Wiki Coding per guidelines or coding per contracts???

[1073358]

For the first 7 years of my coding life, I worked at a large entity. There, we coded everything to CPT/ ICD guidelines.
Recently I went to a conference that basically talked about coding per the contracts. Each carrier has different requirements and if you are contracted, you report as they indicate.

My question is who's right?

A good example would be the yearly preventative visit. My insurance states that they will pay 100% for all labs done on same day as prevent visit if coded as V70.0.

Another example could be if the patient's insurance says that they will cover a lipid panel as part of preventative labs. But say patient has hyperlipidemia. So is it correct to code it as V70.0 indicating it should be paid under that benefit? or do you code it as 272.X, let it go to deductible and then have angry patients who know they have that benefit and want to use it.

 

[BenCrocker]

Insurances tend to throw wrenches into the works I've noticed. And as you've said and as they are written the CPT/ICD guidelines are just that, guidelines. They are not rules. I would say insurance guidelines can over ride the general CPT/ICD guidelines.

As I'm not well versed in anything legal here it's just my opinion. I'd search CMS website to see what they recommend.

 

[mitchellde]

The ICD guidelines are actually rules mandated by HIPAA. See page one of the guidelines third paragraph. The diagnosis is the patient's and the code must reflect the patient diagnosis at that encounter. If the patient is on medication for a condition like Afib or hyperlipemia, then the blood draw is for drug monitoring[(V58.83) or (Z51.81)], which can be used secondary to the V70 DX code. I have never had an issue with this.
The CPT code must reflect the provider documentation for the services provided. If it is stated as a preventive then that is what must be billed.
The payers may not tell the coder what codes to use on a claim. They may only state what is covered or what is deemed as medically necessary. If the diagnosis documented does not meet that parameter then it is patient responsibility.