Wiki Payer Guidelines - WHERE are people finding them?

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centralizedcoding

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Hey there! I'm a pretty new coder, and I started out in Ophthalmology. I'm curious if anyone on here can help when it comes to finding payers' policies for Ophthalmology? Looking for the state of TN in cases where it is local like BCBS of TN. But seriously, I'm not sure if I'm just not good at digging, or they really put these files deep in the abyss. I'm even trying to confirm some basic things for payers like do they require that dilation be performed on their comprehensive exams 92014/92004? Will they pay for refraction 92015 with a medical or vision diagnosis? I've even tried calling the insurance companies to no avail.

If you all have ANY advice, if there is a specific department on the provider line that I can ask for or anything... I am truly beginning to feel lost in the ocean trying to find specific payer requirements. Some of the Medicare Adv ones I've been looking for are Humana MC Adv, BlueCare Adv, and Cigna MC Adv. Commercial payers I've been looking for include the BCBS TN, Aetna, United Healthcare, and Cigna. I know this isn't a specific question, but if y'all have some tips/tricks please help!
 
centralizedcoding said:
Hey there! I'm a pretty new coder, and I started out in Ophthalmology. I'm curious if anyone on here can help when it comes to finding payers' policies for Ophthalmology? Looking for the state of TN in cases where it is local like BCBS of TN. But seriously, I'm not sure if I'm just not good at digging, or they really put these files deep in the abyss. I'm even trying to confirm some basic things for payers like do they require that dilation be performed on their comprehensive exams 92014/92004? Will they pay for refraction 92015 with a medical or vision diagnosis? I've even tried calling the insurance companies to no avail.

If you all have ANY advice, if there is a specific department on the provider line that I can ask for or anything... I am truly beginning to feel lost in the ocean trying to find specific payer requirements. Some of the Medicare Adv ones I've been looking for are Humana MC Adv, BlueCare Adv, and Cigna MC Adv. Commercial payers I've been looking for include the BCBS TN, Aetna, United Healthcare, and Cigna. I know this isn't a specific question, but if y'all have some tips/tricks please help!
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The best way to start is by visiting the payer's website. Make sure to navigate to the provider section, not the member section.

Most payer websites have a search bar, usually located at the top of the page. You can use this to search for CPT codes, diagnosis codes, or keywords related to the policy you’re looking for. The search results will display documents on the site that match your query.

From there, explore the results to find the specific policy or information you need. You may need to refine your search terms if the results aren’t quite what you’re looking for. With some practice, you’ll become more familiar and efficient with searching for payer policies.

Some of the websites also have a section labeled as something like "Clinical Policy Bulletins" or "Reimbursement Policies," where you can just browse the clinical policies alphabetically.


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It takes some learning and practice if you are new to it.
Calling is the absolute worst. Sometimes we are forced to though. Especially when verifying specific patient plan benefits. But, in most portals you can do it there.
If you are coming into an established practice, it seems to me they should already know some of this or have resources? Is there some reason why you are having to do this all from scratch?

Susan has great tips. You would also want to make sure you/your practice is using Availity for certain payers. Other ones may have different names, but you need to be able to access their provider portals.
Use the key words mentioned above and also Coverage Guidelines, Coverage and Reimbursement, Coverage Summary. For Medicare you want LCD, NCD: https://www.cms.gov/medicare-coverage-database/search.aspx You have to make sure you are looking at the correct MAC/State. https://www.palmettogba.com/palmetto/jjb.nsf

Specialty societies have helpful information: https://www.aao.org/practice-management/managing-your-practice
https://www.aao.org/practice-management/articles-list?tid=7532543d-e0d5-477f-89f2-545c63740abb https://www.aao.org/practice-management/coding
 
Thank you both for the advice! I am using Availity, the UHC provider portal, Palmetto portal for Medicare, etc.. I've found BCBS manuals that list their requirements for maybe 8 or so different procedures (but we don't even perform all the ones they list). I simply haven't been able to locate some of the more general guidelines for the eye codes, and would love to find more for a larger variety of procedures to make sure the office understands the guidelines for indications for each payer as well. The last coder they had left before I was hired, and nothing resource wise was really left for me. I really appreciate the key terms you both listed, though, as I'm hoping that some of these key terms may be what I need to find more specific guidelines. I've been trying the cpt code with "lcd" and the term for the actual procedure, but again, I just have yet to locate these documents. I'm very thankful though for the advice, and I will definitely try some of these key terms and keep my eye out for those areas that you both mentioned it may be listed within. Best of wishes to you both!
 
The procedure codes themselves and the descriptions would be the best place to start. There are not always NCD, LCD or specific payer guidelines for every single code. Really, your providers should be able to help with this also.
92002-92014
Older linke but has good info: https://www.aao.org/eyenet/article/fact-sheet-for-the-comprehensive-eye-visit-codes
 
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