Category Archives: Blue Shield

Blue Shield Federal and Obesity/Dietary counseling gets very specific

My first post on obesity counseling can be found here. This is a very specific update to help you get paid a bit more. 


I have been running into problems with certain insurances. They have been bundling and excluding my G0447 and 99401 codes even though I am following my own guide. Blue Shield Federal and some Aetna plans are the most common offenders. Lengthy and boring story condensed, and, it turns out, these plans have specific exclusions for the diagnosis of Z68.30 to Z68.45. 


When I bill the claim with the Z code primary, the code gets denied stating the service is not a benefit. When I bill the claim with either E66.01 or E66.09 on the obesity counseling line item, and leave off the Z code entirely, those line items get paid. 


I also really suggest that if your system has pop-ups, alerts, built in claims edits, or anything along those lines that you utilize those for these specific situations. I know, personally, there is no way that I will be able to remember which specific patients or plans need these special rules without that tool. I do enough follow up as it is, I am not trying to make more for myself.  


One of the things that people often hire me for is an in-depth consult of an entire practice reviewing reports, procedures, and EOBs to help you make sure that you are keeping this type of money in your practice. I also have group and one-on-one training sessions to teach billers and managers how to do this themselves. Call me at (909) 610-9524 or email me at if you want to set something up.  

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Filed under Aetna, Blue Shield, Denials, ICD10, Medical Billing, Obesity Counseling

Ugh. Blue Shield is doing a thing with the 81002.

This may just be Blue Shield of California, I am not sure, but they have been bundling my urine dips (81002) into the office visit recently. 


So, public service announcement, bill your UAs to Blue Shield with a 25 modifier on the office visit and a 59 modifier on the 81002 as in the example below.


B34.4             Z68.28                 Z51.89                                99213 – 25

R10.9                                                                                      81002 – 59 


Also make sure that your code is set up to be a “lab” code and that your CLIA prints on it properly. Some of my providers have run into issues with that. 

Questions? Comments? Criticism? Glowing emails as to how I have saved your office from certain destruction? Please direct those to (909) 610-9524 or


Filed under Blue Shield, Medical Billing, Office Visit, Urinalysis

Why you are out of network for Covered CA

I have two providers who are both out of network for the Blue Shield Covered CA Silver plan. They were both surprised and displeased by this. And so were their patients. As a result, I was tasked with “looking into this, please.” Which, as an aside, I was happy to do, seeing as it is my job.

So, it turns out, the first provider was out of network with the Blue Shield Covered CA Silver plan because in late 2013 when he was sent the application for the three tiers of Covered CA plans, he chose to sign up with only the platinum and gold plans, and specifically opted out of the silver plan. Then he promptly forgot that he signed that paper and in Jan 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied to every visit. And no one was happy.

Since I learned my lesson with that situation, when it came time to contract the second doctor in this story with Blue Shield, I MADE SURE to check all three boxes for all three tiers of the Covered CA plans. So, at the end of 2014 when he started seeing Covered CA people, Blue Shield told Silver patients that he was a provider. They came to him and he saw them and then they had 50% coinsurances applied. When I called Blue Shield with a copy of the application in my hand the provider enrollment representative told me that since the HOSPITAL my doctor had rights in was not contracted with the Blue Shield Covered CA Silver plan, Blue Shield could not give him a contract that included that plan.

So, if you are having issues with large deductibles, large coinsurances, and your claims are being processed as out of network, call provider enrollment. The issue is probably either something that seemed insignificant and has been forgotten, or completely out of your hands, and something the doctor needs to address.

The contact info for Blue Shield provider enrollment is (800) 258-3091 or


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Filed under Billing, Blue Shield, Contracting, Medical Billing