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Fair pricing for codes

Cathye Posted Thu 11th of April, 2019 14:48:52 PM
My son had an MRI at a NYU Langone Health clinic on January 7th, 2019. We are paying out of pocket as he is on disability in California. We went back to NY because he had surgery there in 2000. The codes below are on the bill and the charges. I don't believe they take SSi -Disability so I guess i would be asking for the fair price for private insurance. I would like to negotiate a cash payment if possible. The codes and prices are: 70553 - $2,750.00, 78608 - 4,675.00, A9585 - $420.00, A9552 - 745.00. Any help or advice you can give me would be appreciated. Thank You.
SuperCoder Answered Fri 12th of April, 2019 08:27:55 AM

In New York there are five different localities: MANHATTAN, NYC SUBURBS/LONG ISLAND, POUGHKPSIE/N NYC SUBURBS, QUEENS and REST OF NEW YORK. As per Medicare, different amount is applicable for the localities of New York.

There are two payment system according to the place of service provided:

  1. Medicare Physician Fee Schedule (MPFS)
  2. Hospital Outpatient Prospective Payment System (OPPS)

For code 70553- {Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences}.

Physician Fee for the code 70553 is as follows for different locality:

MANHATTAN, NY

$436.19

NYC SUBURBS/LONG ISLAND, NY

$445.38

POUGHKPSIE/N NYC SUBURBS, NY

$399.83

QUEENS, NY

$444.69

REST OF NEW YORK

$359.99

 

OOPS amount for the code 70553 is as follows for different locality:

MANHATTAN, NY

$585.61

NYC SUBURBS/LONG ISLAND, NY

$598.15

POUGHKPSIE/N NYC SUBURBS, NY

$535.27

QUEENS, NY

$596.82

REST OF NEW YORK

$480.03

 

For code 78608- {Brain imaging, positron emission tomography (PET); metabolic evaluation}.

Physician Fee for the code 78608 is $0.00 for all the five localities.

OOPS amount for the code 78608 is as follows for different locality:

MANHATTAN, NY

$1,647.44

NYC SUBURBS/LONG ISLAND, NY

$1,683.79

POUGHKPSIE/N NYC SUBURBS, NY

$1,493.43

QUEENS, NY

$1,676.74

REST OF NEW YORK

$1,324.30

 

Code A9585 {Injection, gadobutrol, 0.1 ml} and code A9552 {Fluorodeoxyglucose F-18 FDG, diagnostic, per study dose, up to 45 millicuries}, both the payment system allows $0.00 for physician.

For the code A9552, the code status is “C”, which means this code is “Carriers Price the Code”. Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.

If this private payer is following the Medicare fee guidelines, then this should follow the above-mentioned fee amounts. However, you can check with the payer, which policy and fee schedule they are following.

For SSI Disability status, you need to get in touch with the “Social Security Administration”, do they allow benefits of California Certificate at New York.

Also, you can ask for the concession from the insurance for the with the high price charged.

Hope this helps!

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