National Fee Analyzer. Charge data for evaluating fees nationally

National Fee Analyzer Charge data for evaluating fees nationally 2013

Contents Introduction...1 Key to Proper Reimbursement... 1 The Medical Coding System... 1 What This Book Has to Offer... 2 A Coding Overview...11 Coding Systems... 11 Using CPT... 12 Reimbursement Issues...29 Trends... 29 Other Reimbursement Trends... 29 Health Care Plans... 30 Contracts... 36 Auditing... 40 Rules... 43 Setting Medical Fees...49 Choose a Pricing Philosophy for Fees... 49 Developing a Pricing Strategy... 50 Conducting an Impact Analysis... 50 Summary Checklist... 51 Anesthesia...53 Anesthesia Section Arrangement... 53 Anesthesia Codes and Guidelines... 53 Coding and Billing for Anesthesia... 53 and Anesthesia Coding... 56 Other Billing Issues for Anesthesia... 57 Surgery...69 Surgery Section Arrangement... 69 Surgical Coding Methodology... 69 CPT Surgical Terminology and Coding Guidelines... 70 Negotiating with Payers... 76 Radiology...277 Radiology Section Arrangement... 277 Technical and Professional Components... 277 Documentation... 278 Coverage Issues... 278 Code Selection... 278 Interventional Radiology... 278 Modifiers... 279 Coding Insights... 279... 281 Glossary... 282 Pathology and Laboratory... 317 Pathology and Laboratory Section Arrangement... 317 Tracking Lab Work and Other Ancillary Services... 318 Reimbursement... 318 Clincal Laboratory Improvement Act (CLIA) Regulations... 318 Medicine... 369 Medicine Section Arrangement... 369 Guidelines... 369 Modifiers... 370 Coding Insights... 370 Dialysis... 374 and Therapy... 374 and Chiropractic... 374 Evaluation and Management... 417 Evaluation and Management Section Arrangement... 417 E/M Guidelines... 417 E/M Documentation Guidelines... 418 Place of Service Distinctions... 420 Concurrent Care... 420 Consultation... 420 Hospital Observation... 421 Preventive Medicine... 421 Prolonged Services... 422 Case Management... 423 2011 Optum CPT only 2011 American Medical Association. All Rights Reserved. Data only 2011 FAIR Health, Inc.

2013 National Fee Analyzer Introduction 3 Charge Data The data used in the National Fee Analyzer is actual provider charge data collected from health insurance payers by FAIR Health, Inc. This national charge data is aggregated and combined with a relative value and conversion factor methodology. The relative value clinically compares and ranks medical procedures by difficulty, work, risk, and the material costs of these procedures. The conversion factor is the dollar amount developed for each charge by dividing the charge by the code s relative value. Please note that while insurance payers contribute billed charges to the data used in this product, no individual physician or clinic is identifed in the data. Additionally, no allowed amounts or insurance company paid amounts are used in the product. FAIR Health licenses the data to many of its insurance payer customers under the name FAIR Health RV Medical Module. The FAIR Health RV Medical Module product has four releases per year February, May, August, and November. The National Fee Analyzer and the FAIR Health RV Medical Module use data that falls within a 12-month period. For example, the November 2011 release of the FAIR Health RV Medical Module product contains data with a date of service range from September 2010 through August 2011. National 50th and 75th Amounts These amounts were developed using the blended methodology described in the Charge Data section. National 50th This column is the 50th percentile of the database nationally. s are frequently misunderstood. A fee at the 50th percentile does not mean 50 percent of providers charge that amount. If your fee for a given service is at the 50th percentile, then, based on FAIR Health methodology and data, 50 percent of the submitted charges for that service are equal to or higher than your fee. National 75th This column is the 75th percentile of the database nationally. If your fee is at the 75th percentile, then, based on FAIR Health methodology and data, 25 percent of the submitted charges are equal to or higher than yours. Amounts The majority of values for CPT codes are from the Physician Fee Schedule (MPFS). The codes contained in the MPFS are primarily professional services, but some technical (facility) services are also listed. While the amounts from the MPFS reflect the nonfacility reimbursement amounts, it should be noted that for procedures that must be performed on an inpatient basis, CMS does not provide a separate nonfacility rate. For procedures that must be performed on an inpatient basis, the facility reimbursement rate is provided. For 2012, the MPFS fees are based on a conversion factor of 24.6712. For codes that are not valued on the MPFS, the RVU column will display 0.00. For these codes, the fee in the Average column comes from one of the following fee schedules. Average Sales Price (ASP) Drug Pricing Files The ASP Drug Pricing Files provide a national fee schedule. does not adjust reimbursement rates based on geographic area; however, different rates exist for some drugs based on supplier. The majority of codes on the ASP pricing files are for HCPCS J codes. The National Fee Analyzer contains the subset of fees from the ASP drug pricing files that are assigned to CPT codes. Clinical Lab Fee Schedule (CLAB) The clinical laboratory fee schedule contains fees for outpatient laboratory services from the 80000 section of CPT codes. The fee displayed is the CLAB National Limitation Amount. Actual reimbursement rates vary by locality, but the national average reimbursement provides a good benchmark to compare to provider charges and private payer allowables. amounts are subject to change throughout the year. The averages published in National Fee Analyzer are the most current available at the time of printing. Please check with CMS or your local carrier to obtain rates for a specific locality and date. Geographic Adjustment Factors Table A lists commercial (non-) Geographic Adjustment Factors (GAF) so you can align the national average percentile amounts found in National Fee Analyzer with local fees. For example, the GAF for the Birmingham, Alabama area is 0.781. To arrive at a Birmingham areaadjusted 75th percentile amount for code 10040, multiply the national amount by the GAF ($163.86 x 0.781 = $127.97). Table B lists Geographic Adjustment Factors (GAF) so you can adjust the national fee schedule amount to your locality, by multiplying the listed fee by your locality s adjustment factor. Note that this table will not yield the exact reimbursement but should closely approximate the expected amount. Calculating the exact reimbursement amount requires the individual components of each total RVU as well as the associated GPCIs for those components. Commercial Geographic Adjustment Factors In order to adjust the national averages to specific geographic areas, geographic adjustment factors have been calculated by taking the difference from the national average for each service area across all service areas for each geographic area. Averages were then taken across the service Introduction 2011 Optum CPT only 2011 American Medical Association. All Rights Reserved. Data only 2011 FAIR Health, Inc.

