Wiki Please Advise Selective Payer Billing

[istanstu]

I know personally it is not ethical to only bill certain payers for certain CPT codes. I need assistance finding the supporting documentation to explain to my providers that I cant just pick and choose which patients and or insurance plans I bill certain CPT codes to. They seem to think its our choice. The CPT code would be met by all applicable patient encounters during a certain time frame, but they insist on only billing Medicaid and Medicaid plans. Isn't it illegal to only bill one payer and not bill across the board. I would think its fraudulent billing practice and have referenced that we aren't to bill the government payer for more than we would bill all other payers please help me locate any published data to inform them of this mistake on their part.

 

[Pam Warren]

Remember, your payer contracts and payer policies often drive the CPT codes you must use, and that trumps all else.

For example, a consultation code is billable to commercial payers. Even though your doctor might provide a consultation to a Medicare patient, you cannot bill those codes....even though the service is the very same. That's one example of how you have to bill out services using CPT codes that aren't necessarily what your intent is. Another example is the use of G codes. Medicare uses them in lieu of certain other reportable CPT codes that are reported to commercial payers. It's not always consistent across the board.

Make sure that before you categorically create a policy that prohibits a CPT code substitution that you are not contradicting a payer policy or contract guideline.

 

[Codingpanda]

Relating this to billing for optometry

In my example, two patients receive the same comprehensive eye exam at a FQHC facility. One patient has a PPO plan and the second patient has Medicaid.

These are the CPT codes that need to put on the claim.
92014
92015
92340
V2756
V2020
V2103

The claim for the patient with Medicaid will have all codes listed above. However the claim for the patient with the PPO plan will have the codes listed above except for the underlined ones.
My question is, is it legal to not bill 92340/V2756 to the PPO patient JUST because it is considered a non-covered service by that payer? Even though the claim for the patient with Medicaid has those two codes on it?

The more general question also being, is it legal to bill certain payers for certain CPT codes because they will pay and not bill others because they won't pay, even though these were services/supplies given.

Thank you in advance for any responses!