Nov. 11, 2024

Using detailed coding in accordance with CMS (Centers for Medicare and Medicaid Services) policies is critical to ensure we apply benefits and reimbursement correctly to claims. We encourage our providers to strive for the highest level of detail in the coding they use. This pertains to claims submissions for routine and specialized services considering the application of CPT^® or HCPCS Level II code modifiers and proper coding of ICD-10-CM diagnosis codes.

Proactively filing services using claims modifiers and diagnoses that are supported within the member’s medical record will aid in their processing in accordance with CMS guidelines.

To assist with following the CMS billing guidelines, we encourage you to:

• Reference CMS Internet-Only Manuals (IOMs) 100-02 Medicare Benefit Policy Manual and 100-04 Medicare Claims Processing Manuals.
• Follow CMS MLN Connects^® and MLN Matters^® Articles that provide educational updates on billing specific services by provider type.
• Reference CMS Discarded Drugs and Biological Policy for JZ and JW Modifiers.
• Reference ICD-10-CM Official Guidelines for Coding and Reporting.
• Consult with your business partners who code and bill on your behalf to ensure they use proper coding.
• Ensure all appropriate staff are current on correct coding guidelines.

If you have questions, please contact Medicare Advantage at 855-209-7267.