Author Topic: I have a 2 part coding/reimbursement issue  (Read 3084 times)

Alice Scott

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I have a 2 part coding/reimbursement issue
« on: March 15, 2008, 08:41:04 AM »
Hi Alice & Michelle! I have a 2 part coding/reimbursement issue that I am hoping you might be able to help me with. I work for a company that finances medical treatment for disputed workers compensation claims and part of my job is to reprice codes based on the Illinois Work Comp fee schedule, however I am not very familiar with surgery and facility coding and reimbursement regulations. (My experience is primarily billing and collections within Chiro, PT and IM) I know multiple surgical and pain management procedures are reduced to 50% for the second and any subsequent procedures, however I am unsure if that applies to any CPT codes billed in addition to the primary procedure. For example if a doctor is billing CPT code 64520 (injection anesthetic agent, lumbar or thoracic ) and 77002 (Fluoroscopic guidance for needle placement) is the 77002 reduced? Iíve looked for information online, including the Illinois work comp website, even tried Googling it however havenít been able to find anything that explains which services are reduced or included and which ones arenít. The second part is the ASCs (Ambulatory Surgical Centers) we deal with bill the same CPT codes that the doctors use, instead of billing for the room, supplies, staff, time, etc.  and there is nothing indicating if the CPT codes used to bill facility fees are supposed to be reduced as to 50% as well. Is there any specific guidelines or general rules that will help me with this? Do you have reading suggestions or online articles that would help me get a better understanding of the coding and reimbursement regulations for these specialties?

Thank you so much for your help.

Randi F.

Hi Randi,

     I havenít come across this situation before and I too tried to do some research without any luck.  However, when I worked for United Health Care processing surgery claims,  the main surgical procedure was allowed at 100% of R&C and the subsequent procedures were allowed at 50% of R&C.  So that line of thinking is correct.  As for the second part of your question, Iím a little confused.  ASCís should be billing for the facility fees on UB04 forms using rev codes and the professional fees (if they bill them out for the doctors) on the CMS forms using cpt codes.  The facility fees should be different than the cpt codes used for the surgical procedures. 

I hope this information was at least a little helpful.

Thanks and good luck
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I have a 2 part coding/reimbursement issue
« on: March 15, 2008, 08:41:04 AM »