Take the challenge. CPT codes: 20611-LT, 20611-RT, J7326x2 or 20611, 20611-50, J7326x2 ICD-10: M17.0 Coding Rationale CPT Codes: 20610-LT, J7325x16 ICD-10 Code: M17.12 This claim is rejected by the insurance carrier because the injection was outside of the preauthorization window that ended on Oct. 31. Most insurance carriers enforce their preauthorization dates for procedures. In…
Rheumatology Coding Corner Question: Follow-Up Knee Injection
On Nov. 4, a 55-year-old female patient presents to the office for a follow-up visit for injection of the left knee for osteoarthritis. This is her third of three injections that were preauthorized through Oct. 31. She reports pain and swelling in her left knee and rates the pain at an 8 on a 10-point…
5 Steps to Help You Manage Prior Authorizations
Despite continuous movement to streamline the prior authorization process, physician practices are still struggling with jumping through hoops to have procedures and medications covered. A prior authorization (PA) is the process insurance carriers have in place to approve or reject prescriptions based on plan formulary. The PA process is important in ensuring appropriate and cost-effective…
Patients Have No More Skin to Give: Dr. William Harvey Testifies on Rheumatology Issues before Senate Committee
Prior authorization treatment delays, the preferred status conferred on some drugs by pharmacy benefit managers and exorbitant co-payments were among the issues brought before the U.S. Senate Special Committee on Aging on Wednesday, Feb. 7. William F. Harvey, MD, MSc, FACR, a practicing rheumatologist at Tufts Medical Center in Boston and volunteer on the ACR…
ACR Pursues Solutions for Flawed MIPS Infusion Regulations & Billing Codes
While the latest version of the Republican-sponsored healthcare bill once again falters and its prospects of becoming the new law of the land fade, plenty of advocacy work is continuing on behalf of rheumatologists and rheumatology practices. The ACR, along with multiple partners, has renewed its push for regulatory relief in a number of areas…
Active Advocacy in the Sunshine State: Florida Society Presses for Legislative Changes to Protect Patient Access to Medications
At their state capitol in Tallahassee on March 28, seven board members of the Florida Society of Rheumatology (FSR) lobbied to support legislation regarding prior authorization, step therapy and non-medical switching. They also educated lawmakers about rheumatic diseases and how access to the right therapy may dramatically improve patients’ lives. “We talked about the problems encountered…
ACR Puts Forward Principles on Patient Access to Care
The ACR has partnered with the American Medical Association (AMA) and over a dozen stakeholder groups to create a set of 21 principles to reform prior authorization protocols. This coalition represents hospitals, medical groups, patients, pharmacists and physicians with a unified goal of creating a more patient-centered, streamlined and transparent process for prior authorization. According…
Reminder: How to Handle Part D Prior Authorization Requests
As we begin another new year, many rheumatology practices will again receive prior authorization requests from Medicare Part D for all methotrexate prescriptions. When methotrexate is used as a chemotherapeutic drug, it’s covered by Part B, but when it’s used as an oral agent for rheumatoid arthritis, it’s covered by Part D. Early in the…
Principles Would Streamline Prior Authorization Processes
The ACR recently partnered with the American Medical Association (AMA) and a coalition of 16 other organizations representing physicians, medical groups, hospitals, pharmacists and patients to dramatically reshape prior-authorization protocols. The coalition is urging an industry-wide reassessment of these protocols to align with a newly created set of 21 principles, called the Prior Authorization and…
Step Therapy, Biosimilars among ACR’s 2017 State-Level Priorities
Opportunities and challenges will continue to face the rheumatology community in 2017. In response to these challenges, the ACR has outlined its federal– and state-level legislative and regulatory healthcare priorities for the year. Howard Blumstein, MD, chair of the ACR Affiliate Society Council, says that achieving at least some of these priorities at the state…
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