Wiki Coding for different insurance types?


Irvine, CA
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What do beginning CPC medical coders need to know about coding for different insurance types (Medicare, private payer, etc.)? I feel that the CPC course and textbook didn't go over this enough, and I didn't find good resources explaining this online.
Hello ELund
Ok here is some data.....most commercial payers follow the Medicare CMS NCCI site guidelines but not all for all clinical treatments. Government payer are Tricare, Medicare,Champus and Medicaid ) Some Medicare funded patient use billing codes start with letter G see HCPCS manual for G0839 G0837 G0101 for certain treatments as example). But commercial payers may want the CPT codes from CPT manual .The CPT manual is divided by body parts and clinical procedures. It will tell you what treatments can bill together and some you cannot or cause denial. Some CPT code must send medical record to payer when file too. If treatment and medical procedure has to use modifier 22, 52, or 53 need to send medical record when claim transmitted. The unlisted CPT codes usually not covered either. At times the payer may list on so much coverage for certain service like phy therapy or mental health session; as example insurance may pay 10 session a year or limited coverage.

Also each insurance payer wants licensed doctor and therapist to do credentialing paperwork/contract to be in their network. Each of these professional given a 10 digit national number and each medical care place/clinic office is given a taxonomy and NPI number too .....all will be put on claim for billing. Some payers may want modifiers (listed in CPT and HCPCS manuals)to define differ treatments, per differ contract some patient must pay copayment fee on each visit before the insurance pay .Consent must be signed for ALL payer to bill their insurance and if get surgery a special consent done. You will learn patient insurance must be called or go online verify patient coverage before arriving. And if deductible met or not should be listed. Usually medical and mental health claims have different phone numbers and addresses thus important to scan or copy both side of insurance card.

I hope helped you some with this data
Lady T
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