Developing and Managing the Medicare Physician Fee Schedule Practical Tools for Seminar Learning

Transcription

1 Developing and Managing the Medicare Physician Fee Schedule Practical Tools for Seminar Learning Copyright 2008 American Health Information Management Association. All rights reserved.

2 Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service. How to earn one (1) CEU for participation To earn one (1) continuing education unit, each participant must do the following: Step 1: Step 2: Step 3: Step 4: Listen to the seminar, via Webcast link or audio CD. Complete the assessment quiz contained in this resource book. Use the included answer key. Do not return the quiz to AHIMA. Save it for your records. EACH LISTENER must visit and complete the sign-in form and the seminar evaluation. After you complete the evaluation, you will receive your CE certificate which you should print for your records. The certificate must be retained by each participant as a record of their participation, along with a copy of their completed quiz. AHIMA i

3 Faculty Anita Hazelwood, MLS, RHIA, FAHIMA Anita Hazelwood is a Professor in the Health Information Management Department at the University of Louisiana at Lafayette located in Lafayette, Louisiana. She has a bachelor s degree in Medical Record Science, a Master s Degree in Library Science and has been a credentialed Registered Health Information Administrator (RHIA) for 32 years. In January of 2003, Anita was awarded the designation as Fellow by the American Health Information Management Association. Anita has actively consulted in hospitals, nursing homes, clinics, facilities for the mentally retarded and in other educational institutions. She has conducted numerous ICD-9-CM and CPT coding workshop throughout the state for hospitals and physicians offices and has written numerous articles and edited several coding publications for a major national company. Anita has co-authored two books titled ICD-9-CM Coding and Reimbursement for Physicians Services and ICD-10-CM Preview for which she won AHIMA s Legacy Award in On a professional level, Anita has been a member of the American Health Information Management Association (AHIMA) for 32 years and has served as a delegate from Louisiana several times. Anita served on the National Program Committee responsible for the planning of the 1998 national convention held in New Orleans, Louisiana. She was also a member of the Society for Clinical Coding (SCC) and served on the SCC Board as Secretary in 1998 and as the Internet Task Force chairman for As a board member, Anita has reviewed several coding related texts and has served as a resource consultant on coding issues. She is a member of the AHIMA s Assembly on Education (AOE) and has served as Membership Chairman, a member of the Nominating committee, and was on the Board of Directors. Anita was co-chairman of the 1996 Academic Forum of the AOE. She was the coordinator of the 1999 AOE Summer Symposium, a national meeting of HIM educators and practitioners. In addition, Anita has served on the faculty of the AOE s Teacher Preparation Workshop, an annual workshop designed to train new HIM educators. Anita is a member of the Louisiana Health Information management Association (LHIMA) and was selected as its 1997 Distinguished Member. She has served throughout the years as President, President-elect, Treasurer, Strategy manager and Board Member and has directed numerous committees and projects. AHIMA ii

4 Table of Contents Disclaimer... i How to earn one (1) CEU for participation... i Faculty...ii History of Medicine... 1 Participating in Medicare The Resource-Based Relative Value Scale System (RBRVS)... 2 Geographic Practice Cost Indices... 3 Basic Formula for Calculating RVUs for a Service or Procedure... 3 Example: Determining Payment for a Colonoscopy in New Orleans... 4 The Medicare Fee Schedule... 5 Tools to Use in Maintaining an Updated MFS Items Requiring Monitoring... 7 Common Errors in Coding and Reimbursement... 7 Resource/Reference List AHIMA Audio Seminars...xx About assessment quiz...xx Thank you for attending (with link for evaluation survey)...xx Appendix...xx Web Resource List...xx Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key AHIMA

5 History of Medicare The Social Security Act of 1965 The Centers for Medicare and Medicaid Services or CMS Four primary components of Medicare Medicare Part B Enrolling in Medicare s fee-for-service payment system Participating vs. Non-participating physicians 1 Participating in Medicare A physician that enters into an agreement to treat Medicare patients is considered a participating physician or PAR Accepts assignment A physician who does not enter into an agreement to treat Medicare patients is considered a Non-participating physician or Non-Par Accepts assignment Does not accept assignment Limiting charge continued 2 AHIMA 1

6 Participating in Medicare Participating and Nonparticipating Provider Payment Amounts PAR provider Non-PAR who accepts assignment Non-PAR who does not accept assignment Submitted Amount $ $ $ (the limiting charge) Medicare Physician Fee $ $ $ Schedule (MPFS) Allowed Amount 80% of MPFS Allowed Amount $ $ $ (this payment goes to the beneficiary who is responsible for paying the provider) Beneficiary Coninsurance $ $ $ due to provider (after the deductible has been met) Total Payment to provider/supplier $ $ $ The Resource-Based Relative Value Scale System (RBRVS) Background of the RBRVS system Definition of relative value Three components of a medical or surgical service Physician work Practice expense (PE) Site of service differential Professional liability expense (PLI) 4 AHIMA 2

7 Geographic Practice Cost Indices What are GPCIs? Review of GPCIs Where can a physician find the GPCIs for his/her locality? 5 Basic Formula for Calculating RVUs for a Service or Procedure Work RVU x Work [GPCI] + Practice Expense [PE] RVU x PE GPCI + Malpractice RVU x Malpractice GPCI = Total RVU for the service What is the conversion factor? How does the conversion factor affect payment? 6 AHIMA 3

