The Do’s and Don’ts of Medicare & Medicaid Billing



A biller’s most important task is to send ‘clean’ claims to Medicare and Medicaid. Though both are high-volume payers, they perform differently in the US healthcare system.

In 1965, Medicare (a federal healthcare program) was created to target persons over 65 and those under 65 with certain disabilities. It is currently administered by Centers for Medicare and Medicaid Services (CMS). Medicare Administrative Contractors (MAC) is responsible for processing the claims. Medicare is divided into 4 parts: Part A (medically necessary services), Part B (preventive care), Part C (Medicare Advantage Plan) and Part D (Prescription drugs).

Medicaid’s health coverage program is targeted towards low income individuals, families, disabled, and the elderly. This program is funded by federal and state government. Hence, after certain criteria set by the federal government, states have their own Medicaid guidelines and coverage plans. This makes Medicaid billing very complex.

Do’s and don’ts of the insurance coverages:

Medicare – Do:

- Check on the demographics and patient eligibility in the Common Working File (CWF) before billing.

- Acquire the signature of the patient for care and authorization by the provider.

- Code correctly as per tests, services and procedures.

- Document precisely the patient’s symptoms, infirmity, complaints, conditions, injuries and state the description of all services, tests and procedures performed.

- Match the CPT/HPCPS/ICD-10 codes to the utmost level of specificity as per the documented procedures.

- Detail the apt modifiers as per the documented codes.

- Include the accurate length/frequency of treatment.

- File the claim within a year of service rendered.

- Prevent multiple reporting by detailing the units of service as per National Correct Coding Initiative (NCCI) and Medically Unlikely Edits (MUEs).

- File a valid Advance Beneficiary Notice (ABN) along with the appropriate modifier for non-covered services.

- Submit paper claims only on red and white CMS-1500 or UB-04 forms.

Do Not:

- Bill the patient if symptom, condition, infirmity and injuries are not documented (unless a screening code is used).

- Send claims to Medicare if the patient is covered under Medicare Managed Care.

- Account non-specified CPT/HCPCS/ICD-10 codes if specific procedure codes exist.

- Include modifiers unnecessarily.

- Bill tests and procedures separately that can be bundled.

- Create invoice of drugs and wastage together. JW modifier to be used for amount wasted.

- Claim for Venipunctures (36415) on Medicare Part B (it is a hospital claim).

- Bill for routine examinations. Add a GY modifier to CPT/HCPCS code while billing for a denial.

- Bill for Medicare Part B service if the patient has to be managed for an incurable illness.

Medicaid – Do:

- Be aware of the state’s Medicaid plans and federal guidelines (set minimum requirements) before billing.

- Follow compliances and use the correct HCPCS codes, along with appropriate modifiers (document the causes).

- Apply National Correct Coding Initiative (NCCI) edits for all claims (mandated by PPACA).

- Include ‘balance billing’ and ensure that Medicare is the last payer source.

Do not:

- Bill the difference between the amount paid by the state Medicaid plan and the provider’s customary charge to the patient, the patient’s family or a power of attorney for the patient (

- Balance bill a Medicaid patient, their family or their power of attorney for any unpaid balance once Medicaid has paid what they allow under the Medicaid fee schedule. This means that the provider must adjust off the leftover balance once any applicable charges for a copayment, deductible or coinsurance is met (

Medicare and Medicaid billers should be well aware of the guidelines to avoid claim denials and rejections.

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