Superbill’s Guide to Out-of-Network Coding: CPT and ICD-10 Codes

Insurers are always looking for new ways of moving services out-of-network to reduce costs. Regardless of what kind of provider you are, there’s a good chance you’ve had to work through the tedious process of coding services for out-of-network insurance reimbursement. If you’re a therapist or specialist working exclusively with superbills, you know this all too well.

Not only is there more work for providers filing out-of-network claims, there’s also a higher probability of rejection. Because there’s no contract between an out-of-network provider and an insurer, a bill for an out-of-network service often causes the entire claim to be flagged. Insurers pay closer attention to out-of-network claims, scrutinizing them for even the smallest errors. In order to get your client the maximum allowed reimbursement, your coding has to be precise. 

Take note of these tips to ensure your next superbill or out-of-network claim is in tip-top shape. Or, if your office or your patients are still trying to wrap their heads around out-of-network reimbursement, check out our Complete Guide to OON Reimbursement or our post on How to Explain Reimbursement to Patients. 

What are CPT Codes?

CPT stands for Current Procedural Terminology, so CPT codes are a universal coding language medical professionals use to identify specific medical services. Each CPT code refers to a unique service or procedure, ensuring providers and insurers have an accurate common language in which to communicate what services have been performed and how they will be paid. 

Without CPT codes, it would be extremely difficult to standardize how medical professionals talk about their procedures and services. Just look at how many names we have for the providers who perform therapy services. Therapists, counselors, shrinks, mental health professionals/practitioners, etc. And that’s just to describe the provider!

Therapy CPT codes get everyone on the same page about the service rendered. (CPT codes for therapy generally only vary by the length of the sesion. So you’ll code 90832 for a 30-minute session, 90834 for 45 minutes, or 90837 for an hour.)

What are ICD Codes and Which Ones are Current?

ICD stands for International Classification of Diseases, but ICD codes are used to classify more than just diseases. They also identify the general diagnoses that caused a provider to administer a particular service. On a superbill, where you’re likely to find both types of codes, ICD codes are essentially the justification for the CPT codes. 

ICD codes are updated annually, but every decade or so, the ICD releases a new set of codes to replace the old. This is denoted by a new number after ICD in the name. 

As of this year, the latest update to the ICD glossary, ICD-11, is starting to be phased in. That means that ICD-10 codes are still accepted and seen as perfectly up-to-date for now, but ICD-9 codes no longer function. Make sure that you’re coding in ICD-10 or ICD-11 to avoid errors with insurers. 

Medical Coding Best Practices

When it comes to coding medical bills and/or filing insurance claims, it literally pays to get it right... Here's a quick checklist look over next time you code.

Make sure the claim is complete and accurate.

It probably goes without saying, but you might be surprised by how many claims are rejected due to naming errors. Double-check that the patient’s name and address are the same on every document. Some insurance companies will take any opportunity they can find to reject an out-of-network claim.

Code Concisely and Correctly

Insurers assume there is an exact code for every service rendered. While the reality may be more complicated than that, there is a best code or set of codes for every service. Don’t under-code by leaving out appropriate ICD-10 or CPT codes, and don’t over-code by adding extra ICD-10 or CPT codes. While it may seem helpful to fluff the claim with extra codes for a greater reimbursement, you may actually get the claim flagged, which could result in rejection of other parts of the claim that otherwise would have qualified for reimbursement.

Describe the Service When Unspecified

If you can’t find an exact code for the service rendered and have to use an unspecified CPT code, include a description of the service. Describing the service increases its chances of being reimbursed.

If You’re Unsure, Review the Policy

Pretty much every insurer lists their policies online. You can usually confirm whether or not the service rendered will be reimbursed by reviewing the insurer’s website. Yes, this can be tiresome, but these are insurance companies we’re talking about…

Review the Patient’s EOB

It’s tempting after filing a few claims and getting into a groove to assume every patient’s policy with the same insurance payer is identical, but in truth, patients’ policies may differ even under the same umbrella plan. Taking an extra look at each patient’s EOB might inform you to use a different code given the circumstances.

Refile, Refile, and Refile Again

‍A rejection is not the end of the health insurance claims process. In many cases, it’s just the beginning. Every insurance payer has an appeals process, and many reject out-of-network claims on sight on the first go around, in the hopes that you simply give up. Insurance companies' strategies involve trying to wear you down, but thankfully, technology has come to the rescue.

If your practice is spending hours on the phone with insurers, navigating tedious questions like these, you're wasting your time! SuperDial's state-of-the-art tech automates phone calls to insurers, freeing your staff up to do what they do best: provide quality care.

Don't waste time and money on problems of the past. AI-driven healthcare is here. What are you waiting for? Waiting on hold is obsolete! Schedule a consultation to see how SuperDial can optimize your medical or dental practice in just a few clicks.

Lastly, if you want to go deeper on medical coding, the American Academy of Professional Coders has a complete list of CPT codes.