CGS Dermatology Billing (Jurisdiction 15)

Medicare beside a large managed-Medicaid footprint

Both Jurisdiction 15 states run substantial Medicaid managed-care programs whose authorization lists for phototherapy and biologics change on the plan's schedule, not Medicare's. Practices that maintain one internal rule for all payers end up applying Medicare logic to a plan that never agreed to it.

We keep the Medicare policy set and the per-plan authorization matrix separate, so a change on one side never silently rewrites the other.

What CGS Administrators decides for your dermatology claims

CGS Administrators does not write Medicare's benefit categories, but it writes the local coverage determinations, the billing and coding articles and the medical review edits that decide whether an individual dermatology claim is paid. Coverage language for benign lesion removal, actinic keratosis destruction, Mohs micrographic surgery and photodynamic therapy is contractor-level policy, and the version that matters is the one active on the date of service.

The billing and coding article attached to each policy usually carries the diagnosis code list and the documentation wording a reviewer applies. Practices that read only the policy and never the article are the ones surprised by a denial that cites a code they thought was covered.

How we work these claims

• Policy set is loaded per location so a group crossing a jurisdiction line bills each site under the contractor that actually governs it.
• Pre-bill scrub checks lesion counts, destruction units, excision measurements and Mohs stage sequences against the note before release.
• Liability modifiers are paired with a signed advance beneficiary notice obtained before the service, never reconstructed afterwards.
• Denials are grouped by policy citation rather than by CPT, so the corrective action lands on the documentation template that caused them.
• Redetermination deadlines are tracked per claim, with reconsideration and ALJ escalation where the contractor's reading of its own policy is wrong.

Appeals inside the Medicare levels

Medicare appeals run in fixed levels: redetermination by the contractor, reconsideration by a qualified independent contractor, then an administrative law judge hearing. Each level has its own filing window, and a claim that misses one cannot re-enter at the next.

Most dermatology redeterminations succeed or fail on one thing — whether the operative or progress note states the clinical fact the policy asks for. We attach the note excerpt and the policy language side by side rather than sending a form letter.