take the leap. 😭 I keep seeing people say the job market is oversaturated, that it’s hard to get your foot in the door without experience, and that getting certified doesn’t necessarily mean you’ll find a job.
I genuinely want to pursue this, but I don’t want to spend the time and money on a certification just to struggle to find work afterward.
For those who are currently working in medical coding, recently got certified, or are trying to break into the field, is it worth it? Would you still recommend getting your CPC in 2026? How difficult was it to find your first job, and what advice would you give someone starting from scratch?
I would really appreciate honest opinions, both good and bad! I’m trying to make an informed decision before investing in my future. ❤️

Kratom is a big issue in our area lately, and we're coding more and more of it lately. Our providers tend to use F15 codes (other stimulant use/withdrawal etc). I've seen some use the opioid code for it, but I lean more towards the F19 for psychoactive....what do you use?

The practice I work for bills very large claims for procedures and recently several insurance companies have started insisting we split the claims if they are over $99,999.99. The problem is we bill some codes at prices over this amount (the practice manager does not want to change this). We started using modifier 76 and writing in box 19 that these are "split claim part x of x". Is this the correct way to do this? We are not getting great results.

Hi everyone. In a couple of weeks I'm having surgery and I'm in a somewhat confusing situation with my insurance.

I have a primary and secondary health insurance and the primary does not cover this procedure but the secondary does. I understand that my provider will first need to bill my primary coverage, then my secondary, but what I am concerned about is my prior authorization. My secondary coverage did grant a prior authorization for the procedure and will cover the charges associated with the submitted codes. The problem is that my primary insurance apparently will not even let a prior authorization attempt happen, their portal will literally not even accept the submission of it.

My concern is that if there is no prior authorization or notification done for my primary, there will be a billing error, where instead of not paying out for the procedure being covered, they don't pay out because they never received a prior authorization. This will then disallow my secondary from paying out, and due to the patient financial responsibility agreement, the end cost will fall on me.

How realistic is my fear here? Should I insist on the provider submitting a pre auth through fax just to get an official rejection from primary for the services? I spoke to a representative at my secondary insurance and she said that this was not necessary, but I want to be very careful about this situation, due to the procedure being very costly and due to this rep not being an actual legal representative of the company.

I was able to confirm that this is a preferred in-network provider for both insurances at a preferred in-network facility for both insurances.

Any input from the highly experienced career professionals on here would be appreciated, Thanks! :)

Meritain Health Denied Payments!!

We submitted claims to Meritain Health last August, and it has now been over two months without receiving payment.

We have called multiple times to follow up, but the representatives keep giving us the runaround. Last September, one representative told us the claim had been paid on a specific date, but we never received the payment. When we called again, another representative gave us a different payment date and said it would be included in the following week's payment cycle.

Since then, it's been the same story over and over again. We keep getting different payment dates, but no actual payment. Every time we call, the representatives tell us the same thing, and we're getting nowhere.

We usually receive our payments through ECHO, so we are familiar with the payment process. However, the issue is that the claim appears to be stuck in processing. We have been told that it was paid, but no payment has actually been issued, and we have not received a check or payment through ECHO.

We're extremely frustrated and don't know how to escalate this issue. Has anyone else experienced this with Meritain Health? If so, how did you get it resolved? Is there a specific department, supervisor, or escalation channel we should contact?

Any advice would be greatly appreciated. We're tired of getting the runaround and just want these claims paid.

I wanted to be sure regarding a scenario which I faced during work, if Medicare crossover the claim to out of state Medicaid obviously it will not be covered. Can we balance bill the member in this situation for secondary leftover balance?

Hi all, looking for input from anyone who codes for a reference or specialty lab.

Setup: Babesia microti antibody testing by IFA, IgM and IgG run separately. Each class gets a single-dilution screen. If the screen is positive, serial dilutions are done to get an endpoint titer. Same specimen, same IFA method, same date of service.

Current coding: 86753 x1 for IgM and x1 for IgG (2 units total), whether or not a titer is done.

Question: I've seen a large national reference lab list the screen as 86753 x2 and then bill each reflex titer separately as 86317. My read of NCCI Chapter X is that the titer is part of the same procedure for the same analyte (one unit per procedure, payment based on result not methodologic steps). Also, 86317 is "not otherwise specified," so it shouldn't be used when an organism-specific code like 86753 exists. The only counterargument I can see is the reflex testing paragraph, but CMS's examples there are different procedures with new results (antibody ID after a screen, organism ID after a culture).

For those of you in lab billing:

1. Do you bill the titer separately, or treat screen + titer as one unit per Ig class?

2. If you bill it separately, which code do you use (additional unit of 86753, or 86317), and has it held up with Medicare or commercial payers?

3. Has anyone gotten written guidance on this from the NCCI mailbox, the AMA CPT Network, or a MAC?

Thanks in advance. Any references or experience appreciated!

Hi everyone! I’m looking into reimbursement and payer-contracting help for a multi-provider outpatient behavioral-health practice, and I’m having a surprisingly hard time figuring out what these services normally cost.

