Q/A: How do we Know Which Codes a Payer Will Allow?

by  Wyn Staheli, Director of Content - innoviHealth
Mar 22nd, 2019

Question

How do we know which codes a payer will allow?

Answer

The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare NCDs/LCDs), knowing the payer’s policy is the only way to know for sure what they want specifically.

You might want to begin by looking on the provider’s website or calling their Provider relations department. If you do call, keep in mind that you can get two different answers from two different people. It’s best to ask for a copy of their written policy for the service in question (e.g., chiropractic manipulative treatment, physical therapy).

When the payer doesn’t have an official policy, it can be helpful to review other payers’ policies, but that isn’t a guarantee of payment. You’ll still have to follow all other rules and policies for the payer in question.

Tip: A Find-A-Code subscription includes access to Medicare policies and guidelines (e.g., NCDs, LCDs, articles) as well as an “add-on” to your subscription for hundreds of commercial payer policies (e.g., UnitedHealthcare, Anthem). These are great tools to help you quickly find payer policies.