Wiki A general question W/O a specific example


True Blue
Everett, Washington
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How close as a general rule do the different payers follow the CPT guidelines? Can the guidelines be interpreted one way by one carrier and a different way by another payer which would affect the way codes might be submitted for reimbursement? I've found this to be true in the application of modifiers depending on payer preferences. Makes it a real tricky process when fashioning appeals because it all involves "interpretation". And then there's the issue of understanding the particular carrier's edit system. What's the best approach to get a grasp of all this from the billing standpoint?
While I can't speak for all payers I can say the company I work for follows a variety of industry standard resources with the top ones being CMS, AMA/CPT, specialty association guidance, CMS & black & white CPT guidelines. CMS is the gold standard for many payment methodologies and edits and most payers adopt them in some fashion. The edits are created along with physicians and other professionals in the medical field, clinical guidelines set by the AMA, and a wide variety of nationaly accepted clinical standards.

Modifier application has several scenarios depending on payer software and adjudication processes i.e.; modifier 50, some payers want it on one line, some want two lines and 50 on the second line, some want two lines with modifer 59 on line two etc etc. These scenarios will vary and CPT doesn't mandate one correct way. You have to also remember just like when we took our CPC exams, billing requirements are not the same as coding requirements so there is alot of grey in between and HIPAA doesnt madate this for payers either.

The company I work for employs only certified coders with many years experience to analyze provider appeals. We have all worked for the provider side for years prior to working here. When we review appeals and render decisions we are utilizing and interpreting the guidelines the way they are written and intended to be. We back our decisions with nationally accepted standards and guidelines.

I can tell you we do alot of coding & documentation education to folks on the provider side. Many practices do not employ coders and we work with alot of practice staff that are new to coding/billing.

Hope this helps some :)