8 Example: Determining Payment for a Colonoscopy in New Orleans, Louisiana CPT code for a diagnostic colonoscopy = RVUs Work = 3.69 Non-facility PE = 6.38 Professional Liability Insurance = 0.30 GPCIs Work = PE = PLI = Conversion factor $ (continued) 7 Example: Determining Payment for a Colonoscopy in New Orleans, Louisiana (3.69) x x x = = (Total RVU) x $ = $ AHIMA 4

9 The Medicare Fee Schedule Where can a provider find the Medicare Fee Schedule (MFS)? Status Indicator Codes Examples of status indicator codes Updating the Medicare Fee Schedule Notices in the Federal Register 9 Tools to Use in Maintaining an Updated MFS Program transmittals Locating program transmittals Electronic Remit Advice (ERA) CMS s Medicare fact sheet A Resource for Residents, Practicing Physicians and other Health Care Professionals 10 AHIMA 5

10 Tools to Use in Maintaining an Updated MFS National Relative Value File RVU08AB PPRRVU08.xls GPCI08.xls RVUPUF08.doc 11 Tools to Use in Maintaining an Updated MFS American Medical Association s website at Medicare RBRVS 2008: The Physicians Guide by AMA 12 AHIMA 6

11 Items Requiring Monitoring Changes to the CPT/HCPCS codes Appendix B AMA s CPT Changes: An Insider s View AMA s CPT Assistant Revisions to conversion factor Changes in the relative value units The RVS Update Committee (RUC) The physician s charges Global fee periods NCII edits 13 Common Errors in Coding and Reimbursement Clustering Unbundling Missed charges Missed modifiers 14 AHIMA 7

12 Resource/Reference List GPCIs Medicare Fee Schedule Descriptions of Status Indicators CMS Transmittals 15 Resource/Reference List Medicare Fact Sheet hedfctsht.pdf National Relative Value File A Resource for Residents, Practicing Physicians and other Health Care Professionals NCII 16 AHIMA 8

13 Resource/Reference List AMA CMS 17 AHIMA Audio Seminars/Webinars Visit our Web site for updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars American Health Information Management Association AHIMA 9

14 Assessment To access the assessment quiz that follows this seminar, download the seminar s resource book at: Thank you! Please visit the AHIMA Audio Seminars Web site to sign-in and complete your evaluation form to receive your CEU certificate at: AHIMA 10

15 Appendix Web Resource List Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key AHIMA

16 Appendix Web Resource List GPCIs Medicare Fee Schedule Descriptions of Status Indicators CMS Transmittals Medicare Fact Sheet National Relative Value File A Resource for Residents, Practicing Physicians and other Health Care Professionals NCII AMA CMS AHIMA

17 Assessment Quiz Developing and Managing the Medicare To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a copy of the completed quiz with your CE certificate. Do not send a copy to AHIMA. 1. A Medicare patient is seen in the physician s office. The total charges for the office visit are $ The patient has met his deductible for the year. The Medicare fee schedule amount for this service is $ If this physician is a participating physician who accepts assignment, what is the total amount that he will receive for this service? a. $ b. $ c. $ d. $ Using the information in question #1, how much will the physician receive from the patient? a. $ b. $ c. $40.00 d. The patient is not responsible for any payment to the physician 3. Using the information in question #1, if the physician is a non-participating physician who accepts assignment for this claim, the total amount that the physician will receive is: a. $ b. $ c. $ d. $ Which Relative Value Unit reflects the costs of employees, supplies, equipment and other overhead costs in providing a service to a patient? a. Practice expense b. Work expense c. Professional liability insurance d. Geographic cost indices 5. What is the best tool to use each year when performing a review of the fee ticket/superbill/encounter form for the procedures or services provided? a. ICD-9-CM Coding Clinic b. Appendix B of the CPT book c. Medicare Fact Sheet d. The surgical section of the CPT book 6. What is a physician who enters into an agreement with Medicare to accept assignment in full of the MFS allowable amount called? a. A gatekeeper b. A primary care provider or PCP c. A participating provider d. An assigned provider 7. What is the amount that a nonparticipating physician who does not accept assignment can bill a Medicare beneficiary called? a. Contracted write-off b. Prevailing amount c. Contractually-agreed amount d. Limiting charge 8. Under Medicare Part B, what amount of the Medicare fee schedule allowable amount is the beneficiary responsible for as a co-insurance amount? a. 10% b. 20% c. 25% d. The beneficiary does not have a co-insurance under Part B 9. In calculating the fee for a physician s reimbursement for a service performed, the three relative value unit components are each multiplied by: a. A conversion factor b. Geographic modifiers c. Geographic price indices d. Locality adjustment factor 10. What is the practice of charging/coding one or two middle levels of service codes exclusively called? a. Bundling b. Unbundling c. Clustering d. Optimizing Do not send a copy of completed quizzes to AHIMA. Please keep them with your CE certificate, for your records. Be sure to sign-in and complete your evaluation form, to receive your certificate, at AHIMA ANSWERS to this quiz are found on the last page of this Fast Facts Audio Seminar resource book, Practical Tools for Seminar Learning.

18 To receive your CE Certificate visit click on the link to Sign In and Complete Online Evaluation listed for this seminar. You will be automatically linked to the CE certificate for this seminar after completing the evaluation. Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information, in order to view and print the CE certificate.

19 Quiz Answer Key Fast Facts Audio Seminar: Developing and Managing the Medicare 1: a; 2: c; 3: d; 4: a; 5: b; 6: c; 7: d; 8: b; 9: c; 10: c Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA. Please keep it with your CE certificate, for your records. AHIMA