how do i eventually get paid?...• eventually get paid less than you deserve • rant / rave / go...
TRANSCRIPT
HOW DO I EVENTUALLY GET
PAID?
Phillip Ward, DPM
CPT Advisor,
CPT Assistant Editorial Panel Member
This PowerPoint presentation is being provided as a free member benefit for APMA Young Physicians. Please be reminded that CPT code descriptors and coding policies do not reflect coverage and payment policies. The existence of a CPT code does not ensure payment for any service. The coverage and payment policies of governmental and commercial payers may vary. Questions regarding coverage and payment for an item or service should be directed to particular payers. Any coding advice in this presentation reflects the opinions of the APMA Coding Committee only. APMA disclaims responsibility for any consequences or liability attributable to the use of the information contained in this presentation. This PowerPoint is the property of the American Podiatric Medical Association. Any use not authorized in writing by the APMA, including distribution to individuals who are not members of the APMA, is strictly prohibited.
How The Process Should Work
• Evaluate and Manage the patient
• Decide on a diagnosis (ICD)
• Decide on the treatment code (CPT,
HCPCS, DME)
• Bill the patient / insurance company
• Receive payment
How The Process Sometimes
Work • Evaluate and Manage the patient
• Decide on a diagnosis (ICD)
• Decide on the treatment code (CPT,
HCPCS)
• Bill the patient / insurance company
• Wait to Receive payment
• Eventually get paid less than you deserve
• Rant / rave / go home and kick the dog
ICD and CPT Agreement
• The code you pick for the diagnosis must
relate to the code you pick for the
treatment
Diagnosis History Lesson 101
1700 “Nosologia methodica” – Sauvages
1785 “Synopsis nosologiae” – Cullen
Adopted by Royal College of Physician in Edinburg
1855 uniform disease classification system developed in
the United Kingdom “Manual of International Statistical
Classification of Diseases”
1948 World Health Organization revised it for the 6th time
and added morbidity “Manual of International Statistical
Classification of Diseases, Injuries and Causes of Death”
(MISCDICD6th R)
Diagnosis History Lesson 101
• 1955 WHO produced the 7th revision and
named the book “International Classification of
Diseases” (ICD-7)
• 1960’s revised again ICD-8
• 1977 revised again ICD-9-CM
– CM = Clinical Modification
– US adopted ICD-CM-9 2 years after the rest
of the world
• 1980 WHO started work on ICD-10
• 1994 ICD-10 introduced
Diagnosis History Lesson 101
In 1994 the National Center for Health Services
(NCHS) developed the US ICD-10-CM through
the Center for Health Policy Studies
1997 US prototype made available for comments
2003 preliminary analysis of US ICD-10-CM
published
2005 WHO starts work on ICD-11-CM
2014 US adopts ICD-10-CM
ICD-9
• ICD-9 is owned and operated by WHO
• Suggested codes can be submitted to WHO and
if approved by their panel are included in the
next published book (Oct of each year)
• ICD-9 codes are 3-5 digits and can be found
either alphabetically, numerically or by specific
condition
• Examples
– 250.00 non insulin dependent diabetes
mellitus
– 735.0 hallux valgus
ICD-10
• ICD-10 takes effect in the USA
Oct 1, 2015
• 3-7 alpha numeric digits
• Biggest change in healthcare since
Medicare
Current Procedural Terminology
(CPT)
• CPT is owned and operated by AMA
• AMA makes over $25 million annual income from
CPT
– Due to low membership numbers AMA would be out of
business without the income from CPT
• CPT codes describe services and procedures
CPT
• CPT Editorial Panel
– Comprised of 17 members
– Meets 3x/year (Feb, June, Oct)
– Creates new codes and revises existing
codes
– Input from Advisors representing most
medical specialties and coding
organizations
CPT Process
• Code Change Proposal – submitted by society, industry or individual applying for new or revised code
• CPT Advisors given opportunity to comment
• Presented to the CPT Editorial Panel
