Can We Bill for That?

By LuAnn Jenkins, CPC, CPMA, CEMC, CFPC

When searching for the answers to tough billing questions, here are the resources I recommend:

CPB : Online Medical Billing Course

  • Medicare Local Coverage Policies – Detail what is considered medically necessary, including the ICD-9-CM codes.
  • National Correct Coding Initiative (NCCI) – Contains a list of code combinations that cannot be billed and guidelines for each section that provide specifics about services that may be billed separately.
  • CPT® guidelines – The CPT® manual has section guidelines that provide additional coding assistance (CPT® is not a payer policy and not all payers follow CPT® rules).
  • Commercial Payer Coverage policies – Always check individual payers for their policies and guidance. Do not assume all follow Medicare.
  • AMA RBRVS Data Manager – Provides detail of resources used to determine RVUs. For example: how much time is allotted for pre-service evaluation, intraservice work and immediate post-service work; the number of post-operative days and the practice resources expected to be used (staff time, supplies, equipment, medications). This resource will apply to most payers that use RVUs as a basis for their fee schedules.

Billers and coders must be sure that the answers we give are based on documented information, and not an “opinion.” Never assume that a denial from a payer is accurate unless we can confirm that it is based on documented policy. Our goal should be to optimize reimbursement by proving what can be billed, but also to protect our providers by understanding what cannot be billed based on the payer rules.


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