The Do's and Don'ts of Medicare Billing

nurse chats with senior patient
sturti/Getty Images

Medicare billing does not have to result in lots of rejections and denials if you have the proper knowledge of Medicare billing guidelines. The information provided below are some do's and don'ts that are commonly known to prevent billing errors.

Don't forget to visit the CMS website to have access tons of job aids, guidelines, and publications that can be beneficial to proper Medicare billing.

What to Do for Medical Billing

Do code claims correctly based on services, tests, and procedures performed.

Do document the medical record with accurate descriptions of all services, tests, and procedures exactly as performed and adequately detailed with the patient's symptoms, complaints, conditions, illnesses, and injuries.

Do report the CPT/HCPCS procedure codes to Medicare that most specifically matches the documentation in the medical record.

Do select and report the appropriate modifiers to the CPT/HCPCS codes on the claim according to Medicare guidelines.

Do include the length of time, the frequency of the treatment, or the number of units in the medical record for accurate reporting on the claim.

Do report the ICD-9 diagnosis codes to the highest level of specificity that matches the patient's symptoms, complaints, conditions, illnesses and injuries detailed in the patient's medical record.

Do file claims within one year of the date of service for primary Medicare and MSP claims.

Do report units of service based on National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs) to prevent reporting multiple services or procedures that should not be billed together because one service or procedure likely includes the other or because it is medically unlikely to be performed on the same patient on the same day.

Do have a valid Advance Beneficiary Notice (ABN)on file to correctly document noncovered services with the appropriate modifier, i.e. GA or GZ, which will identify the services that can be billed or not billed to the patient.<br/>
Do obtain a signature from the patient authorizing the assignment of benefits, permitting the provider to obtain authorization, and to provide care.

Do verify patient eligibility thru the Common Working File (CWF) before billing the claim to ensure the patient's information hasn't changed.

What Not to Do for Medicare Billing

Don't bill for any service, test, or procedure performed when there is no documentation of symptoms, complaints, conditions, illnesses, and injuries that provide evidence unless a screening code is used.

Don't report nonspecified CPT/HCPCS procedure codes when specific CPT/HCPCS procedure codes are available.

Don't automatically add modifiers to all CPT/HCPCS when the medical record does not support its use.

Don't bill services, tests or procedures separately that should be bundled together because they are considered components of the same service, test or procedure.

Don't bill for drugs administered and wastage together. The amount wasted should be billed on a separate line and indicated with a JW modifier.

Don't submit claims to Medicare for payment if the patient is covered by Medicare Managed Care.

Don't submit charges for Venipunctures (36415) on a Medicare Part B claim. This can only be billed as part of a hospital claim.

Don't bill for routine physical examinations unless you are billing to receive a denial. If billing for a denial, be sure to add a GY modifier to the appropriate CPT/HCPCS procedure code.

Don't bill for Medicare Part B services when the patient has elected Hospice for the treatment and management of a terminal illness.

Don't submit paper claims on anything other than the standard, red and white CMS-1500 or UB-04 forms.

Was this page helpful?