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. We need to be very careful about the Medicare and Medicaid Billing Guidelines.

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 the 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, the disabled, and the elderly. This program is funded by the federal and state governments. Hence, after certain criteria set by the federal government, states have their own Medicaid guidelines and coverage plans. This makes Medicaid billing very complex. let’s understand the Medicare and Medicaid Billing Guidelines in details:

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 the 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 symptoms, 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 invoices for 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 are met (

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