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In Medical Coding, Apply the Right Rules at the Right Time


Rules vary between code book guidelines, payer preferences, and Medicare limitations. Ensure proper reimbursement by following the right rules for the right situations.

When submitting medical claims, not only do you need to get the codes right but you have to apply the right rules. Coding guidelines are found in the CPT® code book and payer policies. HIPAA mandates that providers and payers use the same codes but payers can vary the payment policies and coding requirements. For example, bilateral procedures can be reported in different ways. The "right" way is to follow payer preference which can vary from payer to payer.

Some of the options for reporting bilateral knee arthrocentesis include:

20610-50 with one unit

20610-50 with two units

20610-LT, 20610-RT with one unit each

20610, 20610-50 with one unit each

In the CPT® code book, there are coding guidelines throughout the sections and subsections that provide valuable information for proper code selection. Often the coding guidelines include a description of the procedures and additional procedures that can be billed when performed. For example, the coding guidelines preceding malignant excisions codes (11601-11646) state that a simple closure is included in the procedure. If the excision site requires an intermediate or complex closure, the closure can also be reported if performed. If you did not pay attention to this guideline, you could be losing money if you did not code the intermediate or complex closure.

The parenthetical notes found in the CPT® code book are also valuable. The intent is to assist in proper coding. These instructions are often overlooked which leads to coding errors. For example, following code 64492 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure). CPT® states "Do not report 64492 more than once per day." This instruction informs you it would not be appropriate to submit multiple units of the code on the same date of service.

One of the biggest mistakes a practice can make is applying Medicare rules to all payers. This can cause improper reimbursement. There are some procedures Medicare does not cover that private payers will and vice versa. For example, Medicare allows for a Pap smear every two years for a female who is not considered high risk or of childbearing age. Private payers may cover the Pap smear once per year. If you applied the Medicare frequency limitation, you would lose out on the reimbursement from the private payers.

The good news is the information for private payers can be found in the provider-payer contract, payment policies, and provider manuals. Most payers provide payment polices and provider manuals on their website. Coding requirements for Medicare can also be found on the CMS website in the Medicare Claims Processing Manual, Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs). There is a lot of information available that provides guidance for submitting the codes correctly.

You need to make the time to read and understand the rules and remain up to date. Keep in mind, policies periodically change, which requires you to stay updated on those changes.

Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC has over 15 years experience in the medical field. She manages the clinical development of the AAPC exams program. She oversees the development of exam content for all certification exams and exam preparation material such as study guides and practice tests. She assisted with the development of the Medical Coding Training CPC curriculum that is used by PMCC-licensed instructors and the AAPC distance learning course. E-mail her here.

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