Episode 21

CPT Codes and How You Get Paid in Medicare

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June 6th, 2023

42 mins 43 secs

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work rvu conversion factor in medicare payments resource-based relative value scale (rbrvs) hospice cpt codes rvus (relative value units) modifiers in billing medicare provider requirements coding expertise medicare reimbursement critical care time codes evaluation and management codes cpt code utilization chronic care management codes medicare billing cpt codes

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.