Wiki Payer Guidlines

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Brittany.Crafts@Providence.org

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How do we find out which payers prefer specific CPT codes billed? I'm a new coder, and I've been reading a lot about how different insurance companies want different things, whether it's cpt codes, modifiers etc. For example, We do Family Practice and OB at my clinic, and I was reading on another forum that certain payers want Rhogam charges to be submitted with J2790 and others want the 90384 CPT code. How do we know what the payers want? I've tried looking around on a couple of the insurance websites, but I can't find specific guidelines. Do I need to request them from each insurance company? :confused:
 
Brittany, it does get a bit frustrating with the insurance companies calling their own shots. Of course, they typically do not make their specific requirements available to providers. But congrats to you for recognizing this and reaching out to others for guidance!

Some ideas to get the necessary info is to request it directly via phone call, written letter or email your rep if your fortunate to have one.

I always recommend looking at the denied claims then call the claims department for that insurance company (take very detailed notes), keep asking questions until you understand why the claim was denied, correct the claim and share with coworkers the specific guidelines for that insurance company.

Unfortunately, in my experience, these things are learned by trial and error. Maybe the insurances are hoping the physicians office staff will not follow up by correcting claims and appealing these claims.

Be tenacious, hold the insurance companies responsible to pay the claim.
 
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Another source is the supplier of the medical products. When Synvisc first came out, they were very helpful in advising on what codes to bill to what carriers and what diagnosis codes were considered medical necessary. The vendors want to help you get paid for using their products.
 
I'm interested to know as well.

By the way, is there a software that has the capacity to do this? I would think there is. If there are software that you use for this purpose, which ones are the best to use? Researching and compiling all the guidelines is very laborious and it takes so much time to call all payers.. Thank you for the information.
 
Natalie, you are spot on with your advice. And Marcus, your advice fit the bill when we were billing for botox injections. The original poster's message could have been written by me six years ago. In fact, I'm still learning the ways of the carriers. Nothing in school prepared me for this. You do learn by trial and error. What I have done (and it's taken some time), is to prepare a folder with each carrier's details and requirements specific to our particular practice. I keep a hard copy and an excel databook. I subscribe to carrier network bulletins, and make it a point to extract pertinent data that might affect our providers and add it to the proper insurance folder. It is a lot of work, but it's worked for me and if you do it step by step, it gradually works its way into a mighty nice reference catalogue. I'm so glad I did this! The questions you have were mine and prompted me to embark on this endeavor...It will help to bridge the frustration in your work and to love what you do. I do so love mine!
 
Suzanne-10 years ago I was in the same boat! Then I changed specialties and had to start all over, but it is what I love. Coding and keeping insurance companies honest! Just when you think your on the right track the insurance companies change the guidelines which (typically) they don't like to share. Oh well, it keeps us on our toes and our minds sharp! Keep up the good work!
 
Another thought:
Follow this path from the AAPC home page that supplies invaluable payer policies and manuals: MENU TAB (resources)  (tools)  Health Plans  Provider Manuals & Policy Search
 
I too am having trouble figuring out all the payer guidelines. The advice given is the best there is. You have to call and start a folder for each insurance company. Research, research, research but that is why I love billing and coding. I wish there was a one stop resource it would make it easier. The AAPC tool for the provider manuals is an awsome start.
 
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