HOW DO I EVENTUALLY GET

PAID?

Phillip Ward, DPM

CPT Advisor,

CPT Assistant Editorial Panel Member

This PowerPoint presentation is being provided as a free member benefit for APMA Young Physicians. Please be reminded that CPT code descriptors and coding policies do not reflect coverage and payment policies. The existence of a CPT code does not ensure payment for any service. The coverage and payment policies of governmental and commercial payers may vary. Questions regarding coverage and payment for an item or service should be directed to particular payers. Any coding advice in this presentation reflects the opinions of the APMA Coding Committee only. APMA disclaims responsibility for any consequences or liability attributable to the use of the information contained in this presentation. This PowerPoint is the property of the American Podiatric Medical Association. Any use not authorized in writing by the APMA, including distribution to individuals who are not members of the APMA, is strictly prohibited.

How The Process Should Work

• Evaluate and Manage the patient

• Decide on a diagnosis (ICD)

• Decide on the treatment code (CPT,

HCPCS, DME)

• Bill the patient / insurance company

• Receive payment

How The Process Sometimes

Work • Evaluate and Manage the patient

• Decide on a diagnosis (ICD)

• Decide on the treatment code (CPT,

HCPCS)

• Bill the patient / insurance company

• Wait to Receive payment

• Eventually get paid less than you deserve

• Rant / rave / go home and kick the dog

ICD and CPT Agreement

• The code you pick for the diagnosis must

relate to the code you pick for the

treatment

Diagnosis History Lesson 101

1700 “Nosologia methodica” – Sauvages

1785 “Synopsis nosologiae” – Cullen

Adopted by Royal College of Physician in Edinburg

1855 uniform disease classification system developed in

the United Kingdom “Manual of International Statistical

Classification of Diseases”

1948 World Health Organization revised it for the 6th time

and added morbidity “Manual of International Statistical

Classification of Diseases, Injuries and Causes of Death”

(MISCDICD6th R)

Diagnosis History Lesson 101

• 1955 WHO produced the 7th revision and

named the book “International Classification of

Diseases” (ICD-7)

• 1960’s revised again ICD-8

• 1977 revised again ICD-9-CM

– CM = Clinical Modification

– US adopted ICD-CM-9 2 years after the rest

of the world

• 1980 WHO started work on ICD-10

• 1994 ICD-10 introduced

Diagnosis History Lesson 101

In 1994 the National Center for Health Services

(NCHS) developed the US ICD-10-CM through

the Center for Health Policy Studies

1997 US prototype made available for comments

2003 preliminary analysis of US ICD-10-CM

published

2005 WHO starts work on ICD-11-CM

2014 US adopts ICD-10-CM

ICD-9

• ICD-9 is owned and operated by WHO

• Suggested codes can be submitted to WHO and

if approved by their panel are included in the

next published book (Oct of each year)

• ICD-9 codes are 3-5 digits and can be found

either alphabetically, numerically or by specific

condition

• Examples

– 250.00 non insulin dependent diabetes

mellitus

– 735.0 hallux valgus

ICD-10

• ICD-10 takes effect in the USA

Oct 1, 2015

• 3-7 alpha numeric digits

• Biggest change in healthcare since

Medicare

Current Procedural Terminology

(CPT)

• CPT is owned and operated by AMA

• AMA makes over $25 million annual income from

CPT

– Due to low membership numbers AMA would be out of

business without the income from CPT

• CPT codes describe services and procedures

CPT

• CPT Editorial Panel

– Comprised of 17 members

– Meets 3x/year (Feb, June, Oct)

– Creates new codes and revises existing

codes

– Input from Advisors representing most

medical specialties and coding

organizations

CPT Process

• Code Change Proposal – submitted by society, industry or individual applying for new or revised code

• CPT Advisors given opportunity to comment

• Presented to the CPT Editorial Panel

– Proposal must be defended at CPT meeting

– Panel may modify proposal without presenter’s consent

– Vote to pass, fail, table, postpone to new time

Timing

• Code proposals must be submitted three months in

advance of the meeting at which they will be

considered

• Advisors submit comments on proposals of interest

• Meeting and timing of code inclusion in the CPT

book

– February meeting – Jan 11 months away

– June meeting – Jan 18 months away

– Oct - Jan 14 months away

Timing-Example

– February 2014 CPT codes

• Applications submitted by November 2013

• Considered by CPT in February 2014

• Valued by RUC in April 2014

• Category I codes implemented January 1, 2015

• Category II codes are HCPCS codes and outside CPT

• Category III codes implemented when published by AMA

CPT ASSISTANT

• Owned and operated by AMA

• 15 person panel elected by CPT Assistant

Panel and approved by AMA BOT

• Representatives from specialty societies

as well as payers

• Designed to explain problems and settle

questions in specific CPT codes

• Published monthly

From CPT to RUC…

• All Category I CPT codes are valued through the

RUC process

– Previously established codes with editorial

revisions only generally do not require

RUC review

– Category II and III codes do not get RUC

valuation and are valued by individual

insurance companies

Relative Value Services Update

Committee (RUC) • Owned and operated by AMA, funded through CPT

royalties

• Evaluates physician work and practice expense for

codes and recommends work relative value units and

practice expense inputs

• Comprised of 29 member panel plus specialty advisors

• CMS representatives participate in RUC deliberations

• RUC meets 3x/year + 1 additional meeting every 5

years for 5 year review

Medicare RBRVS

• Components of the Medicare RBRVS

– Resource

– Based

– Relative

– Value

– System

Physician Work – 52%

Practice Expense – 44%

Malpractice Expense – 4%

Reimbursement Formula

Payment

=

(RVU work x GPCI work)

+

(RVU PE x GPCI PE)

+

(RVU malpractice x GPCI malpractice)

x

Conversion Factor

( the CF is set by Congress, this is where the SGR comes into play)

RUC Process

• RUC Survey

– Process by which interested specialties collect information on physician time and intensity for the code

– Survey data is collected by AMA and evaluated then presented to the RUC

RUC Process

• Recommendations for physician work are

presented in-person to a panel of 29 physicians

from different specialties (e.g., Cardiology,

Orthopedics, Radiology, Neurosurgery, General

Surgery, Pathology, Plastic Surgery, Internal

Medicine, etc)

• Debate at the panel then ensues. These debates

can get very contentious and at times

argumentative.

RUC Process

– Most APMA codes considered by full RUC

since MD/DO specialties share the codes

• APMA routinely collaborates with

general surgery, orthopedics, plastic

surgery, dermatology, internal

medicine & others

HCPAC

• Health Care Professional Advisory Committee

• Advises full RUC on clinical issues

– 14 representatives

• 11 non MD/DO groups

• 3 MD RUC representatives

RVUs for Practice Expense (PE)

• Practice Expense Review Committee (PERC)

– Subcommittee of the RUC that reviews

recommendations for practice expense:

• Clinical staff time

• Supplies

• Equipment

• All RUC recommendations are subject to CMS

review and approval

– Historically, CMS annually approves over

95% of RUC recommendations

• Changes are announced via the Federal Register

• New values are implemented on January 1

• Other 3rd party insurance companies assign any

value for a code and it does not have to be based on

the RBRVS or CMS values

APMA INVOLVEMENT

APMA

is the

only organization

representing the interests of podiatric

physicians and surgeons at

ICD, CPT and RUC

NEUROMA INJECTION EXAMPLE

So Why Is This

Important To Me?

Employment models and how

you can get paid • Salary

• Percentage of collections

• Combination of those 2

• RVUs

• RVUs plus bonus over set expectations

• wRVUs

• wRVUs plus bonus over set expectations

Questions?