Coding - Payer Specific?

dmjbear

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Does your practice or health care facility code your professional services (physician services, not hospital) for all services even if the payer bundles the CPT/HCPC or do you code per payer guideline specifics/bundling?

Examples:

1) Blue Cross Blue Shield bundles the G0101 and Q0091 with a preventative exam 99381-99387, would you code the G0101 and Q0091 on the claim or not code it due to the bundling edit? Or do you code it and make adjustments on the billing side?

2) When a patient is seen and has a split bill (preventative/sick visit) Blue Cross Blue Shield does not allow both codes, would you code both or would you remove the CPT that has the least medical necessity for the visit documentation.
 

thomas7331

True Blue
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In the practices and facilities where I've worked, we've followed these guidelines, which I think work well:
  • If the bundled code is an inherent or component part of another more extensive procedure (e.g. per CPT definitions), it should not be coded.
  • If the practice fee schedule for the service is based on CMS-assigned RVU values, and code is bundled under the CMS published NCCI guidelines, then it should not be coded.
  • If the code is bundled due to a specific payer policy that deviates from NCCI, then it should be coded. If the provider is contracted with that payer, then it is written off as a contractual adjustment.
 
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