Follow THEIR Rules

Follow THEIR Rules

So, let’s think about this: all big payers–Medicare, Medicaid, Blue Cross, Aetna, United, Cigna, Harvard Pilgrim, etc–have their own reimbursement rules. So, why do you bill them all according to Medicare’s reimbursement rules? And please note, payment rules are NOT billing rules. But that’s another article…

Medicare doesn’t care how you bill other carriers so long as you don’t bill Medicare more than anyone else. Medicare pays outpatient claims based on CPT codes and in general, doesn’t care what revenue code you use.

Pub 100-04 Chap 4 states:
20.5 – Clarification of HCPCS Code to Revenue Code Reporting
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, Implementation: 04-07-08)

“Generally, CMS does not instruct hospitals on the assignment of HCPCS codes to revenue codes for services provided under OPPS since hospitals’ assignment of cost vary. Where explicit instructions are not provided, providers should report their charges under the revenue code that will result in the charges being assigned to the same cost center to which the cost of those services are assigned in the cost report.”

Other carriers, however, have very different payment rules. Many pay based on what revenue code you bill, regardless of CPT code. It seems to me, that billing other carriers according to what you think are Medicare’s rules and expecting to be paid appropriately according to the carrier’s rules, is like trying to force a square peg into a round hole.

How many of you have taken the time to look at a UB Editor lately?  There are numerous revenue codes that are suggested for individual CPT codes.  And, there are NO suggested revenue codes for other CPT codes.  So, where does all of the “you CAN’T do that” come from?  I have no answer to that question.  But I do know that, back in the 90’s, United Healthcare bought St. Anthony’s Publishing–the bible of hospital billing.  I don’t know what has happened since, but I’ve always been leery of anyone’s interpretation of regulations ever since that happened.  I prefer to go directly to the source documents.  That’s what you will get from us.

We are getting ready to publish a great example from one of our clients’ contracts.  Here’s my first piece of advice:


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