Wiki Coding per insurance- HELP!

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JNH2016

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I have a new SR. Management team that wants to change the way we bill out therapy codes based on what the insurance would cover so for instance- Medicare would be billed how we always have been in the past but commercial plans would get a different billing structure due to their high volume of denials on certain codes. I am inclined to think that the coding needs to be consistent across the board. Am I right or is it OK to change how things are coded (the codes still absolutely are supported by the replacement code). Any help would be appreciated. Thank you!
 
Hi
It depends on the contract from each payer regarding the CPT codes and your company. However,the CMS/Medicare gives a outline how documentation and the dx. codes linked with each CPT should be used. This factor makes the documentation consistent, plus the notes in the CPT manual, but the payer may want certain modifiers, or treatment plans done, Etc. I hope this helps you.
Lady T
 
There is no "Blanket Coding". If you know that a specific payer will not cover "X", whatever that is can't be billed to them. Example: If a patient has a loose body removed that is 5mm or greater, those who follow AAOS can be billed for the removal of them. Other payers don't follow this rule. So your coding is going to change based on the insurance and what they cover. Other than situations like these though your coding should be consistent.
 
I disagree with the idea that you only bill for a procedure if the insurance will pay for it. If a payer won't cover something, you tell the patient their insurance won't pay for it and tell them what the cash pay price is.
 
JNH2016 said:
I have a new SR. Management team that wants to change the way we bill out therapy codes based on what the insurance would cover so for instance- Medicare would be billed how we always have been in the past but commercial plans would get a different billing structure due to their high volume of denials on certain codes. I am inclined to think that the coding needs to be consistent across the board. Am I right or is it OK to change how things are coded (the codes still absolutely are supported by the replacement code). Any help would be appreciated. Thank you!
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I have to ask, what codes are equivalent to each other and are therefore interchangeable?
 
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