'What If' and Scenario Questions

Published 06/30/2021

Physician offices often contact us with different scenarios and "what if...?" questions regarding coding and documentation for particular services. Providers ask the contractors for a definitive response on whether Medicare would make payment. While Medicare contractors can provide information on Medicare rules and regulations, the final determination is based on information contained in an individual patient’s medical record. 

Medicare representatives are available to indicate whether a service is a payable service under Medicare guidelines, but cannot instruct a provider or provide a statement that a specific patient's service is payable or provide instructions on how to code a service. Additionally, contractors may not provide a preliminary medical review determination based on snippets of information or documentation. The final determination of payment is made after the submission of the claim and any medical review that may be performed. Medicare Administrative Contractors will not grant prior approval or affirm a provider’s individual practice’s procedures, coding or documentation are sufficient to meet all Medicare guidelines.

Remember, providers are responsible for determining the correct diagnostic and procedural coding for the services furnished to Medicare patients. After reviewing Medicare guidelines, providers, compliance, audit and/or billing staff can find more information on coding resources in the CMS Internet-Only Manual (IOM) Publication 100-09, Chapter 6, Section 30.1.1 (PDF).

If you have a question about interpretation of procedural and diagnostic coding, please contact the entities that have responsibility for those coding sets.

  • Current Procedural Terminology (CPT®) codes are proprietary to the American Medical Association (AMA). As such, CPT coding questions should be referred to the AMA. The AMA offers CPT Information Services (CPT-IS). This internet-based service is a benefit to AMA members and is available as a subscription fee-based service for non-members and nonphysicians. The AMA also offers CPT Assistant. Information about these resources is found on the AMA's website.
  • The American Hospital Association (AHA) has a website with many resources for answers to coding questions. The website also has a direct link to the AHA Coding Clinic whereby coding questions may be submitted and tracked
  • Level II Healthcare Common Procedure Coding System (HCPCS) codes related to durable medical equipment or prosthetics, orthotics, and supplies are answered by the Pricing, Data Analysis and Coding (PDAC) Contractor. Information about the PDAC Contractor and the services it provides can be found on the PDAC's website
  • Additional information can be found about these resources on the CMS HCPCS General Information web page

This document was developed through the A/B Medicare Administrative Contractor (MAC) Provider Outreach & Education (POE) Collaboration Team. This joint effort ensures consistent communication and education throughout the nation on a variety of topics and will assist the provider and physician community with information necessary to submit claims appropriately and receive proper payment in a timely manner.

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