Monetary Value for CPT Procedure Codes

In 1992, Medicare established a value system for services provided to Medicare patients called the Resource-Based Relative Value System (or RBRVS). This system placed a value on each CPT code that was payable to Medicare based on resources. It replaced the old standard, which was “reasonable and customary” value. The resources the CMS used to determine a value for each code included physician work component, overhead component and malpractice. These values change on a yearly basis according to recommendations from the AMA and specialty societies. The Relative Value Scale Update Committee (or RUC) meets during the year to evaluate the recommendations and forward their recommendations to the CMS. In the fall of each year, the final rules and values are published by the CMS in the Federal Register, which establishes the CPT codes and the Medicare relative values assigned to those codes for the next year. Many third-party carriers also use these RVUs to determine how they will reimburse for services provided to their beneficiaries. The third-party payers will pay differently than Medicare, however, because the conversion factor per RVU will be based on contract negotiations with the payer or the contract offered by the carrier.

Suggestions for Coding and Reimbursement Techniques and Tools

Purchase new coding tools on a yearly basis. You should have a diagnosis coding book, a CPT book and a HCPCS book. You also need to have the Correct Coding Initiative (CCI), a free publication available on the CMS website (www.cms.hhs.gov). The CCI is a bundling program that gives information as to which codes may be charged together and which ones cannot be charged together on the same day of service.

Read payer billing manuals and local carrier directives. The Joint Council of Allergy, Asthma & Immunology website (www.jcaai.org) and publications provide up-to-date information appropriate for allergy practices. Also be aware of the different carrier billing guidelines and know the website for each carrier in order to find its specific guidelines. Each Medicare carrier will have local carrier directives that are accessible to every physician posted on their websites. The CMS also has national guidelines on their website, as well as information, tools and manuals.

1. Education regarding coding should be provided continually for all physicians and their staff. In light of ICD-10, this includes every staff member having a role to help ease this transition. Making a plan prior to this transition with different levels of the staff will ensure the most success. The guidelines for carriers may change, and you are held accountable for knowing the changes and for appropriately submitting claims.

2. A compliance plan should be implemented to support and define all the coding and billing policies of the practice. Designate someone, often the compliance officer, to be the recipient of all coding and reimbursement information and to inform involved individuals of any relevant coding changes. This person also should orient new staff, including physicians, to ensure that updated resources are available in the practice, and should research any changes pertinent to the practice

3. Electronic versions of several books and reference guides are now available for tablets/ IPads, as well as iOS and Android phones.