General Question for the Week of March 26, 2018

General Compliance Question of the Week

Question:

If a procedure or service has been assigned a CPT® code, does that mean Medicare will cover it?

Answer:

The fact that a drug, device, procedure or service is assigned a HCPCS code and a payment rate under the outpatient prospective payment system does not imply coverage by the Medicare program. It indicates only how the product, procedure, or service may be paid if covered by the program. Medicare Administrative Contractors (MACs) determine whether a drug, device, procedure, or other service meets all program requirements for coverage. For example, MACs determine that it is reasonable and necessary to treat the beneficiary’s condition and whether it is excluded from payment.


CPT® is a registered trademark of the American Medical Association.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.