When CMS and AMA Disagree, How Do You Code?

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  • In Billing
  • April 5, 2010
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The American Medical Association’s (AMA) Current Procedural Terminology (CPT®) guidelines state that you can append modifier 50 Bilateral procedure to surgical procedure codes (27215-27218) for pelvis injuries. Bill Medicare for a procedure from this code range with modifier 50 appended, however, and your claim will likely be denied.

Are policy guideline contradictions like these between CPT®, the Centers for Medicare & Medicaid Services (CMS), and private payers giving you whiplash? Mary LeGrand, RN, MA, CPC, CCS-P,  makes sense out of billing for surgical procedures in an American Academy of Orthopaedic Surgeons’ (AAOS) article, published in the March 2010 issue of AAOS Now.
For instance, why would CMS deny a pelvis injury claim appended with modifier 50? Because, the agency says, these procedures are unilateral, not bilateral. For Medicare, CMS says you should use HCPCS Level II “G” codes to report surgical procedures of the pelvis.
As a rule, LeGrand says, report surgical procedures to private payers using CPT® codes and report G codes to CMS. Before doing anything, of course, check payer guidelines and understand how to read the Medicare Physician Fee Schedule (MPFS) and remittance advice remarks, advises LeGrand.
Read the full article.

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