"Claims Processing" & "Insurance" Articles


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How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —

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Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.

Cross-A-Code Instructions in Find-A-Code

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Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.

Are You Aware of the 2021 Star Rating System Updates?

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Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...

Coding with PCS When There is No Code

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ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...

Understanding UCR Inpatient Fees used on DRGs

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"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

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The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

Q/A: Did Noridian Stop Covering the M99.0- Codes?

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Question: I heard that Medicare Noridian Jurisdiction F (Alaska) has been denying claims with M99.00, M99.01, M99.02, M99.03 etc codes when billed with the CMT CPT codes. Did Medicare change their policy?

Who Knew? There are Three Types of Add-On Codes

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Using add-on codes with HCPCS/CPT is not as simple as 123! Although there are three different groups of add-on codes assigned by CMS, these are used to identify code edits. It is easy to see the add-on code with some codes; we can see the instructional notes and phrases such ...

Answering the Question: Does my Insurance Cover Chiropractic Care?

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The question "Does my insurance cover chiropractic care" is the ongoing question chiropractic offices have struggled with for years. Unfortunately, when it comes to insurance, coverage often varies between payers — even varying between plans for a single payer so there isn't one easy answer.

Medical Insurance Coverage for TMJ Disorders (TMD)

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It is agreed that TMJ disorders should be covered by insurance. There are often questions whether it is covered by medical insurance or dental insurance and where the line is that separates coverage.Medical Insurance typically is the primary insurance for TMJ disorders. The reason is that joints are found anywhere ...

Documentation Tips

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Documenting Medical NecessityTo receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using ICD-10 codes and CPT codes. These ...

Q/A: How Do I Bill a House Call?

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Question If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form?  A modifier, or something else? Answer Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...

Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

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Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky. In their notice, Anthem states: "Effective for all commercial ...

A United Approach

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A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

What Medical Necessity Tools Does Find-A-Code Offer?

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Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

What is Medical Necessity and How Does Documentation Support It?

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We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

Q/A: How Many Diagnosis Codes do I use?

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Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that? Answer: More is not always better. You only need to ...

Prolonged Services

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Prolonged Services I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...

Date of Service Reporting for Radiology Services

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Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.

Understanding NCCI Edits

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Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

Home Oxygen Therapy

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Home Oxygen Therapy Guidelines

Are You Protecting Your Dental Practice From Fraud?

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With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...


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