Wiki Documentation/Coding/billing


El Dorado, KS
Best answers
I am looking for clarification and supporting documentation in regards to coding and billing insurance companies for services that you know will not get paid. It is my understanding that coders should code the services provided, regardless of the insurance payor or if they are self pay. Is it considered to be undercoding to not code and submit the services provided? Can we pick and choose according the the payor what is billed and what is not? If Medicaid denies payment, due to content of service does that mean we as coders should not code it. Then I bill the same service to a BCBS and they pay it.

Can someone please direct me.

I was taught code what is documented, send it to the payor, if they deny payment for what ever reason, you address the denial. Is it OK not to bill the self pay patient for services that you know Medicaid will not pay? :confused:
I'm going thru almost the same thing right now and am interested in the answer as well. What I have come up w/ is you can't really pick and choose who and what you bill. If/when you get audited, you'll have a lot to answer for. Not billing for things because they won't get paid for so "we" don't to have the write offs isn't ok to me but I'm interested in what others think.
Coding/Billing is so different sometimes...just because we learn something for coding, it could be different with billing :) I hate that ;)

If you know something is "non covered" up front... prior to billing.. the patient should sign a waiver and self pay up front. for Medicare they have to use an ABN form... for privates like BCBS, they require a signed waiver by the patient that you can make up yourself... you always have to put on there what is non covered, why it is non covered, and how much it will be... the patient has the option of having the service or declining the service... if they sign the waiver, you don't necessarily have to bill the insurance. most physicians i believe file it as a courtesy, if they pay and the patient has already paid, the patient will get a check for the overpaid amount.
some physicians ask that if the patient want to self pay up front, they can file the claim to the insurances themselves and ask for reimbursement directly back to them. sometimes, which i don't recommend... is the patient will sign a waiver, not pay up front, insurance is billed...and then either the insurance pays or the patient is billed after the fact.

the key to all of this is having a signed waiver on file and that you know something is noncovered.
for medicare, if you have a signed abn on file, there are certain modifiers that you have to bill the claim with notifying medicare that the abn is on file. once you receive the denial, you then bill the patient directly.

the link to the abn is

the modifiers for abn to medicare: GA, GZ, GY

i'm not sure if medicaid has a specific waiver they use...i would contact them.

hopefully this helps........:D