Stay Balanced when Performing the Coding vs. Billing Dance

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  • June 10, 2011
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By Shreka D. Rogers, CPC, CMRS
Coding and billing are not the Tango. It is, however, a well-choreographed dance that billers and coders must perform to remain complaint while keeping physicians satisfied with their reimbursement. And with tougher federal regulations, reimbursement is becoming increasingly difficult to optimize. Coders are sometimes faced with a critical decision: Do we code correctly, or code to get paid?
The answer is clear: As coders we have a high standard of ethics outlined by AAPC to which we must strive to adhere. The problem is that proper coding isn’t black and white in every situation.
For example, a primary care physician requests a neurosurgical consultation for a new patient with three months of cervical radiculopathy (723.0 Spinal stenosis in cervical region). The neurosurgeon consults with the patient and forwards a written report back to the referring primary care physician (PCP) with his recommendation for conservative treatment.
In this case, we must be careful to determine correct coding because, depending on the payer, coding may vary. Since 2009, the Centers for Medicare & Medicaid Services (CMS) (including Medicare Advantage) does not recognize CPT® consultation codes 99241-99255; however, some major insurance carriers to date still recognize this series of codes. With that in mind, proper coding would be:
Medicare: 9920x Office or other outpatient visit for the evaluation and management of a new patient … or 9921x Office or other outpatient visit for the evaluation and management of an established patient …
Commercial carrier: 9924x Office consultation for a new or established patient … or 9925x Inpatient consultation for a new or established patient …
Another example is spinal cord stimulators for ambulatory surgical centers (ASCs). Medicare requires that only 63650 Percutaneous implantation of neurostimulator electrode array, epidural be reported without the device code. Major insurance carriers require 63650 and the device code L8680 Implantable neurostimulator electrode, each to be reported.

Stay Current to Stay Correct

In each of the aforementioned cases, coding matches the guidelines for the insurance carrier being billed. CMS and other major insurance carriers have specific guidelines for billing and coding. That information can be found on CMS’ website or the website of the insurance carrier in question. Another benefit for providers are listservs that regularly provide updates and changes for billing and medical policy. By staying within insurance carrier specified guidelines, you can ensure your physician is reimbursed appropriately while maintaining compliance. 
Instances when payer policies vary aren’t limited to our aforementioned examples, and are almost too numerous to count. So it’s important to stay on your toes by regularly reviewing updates and being familiar with insurance carrier payment policies. This will help ensure that you perform with grace the delicate dance of coding vs. billing.
Shreka D. Rogers, CPC, CMRS, has 17+ years of health care experience. She is business and coding manager of Howell Allen Clinic and Saint Thomas Outpatient Neurosurgical Center, where she oversees a staff of conscientious coders and accomplished medical records and patient accounting teams. Shreka was 2009 President of AAPC’s Nashville, Tenn. chapter. Visit her blog at

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No Responses to “Stay Balanced when Performing the Coding vs. Billing Dance”

  1. Marcia Schuller says:

    I finished earning my diploma for medical billing in 2009 thinking that I could get a job right away. Instead, I have found that no one will hire me because I don’t have experience. I was also told by the US Career Institute, where I got my education, that taking a certification test was not necessary to get a job. I am finding out that that is not true either. So I have been studying to take a certification test, but again find no coherent answer as to which test to take. With the AAPC, AHIMA, and AMBA all offering a certification exam with a different credential earned, all of which seems to be considered of different value to different segments of the medical industry, how does one know which test to take? And then, of course, I had to learn all of this by trial and error, researching on the computer, because no one ever even told me any of this info existed! Finally, I look at the actual coding. In one sense it seems quite simple to code for a situation because it’s just common sense. On the other hand, whoever made up the coding has made it all so complicated that it becomes hard! For one thing, what you wrote about in the above article: how every insurance company accepts something different. That is the most inefficient way of doing business that I ever heard of. What if every state had a different criteria for learning to drive a car, or every store had a different monetary system for buying their products? Also, the doctors write such a small amount of info about the patient visit on the encounter form, esp. if it is of any complexity, that I don’t see how a coder can accurately code for the visit unless he/she was in on the doctor visit. You talked about the “dance” of coding. Well, I think the whole thing is a “song and dance”. I don’t mean to direct that statement to you, but to the whole medical profession. Why does it all have to be so difficult? No more info than a coded number gives about a procedure, it seems that the doctor could simply write that much out on the encounter form and bypass all of this coding ritual. It just seems like a silly game everyone is playing!