Wiki Guidelines on Billing Rules

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melanied

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Hello
Who establishes guidelines on billing rules? AMA or CMS?


Thank you
 
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Well, most insurance companies dropped consult codes when Medicare did, so if they're accepting them at all, it's a miracle.
 
SharonCollachi said:
Well, most insurance companies dropped consult codes when Medicare did, so if they're accepting them at all, it's a miracle.
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Medicare did drop 9925 codes and consolidated the other codes, Medicare pays 99221- 99223 consult codes as our Neurosurgeons see patients daily in the Hospital as well as pay for Office Consult codes.
 
AmandaBriggs said:
Each payer establishes their own policies pertaining to billing rules. Some follow CMS's guidance, but there are a lot that don't.
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yes, we know that some follow CMS and some follow AMA. But is it appropriate for them to make up their own rules??
 
melanied said:
Medicare did drop 9925 codes and consolidated the other codes, Medicare pays 99221- 99223 consult codes as our Neurosurgeons see patients daily in the Hospital as well as pay for Office Consult codes.
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99221-99223 are not consult codes, they are "initial hospital care for a new or established patient". They may be the codes you are using when you are called "to consult", but they are not technically consult codes.
 
Keep in mind that insurance companies sell multiple types of policies. It's not a one size fits all. Most policies have spelled out what is covered and what is not. When the insurance receives a claim it has to process it per the policy, but in doing so needs to make sure that what they are paying on also meets medical necessity. Many turn to CMS since they have a policy on everything. They also turn to AAOS and other professional groups as they process claims as well. Different states can also dictate specific items to cover for people who live in those states. So when you ask "Who makes the billing rules" its far from a straightforward answer.
 
melanied said:
yes, we know that some follow CMS and some follow AMA. But is it appropriate for them to make up their own rules??
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It depends on what 'rules' you are talking about. There are some rules that are federal mandates that must be followed by all plans (e.g. under HIPAA, what code sets are allow to be used in electronic claims submissions; or under the ACA, which preventive benefits must be covered in full). There are also state laws that govern payment for plans offered by insurance companies that operate within that state. But then there are payment policies and coverage guidelines, which each plan or payer is free to set up for their own company or plans as long as they stay within the law.

CMS is a federal agency charged with operating Medicare and Medicaid, so it has the authority to regulate how those two types of plans are run, so if an insurance company is operating a managed Medicare or Medicaid plan, then it does have to follow CMS rules for those plans. But CMS has no authority over how insurance companies operate commercial plans, though as some of the other posts point out, many payers do follow some of CMS' policies (probably to save themselves the cost and trouble of recreating them for their own use).

The AMA on the other hand is not a government agency so has no legal authority. Its role is to create and maintain the CPT codes and set RVU values, for which is it compensated, but it cannot dictate billing rules or mandate how payers decide to reimburse these codes.
 
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