Author Topic: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid  (Read 7481 times)

Billergirlnyc

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #15 on: May 14, 2013, 11:18:04 PM »
The RBRVS - used by Medicare/other govt programs for Physician and outpatient services

This may seem a silly question... but I often see refering to "Physician and outpatient services". Shouldn't it be enough to say "outpatient services" or "physician" is added because in an outpatient environment the physician can charge separately from the outpatient service itself? Or is it used to distinguish between hospital and non-hospital services?

I should've added "SOME" outpatient services.

Now, the simple answer to this is the distinction is made because place of service depending on the type of service can affect a doctor's reimbursement because Medicare reimburses doctors based on RVUs (relative value units. -- commercial carriers may be different but for this topic I'm speaking strictly about Medicare). Remember: An RVU has three components: work, practice expense, and malpractice. The place of service is part of the practice expense component, and procedures that can be performed in either a facility or non-facility setting have different practice expense RVUs, depending on the place of service.  I (and I believe Linda did too) sort of went into this in my other responses when I talked about professional services and how they're billed on the 1500 if the doctor is billing for the professional component of a service versus the technical. Medicare looks at if a service is performed at a facility of non-facility setting (non-facility would be the doctor's office, etc). A doctor would be paid more for performing services in his/her office over a facility, because they can't be paid based on all the 3 components of the RVU for services done in a facility setting, since they don't own nor incur any expense at the facility, but they do own or incur expenses at their own private office. So yes it's used to distinguish between facility and non-facility is a better way to look at why they make the distinction.
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rferreira

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #16 on: May 15, 2013, 10:11:31 AM »
However - we need to make a distinction here between private physicians who have privileges at the hospital versus staff physicians who are employed by the hospital.  We bill for private physicians who do procedures on patients admitted to the hospital (inpatient status).  We use the procedure codes (CPT) from the AMA - not the procedure codes from ICD-9, Ver. 3.  It must be that procedure codes from ICD-9, Ver. 3 are used by hospital staff doctors.  Perhaps you know this already?

According to the information that I have, when the staff is employed by the hospital, the procedures have to be coded in ICD to compute the DRG which will define the payment that the hospital will get.
However, as every rule has its exception (and as in healthcare we have plenty of exceptions  :-\) there are some inpatient procedures that are coded in CPT/HCPCS (see, for instance, http://www.hcpro.com/HIM-285237-3288/Inpatientonly-procedures-Accuracy-helps-avoid-denials-ensure-compliance.html).


So - can an inpatient who is treated by a private physician have a DRG(s) assigned to them?  If this previous comment of yours is true, then probably not.

I have no idea. But if you say that a private physician in inpatient will have its services coded in CPT (hence, consequently no DRG will be generated based in these services, unless we have automatic cross mapping and/or dual coding...), I would say that the patient episode will also have a DRG associated to it only if there are additional procedures coded in ICD and diagnoses as well, which will be used to typify the rest of the
treatment provided in the hospital. This assumes two reimbursement streams:
1. insurer->private physician concerning to the services provided by the private physician
2. insurer->hospital concerning to the rest of the services provided by the hospital staff.
If all the treatment is provided by the private physician the 2nd stream will not make sense.
I would not be surprised if this scenario occurs, but as I have no coding or billing experience, I cannot confirm it.

Nevertheless, I'm going to investigate this topic and if I found additional information I'll share it.

Ricardo
« Last Edit: May 15, 2013, 10:14:33 AM by rferreira »

RichardP

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Re: ICD procedures vs. CPT&HCPCS procedures and how physicians get paid
« Reply #17 on: May 15, 2013, 11:14:43 AM »
This assumes two reimbursement streams:
 
1. insurer->private physician concerning to the services provided by the private physician
2. insurer->hospital concerning to the rest of the services provided by the hospital staff.

If all the treatment is provided by the private physician the 2nd stream will not make sense.
I would not be surprised if this scenario occurs, but as I have no coding or billing experience, I cannot confirm it.

A number of our clients co-own a facility (surgical center).  Based on our experience with this, which includes the two reimbursement streams listed below,  I will say that your two reimbursement streams quoted above are absolutely correct.  And this also speaks to the points made by Billergirlnyc in her last several points.  For any reimbursement, there are always at least these two charge streams / reimbursement streams:

1.  cost of the provider (what he gets paid for the procedure(s), labs, radiology, etc. performed), and;
2.  cost of the facility (to include facility overhead and supplies used up in the performance of the procedure(s)).

Codes are structured so as to distinguish between these two cost creaters / reimbursement streams - service/procedure fees and facility fees.  (See Billergirlnyc comments above.)

So, your statement If all the treatment is provided by the private physician the 2nd stream will not make sense needs to be interpreted in the context of these two cost creators:

When the private doctor is providing service in his private office, at least the Medicare reimbursement calculations take into account the facility overhead and supplies used up in the performance of the procedures.  Because both sources of cost are included in this calculation by Medicare, there is only one reimbursement stream.  Both facility costs and procedure charges are included in this one reimbursement.

When the private doctor is providing service in some facility other than in his private office (e.g. surgical center, hospital), by definition there must be two reimbursement streams (from Medicare at least).  Since the doctor does not own the facility in which he is doing the procedure(s), it makes no sense for Medicare to send reimbursement for both facility costs and procedure charges to the provider.  So - provider bills for and gets paid for procedures (using AMA CPT Codes) and facility (surgical center; hospital) bills for and gets paid for facility fees (using ICD-9, Vol 3 procedure codes where appropriate).

So - to rephrase your statement - Even if all the treatment is provided by the private physician, the 2nd stream makes sense because it is needed to cover facility costs.  I've just outlined the basic reason why this statement is true.  As you noted, there are always exceptions - and I'm sure there are exceptions to this as well.  But, this basic setup holds in the majority of instances.

Because of the potential for confusion and error in properly billing for facility fees and procedure and lab charges, we turned down our clients' request that we also handle the billing for the co-owned surgical center.  We asked that they instead turn to someone well-versed in the ways of billing for facilities, which they did.  But we have to coordinate with the facility-fee billers, so it is obvious to us that there are two reimbursement streams to the physicians that co-own and use the surgical center.

Edit:  Regarding the phrase used by rferreira in #2 above -  the rest of the services provided by the hospital staff:  For the purposes of simplification to make a point in this post, I'm including these services provided by the hospital staff, and reimbursement for them, in my term overhead - which is part of the facility fee / reimbursement calculation.  Whether the rest of the services provided by the hospital staff is actually part of the facility fee / reimbursement in real life, I don't know.
« Last Edit: May 15, 2013, 11:24:28 AM by RichardP »