Coding and Billing Guidelines

  • Coding guideline sources

  • We follow industry standard coding recommendations from:

    • American Medical Association (AMA)

    • Centers for Medicare and Medicaid (CMS) coding policies, local and national coverage determinations, and other related policies

    • Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and guidelines

    • Diagnosis-related group (DRG) guidelines

    • International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding guidelines

    • International Classification of Diseases, 10th Revision, Procedure Coding System (ICD-10-PCS)

    • Health Information Portability and Accountability Act (HIPAA)

    • Nationally recognized medical academies and society guidelines (coding and clinical)

    • National Uniform Billing Committee (NUBC)

    • Official UB-04 Data Specifications Manual

    • OPTUM Uniform Billing Editor

    We can’t advise providers how to do billing. Using the most current copies of coding reference books and software is recommended. 

  • Diagnosis coding

  • ICD-10-CM
    ICD-10-CM coding is used by all providers in every healthcare setting. These codes are for diagnoses and are developed and maintained by the Centers for Disease Control & Prevention (CDC) and the National Center for Health Statistics (NCHS). 

     

    Selecting diagnosis coding from the ICD-10-CM:

    • The diagnosis code should be coded to the highest level of specificity/digits to accurately represent the medical condition.
    • The laterality identified in the diagnosis code must not conflict with the laterality identified by the modifiers appended to the submitted procedure codes.
    • Age-banded diagnosis codes should reflect the age of the patient at the time the service was provided.

     

     

    ICD-10-CM

    CPT codes (HCPCS level I)
    CPT codes are a code set managed by the AMA consisting of descriptive terms and identified codes used primarily to identify medical services and procedures provided by physicians and other healthcare professionals for which they bill public or private health insurance programs. 

     

    HCPCS level II codes
    HCPCS level II codes are a code set maintained by CMS used primarily to identify products, supplies, and services not included in the CPT codes. Examples include ambulance services or durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) used outside a physician's office.

     

    HCPCS level II codes (also known as alpha-numeric codes) consist of a single alphabetical letter followed by four numeric digits.

     

    ICD-10 Procedure Coding System (ICD-10-PCS)
    This code set is developed and maintained by CMS. It’s assigned for procedures performed in hospital inpatient healthcare settings.

     

    When a CPT and a HCPCS code have very similar descriptions for a procedure or service, use the CPT code. If the code descriptions are not identical, select the code with the more specific description that reflects the service rendered.

     

    We only reimburse procedure codes that are effective at the time of service in the year the service was provided. If you submit a claim with a deleted code, it will be denied, and the line item will indicate the corresponding denial code.

     

    We abide by federal and state regulations concerning fraud, as well as our contract obligations to members and providers.

    To support this commitment, we have a special investigations unit to prevent fraud and abuse. If you suspect fraud, call the Anti-Fraud Hotline at 800-848-0244 or email  StopFraud@PREMERA.com.

     

     

  • Provider type billing situations

    An advanced registered nurse practitioner (ARNP or nurse practitioner) provides services to members via one of the following methods:

    • Clinic practice: Bills under the name of a contracted, supervising physician (credentialing not required; a clinic can be one or more physicians)
    • Solo ARNP: Bills under his/her own name (credentialing required)
    • Surgical assistant ARNP: Bills under his/her own name (must complete a Data Request Form prior to performing services)

    A physician assistant (PA) provides services to members via one of the following methods:

    • Clinic practice: bills under the name of a contracted, supervising physician (credentialing not applicable to PAs; a clinic can be one or more physicians)
    • Surgical assistant physician assistant: bills under his/her own name (must complete a Data Request Form prior to performing services).

    A locum tenens physician doesn’t need to be credentialed because he/she is considered a temporary provider. However, if a locum tenens physician provides services for more than 90 days, he/she must be credentialed. A locum tenens physician bills under the name of the absent contracted physician, appending modifier Q6 to all services rendered.

     

  • Submitting a corrected claim

    Submitting a corrected claim may be necessary when the original claim was submitted with incomplete or inaccurate information (e.g., procedure code, date of service, diagnosis code).

    The preferred process for submitting corrected claims is to use the 837 transaction, for both professional and facility claims, using claim frequency code 7. Incorrectly submitting a corrected claim as a new claim could result in a denial.

    Here are more resources for submitting a paper or electronic claim:

    Corrected claim cover sheet - Correct billing info, codes or modifiers, or add an EOP on a previously processed claim.
    Support document cover sheet - Submit medical records or other required supporting documentation to process a claim.

    For more details, see the section corrected, replacement, voided, and secondary claims on our electronic transactions web page.