Rules Governing Codes to Use in Medical Billing

There are a few things you will need to know about the rules for using codes in medical billing. When you’re coding, you just look at the fee schedule, find the CPT codes you need, and include them all on the claim form, right? Wrong. Not every code can be grouped or classified similarly, so you have to know what kind of code you’re dealing with:

  • Codes that can’t be billed with other codes: Codes that represent different procedures to the same body part often can’t be billed together. For example, an open reduction (or repair through an incision) of a fracture of the radius can’t be billed with a closed reduction (setting the fracture without an incision) of the same body part.

    In these cases, only the more complex procedure is billed. When would such a situation occur? Suppose the physician tries a less invasive procedure but is unable to attain the desired results, so she ends up performing a more invasive or complex procedure. Only the more invasive or complex procedure is billable.

  • Codes for procedures that can’t be billed under specific circumstances: Men can’t get hysterectomies, so if a claim for a male patient lists a code for a hysterectomy, the payer isn’t going to pay the claim. For obvious reasons, a hysterectomy is a procedure that is only payable if the patient is female.

  • Codes that can only be billed to a patient once in a life time: People only have one of some things (like gallbladders, spleens, and uteruses); therefore, a patient can have such an organ removed only once. If the payer system is up to date, additional claims for these types of one-time-only procedures are always rejected.

  • Codes that require specific conditions to be met before they can be billed: Some codes are age related, others are sex related, and still others are the one-time only codes (explained in the preceding item in the list). For example, various procedures (such as tonsillectomies or adenoid removals) are appropriate only for specific age groups. The CPT book indicates when a procedure code has such a condition.

  • Codes that aren’t compatible with other codes (at least in theory): Sometimes codes just can’t be combined because performing both procedures would 1) be impossible, 2) not make sense, or 3) represent a service or procedure that is incidental to another.

    For example, you wouldn’t submit a procedure code for a right foot bunion repair during the same session when the right foot was amputated. A physician wouldn’t bother with a bunion if the foot was being removed. The same holds true with a cataract extraction for an eye that was previously removed. These codes can’t be combined because the procedures can’t be done at the same time.

    You can find out more about these unlikely — and often a bit humorous — coding scenarios by checking out Medicare’s set of edits known as Medically Unlikely Edits (MUEs). These edits are available on the Centers for Medicare & Medicaid Services (CMS) website and on most Medicare contractor websites.

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