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Question: My practice performed a trigger point injection (TPI) and used ultrasound guidance for the needle placement, but when I submitted the claim, reimbursement for the ultrasound guidance was denied. The payer said ultrasounds were not covered or reimbursable when used for guidance for TPIs. Can I bill the patient directly, now that we know this procedure wouldn鈥檛 have been covered in the first place?

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Answer: The reason for noncoverage matters when billing. When practices enter into contracts with payers, they鈥檙e bound to respect the medical policies that specify coverage. Some reasons for noncoverage may include certain medical services being deemed unnecessary or experimental. There are also situations in which a patient has already used all of the benefits available to them from their insurance. You should look to the contracts and the explanations of benefits (EOB) for the respective payer to know what services are covered before the procedure is performed.

Once you have the information you need in terms of coverage, it鈥檚 also crucial to let the patient know what they鈥檇 owe before any respective services are provided. Otherwise, your practice may end up running afoul of federal and state 鈥淣o Surprise鈥� laws 鈥� and aggravating a patient in the process. In this situation, because the procedure already happened and the claim was submitted and denied, you may not have many reimbursement options left.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, 星空入口