Bill # 258-8797 Status: In Queue | open balance: $12⁰⁰

Sick Visit · Dr. Zev Carrey · Sep-15-2021 | Lucille Ball · F · 5/15/84 · 36y 7m

Summary Related Bills Payer Queue Ledger/Claims Comments 3 Payroll Documents

Error: CPT 78848 is unknown or invalid

Warning: Menashe is untrustworthy. Don't listen to him.

Recommendation: CPT J7321 is missing the GP modifier

General

Assigned To

Type of Service

Place of Service (HCFA 24B)

Date of Service

Treatment Office

Legal Entity

Rendering Provider

Signing Provider

Incident + Case

Authorization #

Rate Code (UB Only)

Bill Type (UB 4)

Procedure - Modifiers	Units	Diagnoses	Charge	Paid	Balance	Added
99202 – 25 – 59 <INACTIVE CPT - NOT BILLED> Replaced by 99212	1	W55.41XA Z63.1 V00.01XD	$250	$0	$0	PIC
99212 – 25 – 59 Office or other outpatient visit for the evaluation and management of an established patient Added by Payer Response EMERGENCY	1	W55.41XA Z63.1 V00.01XD	$250	$105.75	$0	SYS
J7321 – TS Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose Beinhorn, Nomi	1	Z63.1 V00.01XD	$200	$68.15	$0	PIC
20611 Arthrocentesis, aspiration and/or injection Y88291 — 1 ml	1	V91.07XD	$300	$0	$300	PIC

Date	Details	Ref	Debit	Credit	Adjustments	Balance
Bill 258-8797 - Initial Charges
7/14/24	Visit Copay		-	$0.00	-	$0.00
7/14/24	Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service	CPT 99051	$50.00	-	-	$50.00
7/14/24	Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes	CPT 97530 - GO	$359.04	-	-	$409.04
Claim #1 - Anthem Empire BCBS Medicaid Managed - ICN: 273958557701757 - Processed as Primary - Edit Payment - View EOB - View 837
7/29/24	ANTHEM HP, LLC	CPT 97530 - GO	-	$0.00	$359.04	$50.00
				CO-45 359.04 M115
7/29/24	ANTHEM HP, LLC	CPT 99051	-	$0.00	$50.00	$0.00
				OA-96 50.00
Claim #1 - Anthem Empire BCBS Medicaid Managed - ICN: 273958557708944 - Reversal - Edit Payment - View EOB - View 837
10/26/24	ANTHEM HP, LLC	CPT 97530 - GO	-	$0.00	($359.04)	$359.04
10/26/24	ANTHEM HP, LLC	CPT 99051	-	$0.00	($50.00)	$409.04
Claim #2 - Medicare - ICN: 9827389723000 - Denied - Edit Payment - View EOB - View 837
11/8/24	NATIONAL GOVERNMENT SERVICES, INC.	CPT 97530 - 25 - GO	-	$0.00	$159.04	$250.00
11/8/24	NATIONAL GOVERNMENT SERVICES, INC.	CPT 99051	-	$0.00	$30.00	$220.00
11/8/24	NATIONAL GOVERNMENT SERVICES, INC.	CLAIM ADJUSTMENT	-	$0.00	$10.00	$210.00
Claim #3 - Medicaid - Sent 11/19/2024 - AWAITING RESULT - View 837

Insurance	Eligibility	Billable Items	Status
1 Empire Blue Cross Blue Shield Type: HCFA Policy #: IWAAN8358571 Override: Last Name: Arnaz Gender: Male	Last checked: 9/16/2021 Result: Active Policy Deductible left: $49.85	99212 : 25 : 59 J7321 : TS 20611	Complete Date Submitted: 9/16/2021 Date Paid: 10/2/2021 ICN: YT23872 Payment Amount: $154.75
2 Medicare Type: HCFA Policy #: 7VU9U60WG88	Last checked: 7/11/2021 Result: Inactive Deductible left: $507.22	99212 : 25 : 59 J7321 : TS 20611	Complete, Superseded Date Submitted: 10/2/2021 Date Paid: 10/9/2021 ICN: H98446245 Payment Amount: $44.50
3 Medicare Type: HCFA Policy #: 7VU9U60WG88	Last checked: 7/11/2021 Result: Inactive Deductible left: $507.22	99212 : 25 : 59 J7321 : TS 20611	Awaiting Response, Current Date Submitted: 10/2/2021 Date Paid: 10/9/2021 ICN: H98446245 Payment Amount: $44.50
4 Medicaid Type: UB Policy #: ZE155489G Override: DOB: 5/15/1985	Last checked: Unchecked Result: Unknown Deductible left:	99212 : 25 : 59 J7321 : TS 20611	Released, Waiting on other claim(s) Date Submitted: 10/9/2021

