Can a Health Care Provider Bill Medicare a Different CPT Code Than One for Commercial Insurance?


Quick Answer

Medicare uses different CPT codes than commercial insurance for some procedures, claims The American Academy of Family Physicians. Medical codes are complex, and thousands of codes for different procedures and payers exist.

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Full Answer

CPT codes exist for different procedures, lengths of time spent with patients and other considerations such as facility type and payer, as AAFP reports. Some codes are used only for Medicare services and may not be used with private insurance or Medicaid. In practice, many providers bill commercial insurance using a separate set of CPT codes. Activities on the behalf of patients may also be billed using CPT codes, such as reviewing charts and creating treatment plans.

Providers must carefully navigate the differences between Medicare and commercial coding, as AAFP states. Some codes are different depending on the facility. Medicare-approved hospice facilities, for example, have distinct codes from other hospice facilities and for other procedures. Some commercial insurance plans reimburse providers for phone consultations, while Medicare does not, and no code for this service exists that Medicare accepts. Differences between procedures accepted by Medicare and commercial insurance result in different CPT codes and different billing policies.

Codes must appropriately match the services rendered to patients in order to receive approval, as AAFP claims.

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