Service Line Made Billable
Check coverage and billing requirements before you add a service. We put the answer in writing.
A written coverage and billing assessment for one proposed service. We review the payers you name, their coding and documentation requirements, enrollment gaps and available rate information. The fee is fixed at $2,500.
Assessment only. Enrollment, implementation and claim submission are scoped separately.
Summary
How do I know if a new service will be covered before I invest in it?
Coverage is decided by each payer, plan by plan, so a general answer is not a reliable one. Our Service Line answer checks it for one service, in writing, before you buy the equipment.
Payers decide coverage one plan at a time, so the answer is written that way.
One plan covers the service with a prior authorization. Another covers it for one diagnosis and refuses the next. A third excludes it for every member, whatever the chart says.
And a payer that covers a service still pays only a provider it has enrolled.
We start from the payers your patients carry and the enrollment you hold today, then read each payer's published policy for the service. The answer covers four things.
- Which payers cover itPayer by payer, from your own list, including the ones that say no.
- Under what codes and documentationThe codes each payer's policy points to, the diagnoses that support them, and what the visit note has to show.
- What enrollment or contract is missingWhere your enrollment stops short of this service, and what must be filed or signed first.
- What it should payThe rate a payer publishes, where it publishes one. Where the rate lives in your contract, we read the contract.
Your coder confirms each code in the answer against the current code set before a claim goes out.
Five services practices add, and where each one turns.
A medical weight-management program is two questions wearing one name. The visits and counseling are billed against a documented diagnosis. The drug is a separate, harder question. Most employer and Marketplace plans exclude GLP-1 drugs prescribed for weight loss.
- The answer checks
- Which payers cover the visits, which cover the drug and on what conditions, and which exclude it, so you can price the program for patients who will pay cash.
Botulinum toxin for excessive sweating sounds like an aesthetic service. It is a medical one, billed as chemodenervation of the sweat glands. The code depends on the site treated: CPT 64650 for the underarms and CPT 64653 for the scalp, face or neck; hands and feet follow each plan's own rule. Coverage is set plan by plan, so the answer checks each of your payers.
- The answer checks
- Whether each payer covers it, which code and diagnosis it expects, and what the note must show.
Hormone therapy is billable when an FDA-approved product is prescribed for a covered diagnosis, such as menopause or low testosterone. Depending on the product, it runs through the medical benefit or the pharmacy benefit. Prior authorization and step therapy are common. Testosterone prescribed for women is largely excluded.
- The answer checks
- Which benefit each payer uses, which diagnoses it accepts, and what it asks for before approval.
A dentist who makes an oral appliance for obstructive sleep apnea bills the patient's medical plan, not the dental plan, under HCPCS E0486. The diagnosis comes from a sleep test and a treating practitioner's evaluation. The dentist cannot make it. For Medicare, the dentist who provides the appliance must also be the one who bills it, which means enrolling as a Medicare supplier of durable medical equipment (a DMEPOS supplier) first. Commercial plans set their own rules, and the answer reads each one you name.
- The answer checks
- Whether you need the supplier enrollment, which medical plans cover the appliance, and what each needs on file.
An aesthetics practice under a medical director sometimes offers care with a medical basis beside its cash services, scar revision among them. There is no single code for laser scar work, and each payer decides it against its own scar-revision policy. The medical portion can go to insurance while the cosmetic portion stays self-pay, but only when the diagnosis and the note carry it. State law governs who may own and bill for medical care, and that part belongs with your attorney.
- The answer checks
- Which services on your menu a payer would treat as medical, and who must be enrolled to bill them.
Turn the idea into the question we would answer.
Fill in what you know. The box rewrites it as the four questions the written answer covers. Leave out patient names and records; the question never needs them.
Can this be billed?
The question the written answer covers
Carry it into my requestThe button copies the question into the review form on this device only.
A fixed fee for one service, agreed before the work starts.
The fee buys the written answer. Missing enrollment is filed as a Payer Enrollment Sprint at its printed prices. Claims work belongs to billing and revenue cycle, priced from the practice's own numbers in the agreement.
| Item | What it covers | Fee |
|---|---|---|
| Service Line Made Billable | One service, read against the payers you name, answered in the four parts above.A second service is a second answer. | $2,500 |
| Enrollment the answer finds missing | Filed as a Payer Enrollment Sprint, priced per application. | $300 to $450 |
Common questions before you order an answer.
What if the answer is no?
Then you have the coverage findings in writing before investing in the service. A no from most of your payers tells you to price the service as cash, or to leave it off the menu. When one payer covers it and others do not, the answer says which.
Do you need patient records?
No. The answer is built from your payer list, your current enrollment and the payers' published rules.
How long does it take?
That depends on how many payers the question covers and how openly each publishes its policy. You get an estimate when we agree the question.
What happens once I have the answer?
Use the findings to plan the service and confirm the remaining clinical, licensing and payer requirements before billing. If enrollment is missing, the Sprint files it and tracks each payer to an effective date. If the payers exclude it, you can reconsider the investment before buying equipment.
Sources
- CPT 64650 and 64653 for hyperhidrosis chemodenervation: AMA CPT code set.
- HCPCS E0486 and the Medicare DMEPOS supplier rule for oral sleep appliances: CMS Local Coverage Determination L33611.
- Scar revision decided under each payer's own policy: Cigna's scar revision coverage policy, read as the example.
Bring us the service you are weighing.
Name the service, your specialty and the payers that matter.
If the service is already running, say how it is billed today.