I'd ideally like to know how much something like this costs, or what it would be called:

• Understand how our rates compare with similar local practices
• Review our main CPT codes and commercial payers
• Identify which contracts may actually be worth revisiting
• Spot possible rate-tier, telehealth, or place-of-service issues
• Put together a well-supported rate-review request
• Potentially help with the payer negotiation itself

This isn’t full medical billing or revenue-cycle management. We’re mostly looking for good analysis and practical help deciding where to focus.

If you have hired someone for similar work before, would you mind sharing:

• Roughly what you paid
• Whether it was a flat fee, per-payer price, monthly retainer, or success fee
• What was included
• Whether it actually helped
• Anything you wish you had known before hiring them

Experiences from behavioral-health practices would be especially helpful, but I’d be grateful for input from any outpatient group practice.

I’m not looking to solicit proposals through Reddit. I’m just hoping to understand what a reasonable budget looks like before we start speaking with firms. Or what kind of packages I can expect to see. Thanks!

My workplace recently implemented AI inside of epic to pick facility + professional visit charges. More times than not it is incorrect. We were told to just go with whatever ai picks. I have noticed it’s picking higher numbers than what it should be like picking level 5 when it should be a 3. How is this legal practice, to charge more than what it is, just because ai says so?

Hi all,

Just putting my feelers out to see if anyone else here does allergy billing and uses ModMed/EMA as their EHR. We switched back in March and the whole thing has been a cluster. I have some general questions that their support seems to not be able to answer for some unknown reason. It seems like a lot of the real time issues we have confuse support and we have also been given wrong information by the trainers.

I want to preface this with our doc is very stuck in his ways so we are not using it the way it’s intended to be used. We have been doing a lot of ass backwards fixed, which is just adding to the problem.

hey guys! so, we have this recurring denial from a very few wc payers who ask for modifiers PA, AJ or NP on the office visit. The coding team says that this must be appealed. however for all appeals that i submitted a few weeks back are denied and the original decision is upheld. i feel like there is a lot of revenue loss due to the modifier issue. any insight is appreciated. thanks in advance 🙂

edit: we bill on cms 1500

For anyone billing DME/orthotics under Medicare FFS, the Required Prior Authorization List grows on October 28, 2026 (Federal Register, July 30):

Nationwide from 10/28:

• E0194 air-fluidized bed
• K0005 ultralightweight manual wheelchair (base only — options, accessories and seating are not part of the PA review; MACs accept requests from 10/14)
• L1833 knee orthosis, adjustable joints (this one was removed in Aug 2024 and is back)
• L0456, L0457, L0486 TLSOs

Phased by state:

• L3761 elbow orthosis and L3916 wrist-hand orthosis: NY, MI, FL, CA from 10/28; PA, MA, OH, IL, TX, GA, AZ, OR from 1/26/2027; everywhere 4/26/2027.

Separately, newly enrolled suppliers (or a change of ownership) on or after 10/15 get a one-year probationary PA requirement on 40 more codes, counted from the first claim. Established suppliers are not affected by that one.

Decision timeframes are unchanged: 5 business days standard, 2 expedited.

Disclosure: I work on AffirmDME, a PA documentation tool. We keep a free lookup by code/date/state and category guides; happy to link in a comment if that's allowed here, otherwise the sources are the FR notice (2026-15446) and the DME MAC "Required Prior Authorization Programs" pages.

I was wondering what you guys that are already in the field do on a daily basis? How massive is the workload, just daily tasks, etc. Anything of note I guess. Thank you for any answers!

Hello! I am taking my AAPC CPC exam soon! (Still in 2026) i plan on using my physical coding manuals. My HCPCS and CPT books are 2025 editions and my ICD-10-CM is 2024-2025. Are these books good enough for the exam? Will they allow them to be a year old? Or do I need to get all new books? Pls anyone help i fear I have made a silly oversight

Heyy!! I’m 23 years old and currently taking a CPC course through AAPC. I have about one month left before I’m eligible to take the CPC exam, but lately, I’ve started questioning whether it’s actually worth it.
Should I stick with it since I’m already so close to finishing, or should I reconsider my options?
I’ve been working in healthcare for about four years, primarily in front desk roles, and I’m starting to explore the possibility of transitioning into revenue cycle management. I’m still learning about the different career paths within that field, so I’m trying to figure out what makes the most sense for me long-term.
My biggest question is: Would earning my CPC certification still be beneficial if I decide to pursue revenue cycle management rather than working directly in medical coding? Is having my CPC a worthwhile investment for that career path, or would my time and money be better spent pursuing something else?
I guess I’m just having second thoughts and wondering if I’ve invested in the right thing. I’d really appreciate any advice from people who work in medical coding, revenue cycle management, or healthcare in general! ❤️

I have brand new 2026 CPC books. I bought the bundle but don’t need them. I also have the study guide. The first two pages of the study guide have some hand written notes but that’s it. I live in new port Richey but am willing to ship if you pay shipping.