General Surgery Coding Alert

Question: I have a procedure code that one insurance allows $185.00, yet Medicare allows $26.00. Do I have to charge everyone the same amount, so that in this case I cannot charge the one payer more even though they allow more?

Kentucky Subscriber

Answer: Medicares fee schedule should not be the guide to your fee schedule. Just because Medicare only pays $26, you do not have to charge every other payer what the government entitlement program is paying.

You can charge $185 to the other insurance if your fee for that procedure is $185. In fact, if the fee your practice sets for that procedure is higher than $185, you should charge the higher fee. The payer will then reimburse you based on your contract if you are a participating provider, and based on the insureds contract if you do not participate.

--  Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPCOBGYN,CPC-CARDIO, manager of compliance education for the University of Washington Physicians (UWP) and Childrens University Medical Group (CUMG) Compliance Program.