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 Understand
 How physicians generate revenue
 How medical billing works
 Become familiar with
 CPT coding
 ICD coding
Dependent on
adequate and
appropriate
medical
documentation
Document encounter
Pertinent positive and negative findings in history and exam
Differential diagnoses
Treatment options
R...
Rejected by Insurance
Accepted
90%
Rejected
10%
Physicians Practice, 5 Common Medical Practice Denials, May 2014
http://www.physicianspractice.c...
Physicians Practice, 5 Common Medical Practice Denials, May 2014
http://www.physicianspractice.com/medical-billing-collect...
Rejected by Insurance
High Rejection Rate
Slow Submission
Of Claims
Inaccurate or
Incomplete claims
Delayed
Coding
Inaccuracy
Slow approval
Of c...
Low Rejection Rate
Fast Submission
Of Claims
Accurate and
Complete Claims
Prompt
Coding
Accuracy
Good
Documentation
Timely...
Business in Medicine
 Current Procedural Terminology (CPT)
Codes
 Code for services provided
 Hospital admission
 Follow up visit
 Procedu...
= Service
Codes
 Current Procedural Terminology (CPT) codes
 Developed by the American Medical Association
 Describe medical services
...
 Medical documentation
 H&P
 Progress Note
 Operative note
 Order for a test or imaging study
 Diagnosis (ICD) Codes
= Diagnosis
Codes
 Diagnosis codes!
 International Classification of Diseases (ICD)
 ICD-9 - 17,000 codes
 ICD-10 - 155,000 codes
 ICD-...
Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level...
Procedure CPT Code Medicare Allowable
Charge
Arthroplasty, knee,
(TKA)
27447 $1,682
No levels for this service
This is for...
OR
Insurance
Claim #1
Insurance Claim #2
Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level...
Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level...
Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare A...
Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare A...
Medicare
Alone
Medicare +
Supplemental
Insurance
Medicaid
(IL)
No
Insurance
Practice Charge $392 $392 $392 $392
Medicare A...
Rejected by Medicare
Rejected by Supplemental
Only Eligible for payment if
Claim Accepted by Medicare
80%
20%
Portion of
C...
 Complex and Lengthy Process
 Influence factors you can control
 Timeliness of coding
 Accuracy of coding
CPT
ICD
 ...
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
Physician Revenue - Getting paid for the work you do
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Physician Revenue - Getting paid for the work you do

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Gain an understanding of the basics of how physicians are paid - fee for service, quality bonuses, healthcare insurance, revenue sharing and more are discussed in this presentation.

Published in: Healthcare
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Physician Revenue - Getting paid for the work you do

  1. 1.  Understand  How physicians generate revenue  How medical billing works  Become familiar with  CPT coding  ICD coding
  2. 2. Dependent on adequate and appropriate medical documentation
  3. 3. Document encounter Pertinent positive and negative findings in history and exam Differential diagnoses Treatment options Risks and benefits to patient of treatment options
  4. 4. Rejected by Insurance
  5. 5. Accepted 90% Rejected 10% Physicians Practice, 5 Common Medical Practice Denials, May 2014 http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014
  6. 6. Physicians Practice, 5 Common Medical Practice Denials, May 2014 http://www.physicianspractice.com/medical-billing-collections/5-common-medical-practice-denials-and-remedies-may-2014  Duplicate Claim  Missing Required Information  Service Included In Service Previously Paid  Non-Covered Service  Late Claim Filing
  7. 7. Rejected by Insurance
  8. 8. High Rejection Rate Slow Submission Of Claims Inaccurate or Incomplete claims Delayed Coding Inaccuracy Slow approval Of claims Slow payment Audits Inadequate documentation
  9. 9. Low Rejection Rate Fast Submission Of Claims Accurate and Complete Claims Prompt Coding Accuracy Good Documentation Timely Billing Prompt approval Prompt Payment
  10. 10. Business in Medicine
  11. 11.  Current Procedural Terminology (CPT) Codes  Code for services provided  Hospital admission  Follow up visit  Procedure  Code for level of service  Ranked 1-3 or 1-5 for some services  Higher levels result in higher payment
  12. 12. = Service Codes
  13. 13.  Current Procedural Terminology (CPT) codes  Developed by the American Medical Association  Describe medical services  Patient visits  Procedures  Tests  Used by Medicare since 1978, other insurers quickly followed
  14. 14.  Medical documentation  H&P  Progress Note  Operative note  Order for a test or imaging study  Diagnosis (ICD) Codes
  15. 15. = Diagnosis Codes
  16. 16.  Diagnosis codes!  International Classification of Diseases (ICD)  ICD-9 - 17,000 codes  ICD-10 - 155,000 codes  ICD-10 will be required starting in 2015
  17. 17. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed Three levels for this service 1997 E&M Documentation Guidelines Used by physician to determine what level to bill
  18. 18. Procedure CPT Code Medicare Allowable Charge Arthroplasty, knee, (TKA) 27447 $1,682 No levels for this service This is for the physician’s component of the service Hospital and device costs are billed separately
  19. 19. OR Insurance Claim #1 Insurance Claim #2
  20. 20. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
  21. 21. Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
  22. 22. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014
  23. 23. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014 The Medicare Allowable Charge may not cover the cost of providing the medical service and is independent of what a physician might charge (bill) for these services. Physicians are prohibited from collecting the difference between the charge and the Medicare Allowable Charge.
  24. 24. Medicare Alone Medicare + Supplemental Insurance Medicaid (IL) No Insurance Practice Charge $392 $392 $392 $392 Medicare Allowable Fee $204 $204 Medicare Responsibility $163 $163 Supplemental Responsibility $0 $41 Patient Responsibility $41 $0 $0 $392 Total Payment $204 $204 $67 ? 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed 6/26/2014 Illinois Medicaid Fee Schedule, Accessed 7/29/2014 Many practices report the cost of providing services to patients with Medicaid for healthcare coverage exceeds reimbursement. Payment from patients without insurance is variable, but they are charged at the highest rate.
  25. 25. Rejected by Medicare Rejected by Supplemental Only Eligible for payment if Claim Accepted by Medicare 80% 20% Portion of Charges
  26. 26.  Complex and Lengthy Process  Influence factors you can control  Timeliness of coding  Accuracy of coding CPT ICD  Quality of medical documentation

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