– Proposal must be defended at CPT meeting
– Panel may modify proposal without presenter’s consent
– Vote to pass, fail, table, postpone to new time
Timing
• Code proposals must be submitted three months in
advance of the meeting at which they will be
considered
• Advisors submit comments on proposals of interest
• Meeting and timing of code inclusion in the CPT
book
– February meeting – Jan 11 months away
– June meeting – Jan 18 months away
– Oct - Jan 14 months away
Timing-Example
– February 2014 CPT codes
• Applications submitted by November 2013
• Considered by CPT in February 2014
• Valued by RUC in April 2014
• Category I codes implemented January 1, 2015
• Category II codes are HCPCS codes and outside CPT
• Category III codes implemented when published by AMA
CPT ASSISTANT
• Owned and operated by AMA
• 15 person panel elected by CPT Assistant
Panel and approved by AMA BOT
• Representatives from specialty societies
as well as payers
• Designed to explain problems and settle
questions in specific CPT codes
• Published monthly
From CPT to RUC…
• All Category I CPT codes are valued through the
RUC process
– Previously established codes with editorial
revisions only generally do not require
RUC review
– Category II and III codes do not get RUC
valuation and are valued by individual
insurance companies
Relative Value Services Update
Committee (RUC) • Owned and operated by AMA, funded through CPT
royalties
• Evaluates physician work and practice expense for
codes and recommends work relative value units and
practice expense inputs
• Comprised of 29 member panel plus specialty advisors
• CMS representatives participate in RUC deliberations
• RUC meets 3x/year + 1 additional meeting every 5
years for 5 year review
Medicare RBRVS
• Components of the Medicare RBRVS
– Resource
– Based
– Relative
– Value
– System
Physician Work – 52%
Practice Expense – 44%
Malpractice Expense – 4%
Reimbursement Formula
Payment
=
(RVU work x GPCI work)
+
(RVU PE x GPCI PE)
+
(RVU malpractice x GPCI malpractice)
x
Conversion Factor
( the CF is set by Congress, this is where the SGR comes into play)
RUC Process
• RUC Survey
– Process by which interested specialties collect information on physician time and intensity for the code
– Survey data is collected by AMA and evaluated then presented to the RUC
RUC Process
• Recommendations for physician work are
presented in-person to a panel of 29 physicians
from different specialties (e.g., Cardiology,
Orthopedics, Radiology, Neurosurgery, General
Surgery, Pathology, Plastic Surgery, Internal
Medicine, etc)
• Debate at the panel then ensues. These debates
can get very contentious and at times
argumentative.
RUC Process
– Most APMA codes considered by full RUC
since MD/DO specialties share the codes
• APMA routinely collaborates with
general surgery, orthopedics, plastic
surgery, dermatology, internal
medicine & others
HCPAC
• Health Care Professional Advisory Committee
• Advises full RUC on clinical issues
– 14 representatives
• 11 non MD/DO groups
• 3 MD RUC representatives
RVUs for Practice Expense (PE)
• Practice Expense Review Committee (PERC)
– Subcommittee of the RUC that reviews
recommendations for practice expense:
• Clinical staff time
• Supplies
• Equipment
• All RUC recommendations are subject to CMS
review and approval
– Historically, CMS annually approves over
95% of RUC recommendations
• Changes are announced via the Federal Register
• New values are implemented on January 1
• Other 3rd party insurance companies assign any
value for a code and it does not have to be based on
the RBRVS or CMS values
APMA INVOLVEMENT
APMA
is the
only organization
representing the interests of podiatric
physicians and surgeons at
ICD, CPT and RUC
NEUROMA INJECTION EXAMPLE
So Why Is This
Important To Me?
Employment models and how
you can get paid • Salary
• Percentage of collections
• Combination of those 2
• RVUs
• RVUs plus bonus over set expectations
• wRVUs
• wRVUs plus bonus over set expectations
Questions?