Wiki Coding guidelines vs out of network facility

[pfwilliams39]

I'm having a discrepency with coding a pain case. The cpt code is 64483 or 64493. The guidelines state that the fluroscopy is included. In the past, the coder has always billed the 77003 with these codes. Because i'm a new coder, I elected not to bill with the 77003 because that's what is stated in the book.

My employer is stating that since we are an out of network provider, we so not have to following these guidelines because it has more to do with unbundling. Management has been told by an outside source, we do not have to follow certain guidelines because we are not contracted with any payor.

Can someone please tell me the following:
1. Is it a legal issue to disreguard the coding guidelines listed in the book?
2. Do out of network providers have to follow the same guidelines as network providers in reguards to coding?
3. If my employer request me to code a case using cpt codes that I'm not suppose to bill according to the guidleines, what should I do?

 

[drakena74]

I work as a biller for ASC that is out of network. You still have to follow these coding guidelines whether your in or out of network. If the individual insurance company has a policy/procedure/guideline that states you can bill the 77003 (unbundled) with the 64483 or 64493 then go ahead and code/bill this way. Just make sure you always have a copy of this policy just in case the insurance requests the payment back. BUT if there is no policy in place that clearly states that it can be billed then you CANNOT unbundle. This can be seen as fraud whether intentional or not. If the insurance performs an audit and find they overpaid, they will ask for the money back.

Out of network providers have to follow the same policies, procedures & guidelines as in network providers do. The only real differenec between in & out of network providers/facilities is what we can collect from the patient & difference in fee schedule reimbursement from the insurances.

Collect all the documentation to back you up. If you have it in writing your manager really can't say too much about it, but if they insist then state you are uncomfortable doing something that is clearly documented as being incorrect. Start looking for another job if this keeps happening. you don't want to be held liable for their wrong doing.

We do Pain Mgmt in our facility. Please e-mail me if you have any further questions.

jdewitte74@gmail.com

 

[capricew]

i have to agree with drakena74-

The cpt codes are issued by the AMA and that is what you have to follow. I doesn't matter if you have a contract or not. You must follow the verbiage in the CPT code as they are there to set the standard for all codes used. It has nothing to do with your idividual contracts with insurance carriers.

 

[pfwilliams39]

Thank you so much for the clarification. I was under the same impression, but just needed someone to verifiy my though process as well.