🔎 Real Billing Case 1: Why Was K005 Not Paid?

🧾 The Initial Claim

A007 + K005 billed with the same diagnostic code.

• MOH did not reject the claim

• Only A007 was paid

• K005 was unpaid

📌 Lesson 1: MOH requires two different diagnostic codes when billing A007 and K005 together.

🧠 Second Attempt

Two different diagnostic codes used (both mental health related)

• Claim submitted correctly (as assumed)

• Again, only A007 was paid

• K005 remained unpaid

📌 Lesson 2: Simply using two different codes is not enough.

📋 Third Attempt

• A007 + K005 billed again, A007 billed with diagnostic code 799 – Failure to Thrive

• Still, MOH only paid A007

At this stage, it became clear the issue was deeper than diagnostic codes.

🔍 What Was Missing?

To properly understand why K005 was not payable, Dr. A needed to review:

📘 Schedule of Benefits – Detailed fee code restrictions


📑 Remittance Advice (RA) Explanation Codes – Hidden payment clues


⚖️ Code Combination Rules – Eligible billing pairings


🏥 Visit Type Restrictions – Specific service eligibility rules

💸 The Real Impact

Repeated unpaid K005 claims resulted in lost revenue across multiple visits.

Most physicians assume that if a claim isn’t rejected, it’s correct.
But partial payments often signal rule-based restrictions that require deeper interpretation.

🛡 Why This Matters

Understanding complex billing interactions requires

⏳ Time


📖 Detailed policy review


🎯 Experience interpreting MOH rules

This is where a structured billing audit makes a measurable difference.