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More of a billing question

  1. #1
    Toms River, NJ
    Smile More of a billing question
    Medical Coding Books
    not really to do with coding however perhaps someone can enlighten me on this subject. years ago we were always instructed when billing cpt codes they should always be listed highest price to lowest on the hcfa form. i dont believe now as i did not believe then , that the insurance company pays based on how you bill on a claim form. seems to me they pay based on rvu and not on how much is charged. basically when 2 procedures are billed and they are subject to reduction for the 2nd procedure, they will pay 100% on the higher rvu procedure and 50% on the lower rvu procedure no matter how much you charge for each. i am asking because we have new software and if i need to change the order of the cpt codes i will have to do this manually on the hcfa form in the computer. lots of work and time consuming and i feel unnecessary. any thoughts out there?

  2. #2
    The reason you were told to bill highest charge to lowest charge is because codes with a higher RVU generally have a higher price than ones with a lower RVU. The correct order of codes should be based on RVU.

    If your practice has a higher charge for a code that has a lower RVU, then it's time to review how much you are charging for each code. Typically, the higher the RVU, the higher your charge should be....
    Walker Bachman, CPC, CPPM

  3. #3
    Toms River, NJ
    true however my initial question was really is it true that it does not matter the order in which the codes are listed on the claim form? as i stated it is my opinion that it does not matter how we list on the claim form as the insurance will pay due to the rvu not what is listed first on the claim form do you agree with that. thanks for posting a reply

  4. #4
    Oops sorry! .. Some payers may pay that way, I suppose. Others may not. Just to be safe, I always make sure my codes are in RVU order. That way I don't have to worry about it.
    Walker Bachman, CPC, CPPM

  5. Default
    Most insurance carriers we deal with will pay 100% of allowable on the primary code listed, 50% on the 2nd code, and 25% on the remaining codes. So, to increase revenue, most practices list the highest RVU code get the highest reimbursement...on down. We even have one carrier that will ONLY pay the 1st 3 codes, regardless of what else was done. If you trust the insurance carrier to re-order your codes for you and pay the highest reimbursement possible, then go for it. I want to make it as easy as possible for my carriers by listing how I want them to pay.


  6. Default Multiple Procedure Reimbursement
    Medicare indicates that they pay "100% of the highest physician fee schedule amount & 50% of the physician fee schedule amount for each of the other codes". Does anyone know if all insurance carriers follow this rule? Are you familiar with any that do not? Lastly, does anyone have insight as far as the primary procedure performed (which may have a lower allowable) being paid at 100% while another procedure (with the higher allowable) being paid at 50%? I realize some of you may be located in a different geographical area, but any feedback will be helpful.


    Brandy Nyberg, BA, BS, CPC

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