CPT Codes and How You Get Paid in Medicare
June 6th, 2023
42 mins 43 secs
- 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.