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Helpful Websites for Correct Coding

In search of payment guidelines to properly submit your claims? To learn more about correct coding for reimbursement of your services, follow these easy-to-use references for Medicare and other payers.

To review guidelines for National Coverage Determination (NCD) policies or Local Coverage Determination policies, including the Current Procedural Terminology (CPT) codes mapped to International Classification of Disease (ICD) ICD-10CM codes, visit here. An NCD is Medicare’s nationwide determination of whether it will pay for an item or service. Medicare coverage is limited to items and services that are considered "reasonable and necessary" for the diagnosis or treatment of an illness or injury. In the absence of an NCD, an item or service is covered at the discretion of the Medicare contractors, based on a Local Coverage Determination (LCD).

To determine if procedures (CPT) codes are bundled for reimbursement as part of the National Correct Coding Initiative (NCCI), visit here. The NCCI promotes national correct coding methodologies and controls improper coding leading to inappropriate payment in Part B claims.

For Medicare or Medicaid Advantage medical policies, the payer administrating the Medicare or Medicaid plan should provide their specific payer guidelines listed on the website.  Most Medicare Advantage plans follow Medicare/Medicaid guidelines, but the administrative payer may have specific guidelines within Medicare/Medicaid guidelines for payment of claims.

Private Payers
Private payers may also publish guidelines for payment, however, these manuals and/or policies are searched differently from the CMS website. For example, to review UnitedHealthcare (UHC) policies, search for “Reimbursement Policies” visit here, noting UHC also uses the NCCI (National Correct Coding Initiative) edits for many of their “bundling” guidelines, as well as instructions on how to use these edits.    

Aetna and Anthem Blue Cross also post their medical policies and clinical guidelines for correct coding, per their respective policies. Search under “subject headings” for specific guidelines/policies. Visit Cigna to review their respective guidelines under medical policies.  

Has a claim been denied? Search the payer’s website for their guidelines and a timeline to appeal. To learn more about a payer’s rational for denial, review their references cited in their specific payer policy.