Wiki Medicare Advantage Payment Policies and CPT Guidelines - Modifiers

[pbaisden1@humana.com]

If a code should not be reported with modifier 50 per CPT guidance (CPT indicates to bill the procedure X2 and not add the modifier), BUT the Medicare Advantage insurer has a Modifier 50 policy that allows the provider to bill a bilateral code with modifier 50 or RT/LT (the policy does not make any reference to CPT guidelines) as long as the MPFS RVF is not other than 1.....is that appropriate and allowable per Medicare guidelines? Is it correct to bill according to the Medicare Advantage policy even if that policy differs from the CPT guidance? Really looking forward to your assistance and feedback. Thank you!

 

[haraml7]

The Medicare Advantages will follow Medicare guidelines when it comes to medical necessity. However, each commercial insurers have there own billing policies for their plans. So if you are billing to a commercial insurance for a Medicare advantage plan, you would want to follow the modifier policy that the commercial insurers have. When it comes to LCDs, and NCDs, and NCCI edits these Medicare advantage plans will follow Medicare guidelines. So i personally would follow the insurers policy when it comes to modifier placement, because they are still paying the same way and you are not trying to upcode or get separate payment you are just following that insurers policy in this particular scenario and getting paid the same. The CPT book guides us to code appropriately, but the insurers have there policies that you would want to follow.
I hope this helps
let me know if you have any other questions.