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 billing does not have to result in lots of rejections and denials if you have the proper knowledge of Medicare billing guidelines. The information provided below are some do’s and don’ts that are commonly known to prevent billing errors.

What to Do for Medical Billing

• Do document the medical record with accurate descriptions of all services, tests and procedures exactly as performed and adequately detailed with the patient’s symptoms, complaints, conditions, illnesses, and injuries.
• Doselect and report the appropriate modifiers to the CPT/HCPCS codes on the claim according to Medicare guidelines.
• Docode claims correctly based on services, tests, and procedures performed.
• Doreport the CPT/HCPCS procedure codes to Medicare that most specifically matches the documentation in the medical record.
• Doinclude the length of time, the frequency of the treatment, or the number of units in the medical record for accurate reporting on the claim.
• Dofile claims within one year of the date of service for primary Medicare and MSP claims.
• Dohave a valid Advance Beneficiary Notice (ABN) on file to correctly document non covered services with the appropriate modifier, i.e. GA or GZ, which will identify the services that can be billed or not billed to the patient.
• Doverify patient eligibility through the Common Working File (CWF) before billing the claim to ensure the patient’s information hasn’t changed.

What Not to Do for Medicare Billing

• Don’t bill for any service, test, or procedure performed when there is no documentation of symptoms, complaints, conditions, illnesses, and injuries that provide evidence unless a screening code is used.
• Don’tautomatically add modifiers to all CPT/HCPCS when the medical record does not support its use.
• Don’treport non specified CPT/HCPCS procedure codes when specific CPT/HCPCS procedure codes are available.
• Don’t submit claims to Medicare for payment if the patient is covered by Medicare Managed Care.
• Don’t bill for routine physical examinations unless you are billing to receive a denial.

If billing for a denial, be sure to add a GY modifier to the appropriate CPT/HCPCS procedure code.

• Don’t bill for Medicare Part B services when the patient has elected Hospice for the treatment and management of a terminal illness.​
• Don’t submit paper claims on anything other than the standard, red and white CMS-1500 or UB-04 forms.