AUG 17, 2021
Payers Do Not Have Published Policy on Particular Test
Question: What if Medicare and/or a commercial payer doesn’t have a published policy on a particular test? Do I just guess at coverage, or is a medically reasonable diagnosis a guarantee of coverage?
Answer: Never guess. Guessing is a primary reason for claim denial. The best source for a list of covered ICD-10 codes to CPT code is the payer policy. But if there is no policy, the next best source is the Academy’s Coding Coach Complete Ophthalmic Coding Reference or Retina Coding Complete Reference Guide. Although common sense should also guarantee coverage, unfortunately that is not the case. Many payers use the content in Academy materials to help with policy development. Many practices use the diagnoses in these products as part of their appeal for coverage.