PHYSICIAN ALERT: PART III, HOW TO PACKAGE YOUR CLAIM TO THIRD PARTY PAYORS TO OBTAIN THE HIGHEST PAYMENT FOR MEDICAL SERVICES
Apple understands that packaging matters. The sleek iconic packaging of the iPad, iPod, and Mac laptop have contributed to sky rocketing sales for Apple. Steve Jobs credited packaging with the incredible success of Apple.
Likewise, packaging of claims by physicians seeking reimbursement from third party payors matters. The right packaging of claims will enable physicians to receive the highest possible payment for the medical services rendered to patients.
CPT Codes and RVU’s
Current Procedural Terminology (CPT) is a numeric coding system maintained by the American Medical Association and constitutes a uniform coding system comprised of descriptive terms and identifying codes that are used primarily to identify medical services and procedures furnished by physicians to patients. Health care professionals use the CPT to identify the services and procedures for which they bill public and private health insurance programs. Relative value units (RVU’s) are assigned to services to quantify the relative work, practice expenses, and administrative costs of furnishing the services. The RVU’s are a means by which a CPT code is converted into reimbursement and are used to determine the allowable payment for any code included in a third party payor’s physician fee schedule.
Medical providers submit claims to third party payors using CPT codes and RVU’s. Incomplete or inaccurate medical coding will cause a practice’s reimbursement to get delayed, partially paid, or denied altogether. Delayed, partially paid, or denied claims equal lost revenue and cash flow problems for the practice. Medical coding errors, sloppy documentation by physicians of treatment to a patient, turning over incomplete paperwork to medical coders, improper bundling or unbundling of procedures, under-coding or up-coding, and duplicate billing are all errors that impact how much and when payment is made to a practice by a third party payor.
How to Avoid Errors in Medical Coding
To avoid these errors, a practice may create an in-house department and educate billing personnel as to these common errors. Once a protocol is in place to avoid coding errors, the practice should engage a law firm to oversee problematic and difficult coding cases. The law firm needs to understand coding protocol, third party payor reimbursement policies and rates, and the nature of the medical services that have been coded.
Maggs McDermott & DiCicco has years of experience in reviewing submissions by medical practices to third party payors and analyzing the use of CPT codes and RVU’s. We put our clients in a position to maximize their reimbursements from third party payors by packaging their claims in the most efficient and persuasive manner.