Utilize standard billing and coding resources

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Utilize standard billing and coding resources

These include:

  • CPT®, ICD-10-CM, and HCPCS coding manuals
  • Local payor coverage policies
  • American Medical Association guidelines
  • Medical societies’ insights
  • AMA coding vignettes

Good clinical documentation

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Good clinical documentation

Including, but not limited to:

  • A thorough history and physical
  • Treatments tried and failed
  • Reason(s) for treatment
  • Anticipated clinical results from treatment
  • Muscles injected
  • Total units billed with breakdown of actual units injected and unavoidable wastage
  • Change in patient’s ability to perform activities of daily living
  • Duration of patient’s effect from treatment
  • Outcomes
  • Anticipated results from future injections

Good clinical documentation is important for the successful processing and payment of claims—without it, claims may be delayed or even denied. It's also critical for a successful payor chart audit.

Understand relevant third-party payor coverage and reimbursement

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Understand relevant third-party payor coverage and reimbursement

Get to know the contracts and other policy guidelines of payors, including:

  • Commercial payors
  • Medicare (view the current Medicare ASP information)
  • Medicaid
  • Dual eligibles: If patient has both primary and secondary coverage, investigate the coverage and plan’s rules for coordinating patient’s medical benefits prior to injection

This summary is intended solely for educational purposes. Information should not be construed as legal advice nor is it advice about how to code, complete, bill, or submit any particular claim for payment. It is important to check with the health plan directly to confirm coverage for individual patients.