It's known to all that Medicare coding rules are tough and challenging; and sometimes it's difficult to gather which services you can bill rightfully. However if you remember these seven key billing practices, you will be collecting all of the pay you rightfully deserve.
Bear modifier 50 in mind: Many procedures are inherently unilateral and you will not get full reimbursement for bilateral versions of those procedures unless you add modifier 50 (Bilateral procedure).
Be careful: Often medical coders forget the modifier 50, and if your doctor performs and documents a bilateral procedure for one of those services, see to it that you submit your claim for a bilateral service.
Gather copays at the visit: You will save yourself time and money later on if you calculate copays following a patient's service and collect that money before they leave your office.
Bear in mind: If it is not a copay, you can gather it before the patient sees the doctor. Just because a doctor plans to carry out a service does not mean he will perform and document it properly. As such, it is a good idea to gather after the patient has already seen the practitioner.
Some coders are of the opinion that if the correct coding initiative (CCI) forbids billing two codes on the same date, that is the end of the story. However in fact, you may be missing out on some legitimate cases where CCI allows you to use a modifier like 59 (Distinct procedural service) to override an edit.
Always scan the CCI edits ( Source "" ) for the procedures you carried out to see which code pairs a modifier can override. You should of course only use the modifier 59 when the services are separate, distinct, and medically necessary, and the doctor has thoroughly documented the distinct nature of both services.
Keep a watch for supervision and interpretation: You need two codes – the S&I code plus a surgical code for many invasive/ diagnostic radiology codes. Regularly, coders forget to add the surgical code, moreso on the outpatient hospital claims.
For instance: You may keep in mind to report CT guided needle biopsy code 77012; however leave out the associated site-specific percutaneous needle biopsy code.
When you feel you've been wronged, appeal: As many practices fear being labeled "troublemakers" or even worse yet, non-compliant with the FCA's regulations, they accept Medicare payers at their word and this is not always a good idea.
If your MAC denies your claim or requests a refund, investigate the issue before you take the payer's word for it. You should make an appeal any time you feel your payer has denied your claim wrongly or erroneously requested a refund.
Ensure you have up to date coding guidelines
In some practices, coders have not updated their CPT, ICD-9-CM, or HCPCS coding manuals in years as they do not think that changes are enacted often enough to warrant purchasing new books. But then outdated codes can lead to claim rejections. What's more, the modifiers, coding rules, and parenthetical notes also change from year to year, and it is tough to understand which regulations apply if you do not have present resources. If you use a computer-based program for these resources, you can normally get all the updates through there; however paper manuals should be annually replaced.
Join outpatient E/M with initial hospital care record for same-day admits
If you witness a patient in your office and then perform initial inpatient care for the same patient on the same date, you should report one E/M code only.
When the doctor provides both services on the same date, combine the work documented in the office with the work documented in the hospital to figure out the proper level of initial inpatient care (99221-99223).
Bear modifier 50 in mind: Many procedures are inherently unilateral and you will not get full reimbursement for bilateral versions of those procedures unless you add modifier 50 (Bilateral procedure).
Be careful: Often medical coders forget the modifier 50, and if your doctor performs and documents a bilateral procedure for one of those services, see to it that you submit your claim for a bilateral service.
Gather copays at the visit: You will save yourself time and money later on if you calculate copays following a patient's service and collect that money before they leave your office.
Bear in mind: If it is not a copay, you can gather it before the patient sees the doctor. Just because a doctor plans to carry out a service does not mean he will perform and document it properly. As such, it is a good idea to gather after the patient has already seen the practitioner.
Some coders are of the opinion that if the correct coding initiative (CCI) forbids billing two codes on the same date, that is the end of the story. However in fact, you may be missing out on some legitimate cases where CCI allows you to use a modifier like 59 (Distinct procedural service) to override an edit.
Always scan the CCI edits ( Source "" ) for the procedures you carried out to see which code pairs a modifier can override. You should of course only use the modifier 59 when the services are separate, distinct, and medically necessary, and the doctor has thoroughly documented the distinct nature of both services.
Keep a watch for supervision and interpretation: You need two codes – the S&I code plus a surgical code for many invasive/ diagnostic radiology codes. Regularly, coders forget to add the surgical code, moreso on the outpatient hospital claims.
For instance: You may keep in mind to report CT guided needle biopsy code 77012; however leave out the associated site-specific percutaneous needle biopsy code.
When you feel you've been wronged, appeal: As many practices fear being labeled "troublemakers" or even worse yet, non-compliant with the FCA's regulations, they accept Medicare payers at their word and this is not always a good idea.
If your MAC denies your claim or requests a refund, investigate the issue before you take the payer's word for it. You should make an appeal any time you feel your payer has denied your claim wrongly or erroneously requested a refund.
Ensure you have up to date coding guidelines
In some practices, coders have not updated their CPT, ICD-9-CM, or HCPCS coding manuals in years as they do not think that changes are enacted often enough to warrant purchasing new books. But then outdated codes can lead to claim rejections. What's more, the modifiers, coding rules, and parenthetical notes also change from year to year, and it is tough to understand which regulations apply if you do not have present resources. If you use a computer-based program for these resources, you can normally get all the updates through there; however paper manuals should be annually replaced.
Join outpatient E/M with initial hospital care record for same-day admits
If you witness a patient in your office and then perform initial inpatient care for the same patient on the same date, you should report one E/M code only.
When the doctor provides both services on the same date, combine the work documented in the office with the work documented in the hospital to figure out the proper level of initial inpatient care (99221-99223).
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