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Understanding CPT® Code Payment Components

Determinations More Complex than Most Believe

By Staff Reporters

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Currently, there are more than 10,000 physician services designated by the current procedural terminology (CPT®) or healthcare common procedure coding system (HCPCS) codes.  Each reflects the three major cost drivers of a particular procedure:

  • Physician work effort or the relative value unit (RVUw) of medical providers’ work efforts, pre-service, intra-service and post-service time.

Patients may exhibit anxiety when examined orduring procedures resulting in the need for additional timeand effort by the physician to respond to and prepare for the examination or procedure. This uniformly adds moretime and stress to the pre-service and intra-service period as doctors respond to constantly changing behavior, questionsand level of cooperation in varying specialties.  Follow-up communicationwith employers, family, friends and concerned others requires increased post-service times.

  • Practice expenses (RVUpe), including non-physician costs but excluding medical malpractice coverage premiums.

The practice expense component of the resource-based relative value scale (RBRVS) includes clinicalstaff time, medical supplies, and medical equipment.  Often, the costsof supplies and equipment are not proportional to practicesize.  Major factorsaffecting practice expense are the volume of telephone, cell, or Internet management services, and the case management and administrative work required. For example, high patient turnover requires more examination rooms to maintain physician efficiency. High volume requires moreclerical staff to deal with larger patient-flow volume and resulting phone calls, difficultiesdressing and undressing patients, and is marked by increasedcomplexity and time in collecting laboratory specimens.  Thesefactors must be accounted for in any resource-based practiceexpense study and in the resulting practice expense calculationsfor medical services; and

  • Malpractice (RVUm) representing the cost of liability insurance.

The RBRVS system assigns RVUs to cover the malpractice expensesincurred by physicians. These malpractice RVUs, originally calculatedfor office-based physicians, may systematically undervaluethe practice liability costs for some specialties. The prolonged statutes of limitation on some legalactions may result in increased malpracticerisk exposure for physicians providing such services [i.e., pediatricians]. The differences in exposure may not be calculated in theRBRVS system, and were not included in initial studies.  Specialty specific survey data for malpractice expenseshould be used for this component when assigning final RVU valuations.  Without specialty-specific CPT® codes, however, there was no wayto do this objectively.

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7 Responses

  1. Medical Coding

    For a Health Information System Department, and its coders, the following medical vocabularies are mandated:

    For diseases: the 9th or 10th International Classification of Diseases (ICD) Clinical Modification should be used. ICD9-CM is maintained by the Centers for Disease Control National Center for Health Statistics, while ICD-10 is maintained by the World Health Organization.

    For medical procedures: a combination of ICD-9-CM, Current Procedural Terminology maintained by the American Medical Association, the Current Dental Terminology maintained by the American Dental Association, and Healthcare Common Procedure Coding System (HCPCS) maintained by CMS, which is also used for medical devices..

    For drugs: these should be coded according to their National Drug Code classification.

    Ann Miller RN MHA
    http://www.HealthcareFinancials.com
    [Executive-Director]

    Like

  2. More on Bizarre CPT® Codes

    Did you know that some CPT® codes could seem downright insulting?

    For example, R46.1 is “bizarre personal appearance,” while R46.0 is “very low level of personal hygiene.”

    And, it’s not clear how many klutzes want to notify their insurers that a doctor visit was a W22.02XA, “walked into lamppost, initial encounter” (or, for that matter, a W22.02XD, “walked into lamppost, subsequent encounter”).

    Continued at the Wall St. Journal:

    http://online.wsj.com/article/SB10001424053111904103404576560742746021106.html?mod=WSJ_0_0_WP_2715_RIGHTTopCarousel_1

    Helen

    Like

  3. OIG to Focus on Upcoding of E/M Codes

    When the fraud-busting unit of the U.S. Department of Health and Human Services (HHS) publishes an analysis of physician behavior, questions naturally arise as to whether some sort of crackdown on physician misbehavior is around the corner. Case in point is a report issued in May by that dreaded HHS unit, the Office of Inspector General (OIG). The OIG found that from 2001 to 2010, physicians increased their use of higher-level — and more lucrative — billing codes for evaluation and management (E/M) services in the course of treating Medicare patients.

    The coding trend of up, up, and away held true across 13 different categories of E/M services, which include new patient office visits, initial and subsequent inpatient hospital care, emergency department visits, and initial and subsequent nursing home care. The OIG states that it did not determine whether physicians who chose more 99214s and other higher-level E/M codes in 2010 billed Medicare inappropriately or fraudulently. That line of inquiry, it says, will be the focus of future reports.

    Source: Robert Lowes, Medscape News [7/20/12]

    Like

  4. CMS proposes complex care payment

    Medicare only pays for primary care management services as part of a face-to-face visit.

    http://www.physbiztech.com/news/compliance/cms-proposes-payment-complex-care-management

    Under a proposed rule issued July 8th, the Centers for Medicare & Medicaid Services would make a separate payment to physicians for managing select patients’ care needs beginning in 2015.

    Dr. Thacher

    Like

  5. To iMBA, Inc

    While most of the healthcare service payment in the USA is processed through third party with CPT codes for billing procedures; in Hong Kong, 66% of private healthcare services were mainly financed by out-of-pocket household payment and insurance pay-out only 28% of all private healthcare services (Hong Kong’s Domestic Health Accounts as at 2007-08).

    Yet, some of the private hospitals only accept certain Private Insurance Companies or cash.

    Hong Kong is blessed with a public healthcare system where 90% of in-patient services are provided by public hospitals (27,000 hospital beds and 87% of total hospital beds in Hong Kong).

    As long as you have a Hong Kong Resident ID Card; the charges is about HKD $100 (USD $13) per inpatient bed. Hong Kong public healthcare is mainly subsidized by the government.

    On the other hand, if you have to seek healthcare service at local Chinese Public Hospital in China. The patients have reported that payment for the service is paid prior to the treatment received and often the fee is much different (higher) than the standard charges demanded by the public hospital.

    Ken Yeung MBA
    [Certified Medical Planner™ candidate]

    Like

  6. Why CMS Wants Surgeons to Code Every 10 Minutes

    The comments flooded in after the CMS proposed in July that surgeons collect data on every 10 minutes of perioperative activity. “Undue burden,” the American Medical Association called the suggested requirement. The American Association of Neurological Surgeons and Congress of Neurological Surgeons warned that the approach “is onerous and will result in under-reporting of data.” To stop and code how they spend every 10 minutes of their time would be a tall order to ask of anyone, much less busy doctors and surgeons. So why did the CMS do it?

    As the agency explains in its 2017 Medicare Physician Fee Schedule, the CMS pays for certain services, like surgery, as global packages, issuing a single established payment “for particular services that we assume to be typically furnished during the established global period,” which can be zero, 10 or 90 days. The problem with this is that the CMS was having trouble with the valuation of its 10 and 90-day global packages, which meant it was paying for it-didn’t-exactly-know-what services. To determine precisely what services physicians were providing, “all codes are intended to be reported in 10-minute increments,” as either typical, complex, or critical inpatient or outpatient visits, the CMS said.

    Source: Elizabeth Whitman, Modern Healthcare [9/28/16] via PMNews #5,769

    Like

  7. Update

    ICD-9 contained about 14,400 -16,000 different codes: but ICD-10 has over 70,000 codes. So much for value based care!

    Dr. David Edward Marcinko MBA

    Like

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