Episode 21

CPT Codes and How You Get Paid in Medicare

Your Hosts

About this Episode

  • Discussion topic: Getting paid through the Medicare system
  • Introduction to CPT codes and HICPICS codes
  • Medicare's payment process for healthcare providers
  • Future guests and topics related to Medicare reimbursement
  • Mention of the Aging Here newsletter and interview opportunities
  • Differentiating between CPT codes and ICD-10 codes
  • History and purpose of CPT codes
  • Explanation of RVUs (Relative Value Units) and how doctors are paid
  • Simplified process of submitting CPT codes to Medicare for payment
  • Potential fraud issues in fee-for-service Medicare
  • Importance of documentation and medical necessity for CPT codes
  • Challenges with lack of comprehensive guidelines for new codes
  • Providers struggle with the interpretation and utilization of CPT codes.
  • Some codes are rarely utilized, while others require expertise to maximize billing.
  • Coding rules can be complex, with restrictions on code combinations and frequency of billing.
  • Providers face the risk of financial penalties or legal consequences for incorrect coding.
  • Medicare is a significant payer and requires compliance with its rules.
  • Physicians, nurse practitioners, and physician assistants primarily use CPT codes.
  • Modifiers can be used to bill for additional services or special circumstances.
  • Hospice CPT codes exist separately from Part B coding.
  • CPT codes have RVUs (Relative Value Units) that determine payment.
  • RVUs are divided into work RVUs, which assess the labor involved in a procedure.
  • Work RVUs consider time, technical skill, physical effort, mental effort, judgment, and stress.
  • Work RVUs are subject to negotiation and lobbying each year.
  • The conversion factor translates RVUs into payment amounts.
  • The conversion factor is subject to annual adjustments and can significantly impact reimbursement.