Billing and Coding Medicare Fee for Services Claims

Touseef Riaz

October 14, 2022

Billing and Coding Medicare

Medicare fee-for-service plans are health insurance plans people can purchase in the individual or group market. The program pays for doctor visits, hospital stays, and prescription drugs. These claims can be filed electronically or through paper forms. All professional medical providers who bill Medicare fee-for-service and their staff who prepare the claims must understand how to get the claims paid by Medicare. So this way, you will be able to determine when the claim is ready to be filed; determine when a claim should be corrected. Moreover, you can adjust overpayments, deductibles, and coinsurance amounts; read an explanation of the benefits statement, and calculate a patient responsibility amount (which includes co-pays) with billing and coding medicare fees.

Billing and Coding Medicare

How Does the Fee-for-Service Health Plan Work?

Fees for service in Medical Billing are the most common type of health insurance in the United States. These plans offer end-to-end independence and flexibility to those who can afford them.

Before the value-based care initiative was introduced, primary health care insurance was a fee-for-service health plan. The FFS coverage, sometimes referred to as indemnity insurance, is more expensive, but for those who can afford it, a fee-for-service health plan offers complete freedom and flexibility.

Clients with FFS have less contact with the insurance company and are free to select the doctors and hospitals of their choosing. However, a service health plan fee demands more expenses as clients may need to pay their medical fees upfront and submit bills for reimbursement.

Billing and coding Medicare Fee-for-Service claims

When you bill for a service, the provider must submit a claim to Medicare. The provider will typically submit their claim electronically using your billing software. Following the claim’s submission, it will be reviewed by an analyst who verifies that all of your claims are correct and accurate before Medicare pays them. Moreover, if you are unfamiliar with Billing And Coding Fee-For-Service Claims procedures, here’s how it works:

  • Billing is where you document physician or other care providers (such as nurses’) services. According to established guidelines, this includes recording dates, amounts paid out in cash/check or credit card bills, and any co-pays/deductibles applied when paying out these funds (if any). The objective is to ensure that each payment matches up precisely with what was provided, so there isn’t confusion about who owes what amount later down the road!
  • Coding refers specifically to putting certain codes onto claims forms indicating procedures performed during certain lengths of time—for example, “laceration repair.” These codes help doctors understand exactly which kind(s) were done at any given point during treatment sessions without having them constantly look back over all old notes themselves later on.”

For many claims, a CMS-1500 form is used to file the claim.

If you want to understand how the Medicare fee-for-service system works, it is essential to know that there are many different types of claims. For example, a physician may bill for an office visit, or they might bill for bloodwork done at the hospital. A skilled billing and coding medicare professional can explain your claim type and what information should be included on your form CMS-1500 (Claims Made by Providers). When you file a claim with your doctor’s office or hospital — whether it’s online or on paper, so they need to include specific information in order for the government agency that pays providers’ bills (Medicare) to process them correctly:

Revenue codes 

Care providers in the healthcare industry use revenue codes to indicate a service category. Revenue codes are used on the UB-04, entered by the patient’s healthcare provider. The revenue codes describe various services and are joined by the provider. They also tell insurance companies whether the procedure was performed in the emergency room, operating room, or another department.

Evaluation and management of CPT codes

The CPT codes for billing and coding medicare affected by the updated Outpatient E/M Guidelines are 99202-99215. These codes are primarily used for office visits and telehealth services, but they can also be used to describe a telehealth E/M service. The guidelines were announced in 2019 and are slated to be implemented in 2021.

The new guidelines allow providers to bill CMS and private payors based on time or medical decision-making (MDM). However, they do not allow providers to bill for time spent on other services unrelated to the visit or E/M service. For example, if a provider performs an EKG, this would not be considered part of the visit or E/M service and would not be billed under these guidelines.

If you’re trying to find a means to provide telehealth services in your practice, we encourage You can reach out to us right away to learn more about how we can help!

Standardized forms 

The paper medical claims forms are standardized, so you can use them to file a fee-for-service claim without the help of an adjudicator. The paper medical claims forms are also available in both English and Spanish. In addition, you can fill out your state or use software to do it for you.