			Billable Items
			E/M Code	J7321	20611	97505	90832
Dr. Zev Carrey	Appt #87987	9:15a	99212
Dr. Yevgeney Kantor	Appt #77564	9:30a
Dr. Robert Chaney	Appt #12345	10:00a	99203

Procedure - Modifiers	Units	Diagnoses	Charge	Provider	Bill #
99212 – 25 – 59 Office o/p est sf 10-19 min	1	W55.41XA Z63.1 V00.01XD	$250	Dr. Zev Carrey	258-8797
J7321 – TS Hyalgan supartz visco-3 dose	1	Z63.1 V00.01XD	$200	Dr. Zev Carrey	258-8797
20611 Arthrocentesis, aspiration and/or injection, major joint or bursa	1	V91.07XD	$300	Dr. Zev Carrey	258-8797
90832 individual psychotherapy services rendered for 30 min by licensed provider	1	W61.62XD	$300	Dr. Yevgeney Kantor	655-1245
20611 Arthrocentesis, aspiration and/or injection, major joint or bursa	1	R46.1	$130	Dr. Yevgeney Kantor	655-1245
97505 Therapeutic Activities	1	V9135XA V97.33XD	$85	Dr. Yevgeney Kantor	655-1245
99203 Office o/p new - low complexity	1	Y92.241	$400	Dr. Robert Chaney	987-6543
97505 Therapeutic Activities	2	W61.33	$175	Dr. Robert Chaney	987-6543

Bill # 258-8797 Status: In Queue | open balance: $12⁰⁰

Current Attachments

Add New Attachments

$475.00

$199.75

$12.00

Complete

Complete, Superseded

Awaiting Response, Current

Released, Waiting on other claim(s)

Electronic Remittance Advice
Payer: Empire Blue Cross Blue Shield Church Street Station P O Box 1407 New York, NY 10008-1407	ETIN: 134098881	Payee: Brooklyn Community Medical P 2555 Nostrand Ave Brooklyn, NY 11210 HCFA NPI: 1184878555
	Batch #: 384555
	Check/EFT #: 20211002123151 (Split)
	Date Received: 10/2/2021

Rendering Provider	Units	HCPCS	Mods	Charged	Allowed	Deductible	Copay	Coinsurance	Paid by Insurer	Balance	Remarks
Status: Processed as Primary				Policy #: WX72982398					Group #:
Patient: Lucille Ball				Claim Control #: 28388918-2588797					Service Date: 9/16/2021
Insured: Desi Arnaz				ICN: 111367415400					Date Submitted: 9/27/2021
Provider: Dr. Zev Carrey				Place of Service: Independent Clinic (49)					Production Date: 10/1/2021
Billable Items				Charges		Patient responsibility			Total
Carrey, Zev	1	99212	25, 59	$250.00	$147.75	$0.00	$0.00	$9.00	$138.75	$9.00	PR-2 9.00 CO-45 102.25
Carrey, Zev	1	J7321	TS	$200.00	$16.00	$0.00	$0.00	$4.00	$16.00	$4.00	OA-96 184.00
			Total	$400.00	$163.75	$0.00	$0.00	$13.00	$154.75	$13.00
Subscriber Number (HIC): 66513488200				Account #: 28388918		Bill #: 2588797			Next Payer: Medicaid
Remarks: All CPTs covered.

Type	Comment
Bill	Spoke with HealthFirst, delay 1 week. Ref# 938-188873 938-188873.pdf Menashe Rottenberg @10/18/21 3:35p
Patient	Patient will pay co-pay at next visit Chavi Goldwasser @10/12/21 11:29a
Patient	Authorization only valid for 99211-99214 Yekutiel Bassul @7/22/21 9:54a
Insurance	Use Medicaid number YT-2928921 after Jun 2020 Moshe Dov Kleinman @5/22/20 1:16p \| Dismissed by Menashe Rottenberg @9/4/20 6:04p

This Bill	New Bill	Service Line
		99213-25
		97110-GP
		97110-GP
		99202

Bill # 258-8797 Status: In Queue | open balance: $1200

Current Attachments

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$475.00

$199.75

$12.00

Complete

Complete, Superseded

Awaiting Response, Current

Released, Waiting on other claim(s)

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Bill # 258-8797 Status: In Queue | open balance: $12⁰⁰