Powered by Oracle® RightNow

Claims & Billing Tips for New Providers

  1. A patient had an x-ray performed and the radiologist reads the x-ray. It is determined the patient requires surgery. Can both the radiologist and the surgeon bill for reading "professional component" of the x-ray?

    No. The surgeon should not bill for the interpretation of the x-ray. The surgeon is merely using the results in his/her medical decision making, which is factored into his/her Evaluation and Management (E/M) service. Other physicians should not bill reviews or re-reads for previously interpreted exams.

  2. When a provider performs repair of two separate intermediate benign lesions (i.e. one on the back and one on the shoulder), can the provider be paid separately for each lesion removed?

    The CPT codebook instructs the provider to bill the sum of the lengths of repairs for each group of anatomic sites. For example if one repair is 5.2 cm (CPT code 12032) and the other repair is 8.0 cm (CPT code 12032), the total length should be billed as CPT code 12035 (12.6 cm to 20 cm)

  3. How do I bill for a service that is performed more than once for the same patient on the same day?

    Some procedures can be billed on one line of service with the appropriate number of units indicated. Other procedures must be submitted one service per line. The first service is submitted with no modifier and the second and subsequent services with modifier 76. Modifier 76 cannot be used with surgery codes.

  4. Will Medicare pay an injection administration code along with an office visit on the same day?

    Yes if a significant and separately identifiable Evaluation & Management (E/M) service is performed on the same day and modifier 25 is appended to the E/M code. However, if the administration code has a status indicator of "T" on the Medicare Fee Schedule Database (MPFSDB), then Medicare will not reimburse for the administration. Status "T" means the service has Relative Value Units (RVUs) and payment amounts, but they are only paid if there are no other services payable on the same date of service by the same provider.

  5. Where can I obtain a copy of the list of payable diagnosis for a particular service?

    First, you should check to see if we have a policy on the procedure code in question. In some cases, the policies list the payable diagnosis. If not, you may request a copy by contacting our Freedom of Information (FOI) Department. A list of payable diagnosis is not available for all procedure codes. For more information on how to request this information, see our Freedom of Information page.

  6. If I am a non-participating provider and decide to accept assignment on a claim do I become a participating provider?

    No. You must enroll in the Participation program to be considered a participating provider. However, when accepting assignment on a claim by claim basis, you must adhere to the assignment agreement.