HOW DO I EVENTUALLY GET PAID? Phillip Ward, DPM CPT Advisor, CPT Assistant Editorial Panel Member

Transcription

1 HOW DO I EVENTUALLY GET PAID? Phillip Ward, DPM CPT Advisor, CPT Assistant Editorial Panel Member

2 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.

3 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

4 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

5 ICD and CPT Agreement The code you pick for the diagnosis must relate to the code you pick for the treatment

6 Diagnosis History Lesson 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 6 th time and added morbidity Manual of International Statistical Classification of Diseases, Injuries and Causes of Death (MISCDICD6 th R)

7 Diagnosis History Lesson WHO produced the 7 th revision and named the book International Classification of Diseases (ICD-7) 1960 s revised again ICD 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 ICD-10 introduced

8 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

9 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 non insulin dependent diabetes mellitus hallux valgus

10 ICD-10 ICD-10 takes effect in the USA Oct 1, alpha numeric digits Biggest change in healthcare since Medicare

11 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

12 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

13 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

14 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

15 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

16 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

17 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

18 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

19 Medicare RBRVS Components of the Medicare RBRVS Resource Based Relative Value System Physician Work 52% Practice Expense 44% Malpractice Expense 4%

20 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)

21 RUC Survey RUC Process 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

22 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.

23 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

24 HCPAC Health Care Professional Advisory Committee Advises full RUC on clinical issues 14 representatives 11 non MD/DO groups 3 MD RUC representatives

25 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

26 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 3 rd party insurance companies assign any value for a code and it does not have to be based on the RBRVS or CMS values

27 APMA INVOLVEMENT APMA is the only organization representing the interests of podiatric physicians and surgeons at ICD, CPT and RUC

28 NEUROMA INJECTION EXAMPLE

29 So Why Is This Important To Me?

30 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

31 Questions?