Rule: Billing/Coding Based on Payer

Hi. Can anyone direct me to the official rule that states that a private practice can not and should not bill patients differently based on insurance?

Example: Patient has a lumbar diskectomy with the operating microscope. If the patient has a private insurance then 63030 and 69990 would be reported. However, if the patient has Medicare only 63030 would be reported since Medicare considers 69990 bundled into 63030.

Where is the rule that states that this is fraudulent or inappropriate reporting?

Thanks, Jen

re: Rule: Billing/Coding Based on Payer

The applicable "rule" in this instance is your contract with the prospective carrier. As you know, not all carriers follow the guidelines set forward by Medicare. You would need to decipher what procedure the carrier determines to be bundled and then in the event of an denial for something you do not believe should have been bundled, you will need to submit an appeal disputing the denial with appropriate documentation to support your physician if necessary, you may have to request a narrative from the physician. Each insurer adopts their own payment methodology, you have to learn it and renegotiate what is not fair based on your practice.

Best Wishes

Machell Jones, CPC
Coding/Compliance Specialist

re: Rule: Billing/Coding Based on Payer

That's what I've heard as well, but whenever I go to coding courses we are told that we should be billing all patients the same regardless of the payer or their specific rules. I can never seem to get clarification on this or what they mean by it. I was wondering if there was something I could reference in writing from a reliable source. Anyone?