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Thread: Cms - Does anyone know for sure if CMS requests

  1. #1

    Default Cms - Does anyone know for sure if CMS requests

    AAPC: Back to School
    Does anyone know for sure if CMS requests supercede CPT Guidelines? I was recently told this but I would like to see it documented somewhere. Does anyone know where I would find this information? I don't feel comfortable changing codes because the insurance company wants us to.


    Last edited by ank3t; 10-04-2016 at 06:08 AM.

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    If CMS is requesting a specific service be submitted to it in a specific format and you have that request in writing, you should provide it to that payer in that format.

    While I do not enjoy altering stated coding guidelines myself, it is sometimes necessary from a compliance standpoint. For instance, it doesn't have to be "written" somewhere that you attach a "GA" Modifier to a service for which you have a signed ABN (we're talking a Medicare Bene here), it is simply sound and compliant coding.

    I believe it is the responsibility of the practice/physician once the agreement is made to participate in the Medicare program. The Federal Register searches I've done are not showing me exactly what I need to see.

    Hopefully someone else will have the specific document or mention of it.

    Of course, when we say that CMS guidelines supercede stated guidelines elsewhere, it would only apply to either Medicare or Medicaid patients--dependent upon the specific situation.

    Good luck.
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3


    CMS is not a coding authority. The major authorites are AMA, AHA, and AHIMA per the Federal Register. CMS must follow the coding rules and has to be educated on them at times.

  4. #4


    For Medicare / Medicaid patients, CMS guidelines supercede other guidelines. They spell out exactly what they want and since they hold all the money, and can implement all the laws, they are the one's carrying the big stick.

    For non medicare payers, AMA for CPT, Coding Clinic (AHA) for ICD-9 should be the rules. If a private payer publishes their rules, and a physician agrees to participate with that payer, they have agreed to "play" by their rules.

    The problem lies with the private payers that do not publish their rules, do not follow AMA or AHA or even CMS

    Also, keep in mind that the Kennedy Kassabaum bill gave the federal government the authority to prosecute physicians under the federal fraud statutes, claims of fraud in dealing with private payers even when the rules with them are not very well defined. For example, a physician can be accused of unbundling, but what is unbundling when the private payer does not publish their bundling rules (they are propietary) and the physician only has access to CMS's NCCI (there are no bundling rules from the Coding authorities ie: AMA and AHA). It becomes a very fine line that is walked.

    For the sake of the CPC credentialling exam, the AMA rules for CPT coding and the rules spelled out in your ICD-9 manual are the only guidelines and rules you are being tested on. You are not tested on reimbursement, medicare , cms or any other guidelines.

    I hope this was of some help.

  5. #5


    Yes, the testing guidelines define correct coding. CMS does not. CMS is required by law to follow the coding rules, but they stray. And they are sometimes corrected.

  6. #6
    Join Date
    Apr 2007
    Knoxville, TN

    Default CMS Rules

    Remember that anytime you sign a PAR or Contractual agreement with a carrier (Medicare and 3rd Party) you are agreeing to their rules and guidelines-- and their rules and guidelines "trump" CPT's rules and guidelines for their patients.

    Go back and look at the wording of WCOMP policies to verify this is correct-- in TN the WCOMP policy specifically states that if TN WCOMP does not have a specific rule about something, then you follow CPT guidlines.

    Also, some LCD's (local coverage of determinations) that Medicare and other insurance companies follow do not completely agree with CPT-- that's why they have their own rule.


  7. #7
    Join Date
    Apr 2007
    Alexandria, LA


    Remember that HIPAA does not require standard guidelines, only the codes. If you read almost any CPT Assistant article they end with a statement that this is how AMA thinks the situation should be coded but 3rd party payers may have their own rules and you should follow those rules for that payer.

  8. #8

    Wink Contracts

    CMS like any payer, sets it own rules. Even payers like BCBS, who refer to CMS as a reference may not follow it to the letter.

    Think about some of the codes of the CPT book with HCPCS equivalents. If you followed CPT's rules in coding for a preventative exam, colonscopy, or additional arthroscopic knee procedure, you would would use CPT codes, but MC specifically lists them as being bundled or have crosswalks to the HCPCS code.

    Long story short payers can dictate what guidelines they use, period and they are often in your contract. For example Aetna, Cigna, and AvMed, to name a few, utlize McKesson's guidelines. Aetna specifically has a modification to it posted on its website disclaiming some of the code sets so it helps to familiarize yourself with those to in addition to the bundling logic.

    Keep in mind also that many times the processors/reviewers do not have coding knowledge at all and follow a specific guideline to deny. That leaves it up to the provider to catch the denial and appeal it timely.

    I hope this is helpful,


  9. #9

    Wink Cms

    I spoke with the AMA in Chicago last year related to your question.
    The AMA spokesperson stated CMS does have the authority to "revise" CPT guidelines and function differently than the parameters of the CPT guidelines. Unfortunately, many payers have small print that may state they follow CMS coding and payment guidelines.

  10. #10

    Default Cms

    If you are billing CMS, then yes, CMS guidelines are what you need to follow. THere are payor specific rules that apply. www.cms.hhs.gov/manuals
    Pub 100-4 is the claims processing manual...depending on what you are looking for will determine the chapter

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