26. CODING What I did and why I did it Each year, in the United States, health care insurers process over 5 billion claims for payment. Centers for Medicare and Medicaid Services, 2006
32. Service/Goods/Facilities America's Health Insurance Plans, a trade group for the managed care industry, said that a survey of its members found that 75 percent of current claims were now electronic, compared with 44 percent four years ago. New York Times, May 26, 2006
33. Service/Goods/Facilities UB04 Facility type claims Cover a period. Revenue Codes Developed by the American Hospital Association, to bill services, drugs, and supplies furnished in the hospital. These lines shows the total for ALL the charges for that type of service in that period. Prospective Payment Systems DRG In-Patient: Diagnosis Related Group APC Outpatient: Ambulatory Payment Classification Per-Diems
34. Service/Goods/Facilities RBRVS Resource Based Relative Value Scale President George H.W. Bush Omnibus Budget Reconciliation Act, 1989 1988- Dr. William Hsaio Harvard University Relative Values Assigned - Physician Work - Practice Expense Facility Non-Facility - Malpractice Geographically adjusted - GPCI (“gypsy”) CMS 1500 (08/05)
35. Relative Value Update Committee Determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA representative, a representative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee. Who Decides?
36. How do I use it? Find the CPT code It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/
37. How do I use it? Determine the GPCI (Geographic Practice Cost Index) for each RVU It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/
38. How do I use it? Multiply the RVUs by their GPCIs Multiple the WORK result by the Budget Neutrality Factor
40. How do I use it? Multiply the adjusted RVU total by the National Conversion Factor and you’re done!
41. or, you can go to: http://www.medicarenhic.com/cal_prov/fee_sched.shtml And download the fee schedule!
Why start with Winston Churchill? Because England, like every other modern industrialized nation but ours, differs from us in the way they have all chosen to provide healthcare to their citizens. This decision has given us a complicated, expensive, and by many measures a deeply flawed system. This talk however will not debate that issue. Michael Moore’s recent movie “Sicko” has done a pretty good job illustrating some of these problems. Instead, I will give a brief discussion of our system as it exists now and ideally provide you with the background you should have in order to function adequately within it.