This should be done before you provide the service. In all cases, if the patient’s policy coverage is unclear, inform the patient that they may be responsible for paying for the service. Inform Patient of Potential Financial Responsibility Stay up-to-date on these policies for your local payers to ensure claims are processed as medically reasonable and necessary. The database has quick and advanced search capabilities to search by geography, Medicare contractor, key words, CPT codes, HCPCS codes, and ICD-10 codes.Ĭommercial insurance companies and some Medicaid payers will have similar types of information about their coverage guidelines on their websites. The Centers for Medicare & Medicaid Services (CMS) offers an online, searchable Medicare Coverage Database that allows anyone to freely search NCDs, LCDs, and other Medicare coverage documents. These documents provide information regarding CPT and Healthcare Common Procedure Coding System (HCPCS) codes, ICD-10 codes, billing information, as well as service delivery requirements. There are two resources to help you determine if Medicare considers services to be medically reasonable and necessary: national coverage determinations (NCDs) and local coverage determinations (LCDs). If the patient’s policy coverage is unclear, inform the patient that it may result in an out-of-pocket expense before performing the service. You can often verify coverage information by researching the service on the payer’s website. For instance, the patient wants the service more frequently than Medicare allows or for a diagnosis that Medicare does not cover. A patient may ask for a service that Medicare does not consider medically reasonable and necessary under the circumstances.

E1399gylt statutorily excluded