Billing and coding medicare–staff expertise 

All professional medical providers who bill Medicare fee-for-service and their staff who prepare the claims must understand how to get them paid. The difference between a procedure code and a CPT code can be confusing, but it’s easy to remember if you keep these rules in mind:

  • Procedure codes are used for services performed by physicians, dentists, podiatrists, and psychologists.
  • CPT codes are specific to each type of service—for example, an x-ray or CT scan may be considered CPT 643 (General Radiology), while a lab test might be coded as 645 (Laboratory). In addition to these two types, miscellaneous codes don’t fall into either category but are still crucial for billing purposes.* The golden rule when coding and Billing are simple: If you can fit all your information on one line without using any special characters like pound signs or asterisks, then use one line.* There are three categories of specialty codes: Critical Access Hospitals (CAHs); Rural Health Centers/Units; Primary Care Providers

Three categories of CPT codes: 

As a national coding set for physicians, Unlike other professional healthcare services and techniques, CPT’s evidence-based codes precisely cover the entire spectrum of healthcare services. All these codes are five digits and can be either numeric or alphanumeric, depending on the category. CPT code descriptors are clinically focused and utilize common standards so that diverse users can have a common understanding across the clinical healthcare paradigm. Additionally, these codes have a unique approach that allows you to be sure that you are accessing accurate information about your patient’s health care needs.

There are three main types of CPT codes:

Category I: These are used when a procedure or service is performed on an individual. Codes range from 00100-99499 and are generally ordered into sub-categories based on procedure/service type and anatomy.

Category II: These supplementary alphanumeric tracking tags are used to track performance. Using them is not necessary for proper coding and is optional.

Category III: These transient alphanumeric numbers are used for cutting-edge techniques, technologies, and services. They were developed to gather information, evaluate, and, sometimes, pay for novel services and procedures that do not yet match the requirements for a Category I code. 

The golden rule in coding and Billing: 

The golden rule of coding is that the code you choose should be the one that best describes the service provided. In other words, it’s best to use a code that describes what was done rather than simply using one based on convenience or ease of entry into your computer system.

For example, if a nurse provides an antibiotic for an ear infection and then later does a strep test, you would want to use two codes: one for administering antibiotics and another for performing strep tests (because these things are related). However, you wouldn’t want both medications listed under “Antibiotics” because there would be no way for someone else looking at your billings or claim forms to differentiate between them!

This is why most billing companies require their providers’ staff members include detailed descriptions in their medical records. So this way, they’ll know precisely what services were provided at each visit without confusion about which codes should go where – especially since those details aren’t always available through verbal communication alone during patient holidays.”

What is CPT Medicare?

CPT Medicare is a set of health care codes that describe the services, supplies, and procedures performed in the medical setting. The American Medical Association created these codes (AMA) and used them to report medical services and systems to Medicare and other health insurance companies. The AMA also maintains an extensive library of these codes, which you can use for your billing purposes and for reimbursement from insurers.

CPT Medicare Category Descriptions: Some examples of categories include “diagnostic testing” or “unlisted diagnosis.”

CPT codes that are not covered by Medicare

If you’re a Medicare patient and need to submit a service code, knowing which CPT codes are not covered by Medicare is essential. A service code is a unique number that identifies a particular medical procedure or device. It allows healthcare providers to bill Medicare for their services efficiently.

CPT codes are considered experimental or investigational by the Centers for Medicare & Medicaid Services (CMS) because they haven’t been evaluated through clinical trials yet. In addition, some of these medical Billing And Coding claim codes may be used for non-Medicare patients; therefore, they should not be billed directly to your plan.

What is the difference between a procedure code and a CPT code?

Codes report services provided by a physician or other healthcare professional in the medical field. CPT codes say services are provided during an encounter that lasts longer than 15 minutes. So, for example, if you see your primary care doctor and get an X-ray done on your foot (a procedure), this would be considered a single service under Medicare billing rules. However, if you visit the same doctor for another reason—in this case because you have a cough—and he performs chest compression maneuvers on your chest (a procedure). So, this way, they would be considered two different procedures because neither lasted 15 minutes.


In conclusion, Billing and coding Medicare fee-for-service claims are essential skills that every professional should master. This article provides some basic information about coding Medicare fee-for-service claims. Moreover, if you are looking for professionals, you can hire U Control Billing to complete the services




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