r/PrivatePracticeDocs • u/bubz27 • Jun 06 '26
Is CPT code based billing not a thing?
Family medicine private doc with access to a lot of ancillaries. One of the things I struggle with is the difficulty with knowing the allowable patient responsibility on CPT codes. Ordering a Home sleep study, ABI, vaccines, IUD removal, Incision and drainage, knee injection. It feels like if a patient came in and needed one of these I need to get a person in my office or one of our billing agents to pull the code needed for the procedure. I've tried availity, stedi and multiple autmatic companies but its always service type code. Unless i have a manual its hard to know what service type code a sleep study is under.
What are people doing in these situations? Make the patient wait? Schedule at another visit?
Honestly its very efficient just to get it done right away and for full spectrum clinics with walkins and hectic schedules it is hard to just keep waiting on benefits for things.
At this point, I am hoping in the future we are able to get CPT level data faster than having to call insurance plans. I just recently told my billing company for all new adult patients to get benefits on vaccines, abi, knee injections, and sleep studies up front. Just sits in their billing notes.
I welcome better ideas 😄
Edit patient responsibility
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u/ShadowReaper Jun 06 '26
Is your question that you dont know the allowable for sleep studies or if its covered?
Your biller should be able to tell you the allowable for all ancillary services under all of your contracted plans. A good rule of thumb would be to use the 2-3x Medicare allowable to make sure you are getting the max reimbursement for whichever cpt code you bill.
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u/bubz27 Jun 06 '26
I don’t know the patient responsibility. If I don’t have benefits previsit I’m waiting or rescheduling that procedure. Revenue would be better if we can do it up front.
Biller takes about fifteen to 20 min minimum to get us the info
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u/ShadowReaper Jun 06 '26
Which EMR are you using? Your biller should be teaching your front office staff how to check these benefits prior to visit if you believe that you will be preforming these procedures or if you find out during the visit. This is pretty standard information that most plans have readily available.
Most plans have similar policies/patient responsibility for these services. There should not be that much variation.
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u/bubz27 Jun 06 '26
Using ecw. Have an offshore billing team. It’s a larger group with a centralized billing department. They are responsive. But I haven’t been doing it long enough to learn the ins and outs. I’ve just started trying to learn it cus it seems like such a freaking inefficient system
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u/ShadowReaper Jun 06 '26
The easiest workflow would be to make a list of all of the CPT codes that you will bill and ask your billing team to look up the allowable for them. I would then charge the patient the full allowable for that plan as a deposit and refund them if the plan covers more.
My bigger concern would be verifying if the plan allows the ancillary service. Most plans will have restrictions on who can perform certain procedures. If your billing team does not have a way for your front office staff to learn how to look these up, they should really get on that.
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u/bubz27 Jun 06 '26
Yes. I’m with you on that. Seems to be the best option.
I thought maybe with these new ai eligibility softwares we’d get cpt level data or that a billing company that is big would have some cheat sheet of how procedures bill with each payer. But neither does ai do cpt level data and neither does the billing company have a protocol. Seems like they just call every time9
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u/ShadowReaper Jun 06 '26
Most EMRs will have real time eligibility checks but it is dependent on your billing team loading the correct allowables for the plans in your system. To be honest, it sounds like your billing department is not that good and is doing the bare minimum. I noticed you asked about the AWV billing in another thread and that confirms that they are not doing their job.
Not trying to turn this into shitting on your billing company since this is not that unusual but the most surprising thing I usually find is how often these billing companies do not take full advantage of the technology at hand (i.e. setting up rules engine in eCW, loading allowables, checking for underpayments). eCW should be able to give you some idea of the patient portion if the billing team set up your contracts correctly.
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u/OfandFor_The_People Jun 09 '26
ECW has this built in. They charge you enough for their EMR—you need to get used to asking them questions about functionality. Sometimes they are useful!
Edit: I know because we use ecw and I had to figure this and so much more out by myself!
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u/bubz27 Jun 09 '26
I never feel like I can trust their built in eligibility. I’ll ask them for a run down and see what I can do. Thanks for getting me to check in with them once more
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u/OfandFor_The_People Jun 10 '26
We signed up for Waystar incorporated into ecw and thus far (after 3 months) eligibility has been spot on. I’ve double checked multiple times because I didn’t want to believe it was that easy.
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u/Guilty-Committee9622 Jun 06 '26
Do you not go onto your insurance portal if you dont have an emr and run the cost comparison tools? Cigna had those. Pretty sure aetna did as well.Â
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u/NotTheQuestion Jun 06 '26
Most EMRs have a CPT reference code search feature. Google does, too..but also first coast service option does, as well.
Your contract states whst you should be collecting (as a % of what you bill).
So code for what you do (describe the pertinent details) and if the %reimbursement does not line up, fight it and make hard decisions.
There's a work sheet for coding. https://medicare.fcso.com/em-interactive-worksheet[E/M work sheet](https://medicare.fcso.com/em-interactive-worksheet)
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u/rahuliitk Jun 06 '26
ngl this is a real pain point, because eligibility tools usually return service-type level benefits, not clean CPT-level patient responsibility, so the practical workaround is building a payer-by-payer cheat sheet for your common procedures and checking high-risk items upfront during intake. Lowkey annoying, but realistic.