2013 National Fee Analyzer Surgery 85 p CPT Code Description RVU 50th 75th 90th Fee 15130 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children + 15131 each additional 100 sq cm, or each additional 1% of body area of 26.48 1284 1610 1814 926.80 4.04 218 273 307 141.40 15135 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children + 15136 each additional 100 sq cm, or each additional 1% of body area of 34.29 1625 2038 2295 1,200.15 3.41 203 255 287 119.35 15150 Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less 27.34 1291 1619 1824 956.90 + 15151 additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) + 15152 each additional 100 sq cm, or each additional 1% of body area of 15155 Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less + 15156 additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) + 15157 each additional 100 sq cm, or each additional 1% of body area of 15200 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less + 15201 each additional 20 sq cm, or part thereof (List separately in addition to 15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less + 15221 each additional 20 sq cm, or part thereof (List separately in addition to 15240 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less 4.83 261 328 369 169.05 6.61 348 437 492 231.35 26.95 1298 1628 1834 943.25 7.13 377 473 533 249.55 7.14 435 546 615 249.90 32.27 1451 1819 2049 1,129.45 5.82 322 404 455 203.70 30.13 1306 1638 1844 1,054.55 SAMPLE DATA 5.35 290 364 410 187.25 36.47 1480 1856 2090 1,276.45 Surgery + 15241 each additional 20 sq cm, or part thereof (List separately in addition to 15260 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less + 15261 each additional 20 sq cm, or part thereof (List separately in addition to 15271 Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area 7.23 363 455 512 253.05 39.51 1596 2001 2254 1,382.85 8.45 406 509 574 295.75 5.6 297 373 420 196.00 + Add-on Code, Modifier 51 Exempt. Moderate Sedation a Modifier 63 Exempt # Resequenced Code Revised Code New Code 2011 Optum Data only 2011 FAIR Health, Inc. CPT only 2011 American Medical Association. All Rights Reserved.

2013 National Fee Analyzer Medicine 379 CPT Code Description 90804 Individual psychotherapy, insight oriented, behavior modifying 20 to 30 minutes face-to-face RVU 50th 75th 90th Fee 2.56 81 97 110 89.60 90805 with medical evaluation and management services 2.98 93 112 126 104.30 90806 Individual psychotherapy, insight oriented, behavior modifying 45 to 50 minutes face-to-face 3.44 103 124 140 120.40 90807 with medical evaluation and management services 4.14 119 143 162 144.90 90808 Individual psychotherapy, insight oriented, behavior modifying 75 to 80 minutes face-to-face 5.04 145 174 197 176.40 90809 with medical evaluation and management services 5.79 167 201 227 202.65 90810 Individual psychotherapy, interactive, using play equipment, approximately 20 to 30 minutes face-to-face 2.64 87 104 118 92.40 90811 with medical evaluation and management services 3.38 100 120 136 118.30 90812 Individual psychotherapy, interactive, using play equipment, approximately 45 to 50 minutes face-to-face 3.76 111 133 150 131.60 90813 with medical evaluation and management services 4.49 128 154 174 157.15 90814 Individual psychotherapy, interactive, using play equipment, approximately 75 to 80 minutes face-to-face 5.4 156 187 211 189.00 90815 with medical evaluation and management services 6.2 180 215 244 217.00 90816 Individual psychotherapy, insight oriented, behavior modifying residential care setting, approximately 20 to 30 minutes face-toface 2.19 91 109 123 76.65 90817 with medical evaluation and management services 2.63 104 125 141 92.05 90818 Individual psychotherapy, insight oriented, behavior modifying residential care setting, approximately 45 to 50 minutes face-toface 3.25 115 138 157 113.75 SAMPLE DATA 90819 with medical evaluation and management services 3.76 133 159 180 131.60 90821 Individual psychotherapy, insight oriented, behavior modifying residential care setting, approximately 75 to 80 minutes face-toface 4.8 163 195 221 168.00 90822 with medical evaluation and management services 5.4 187 224 254 189.00 90823 Individual psychotherapy, interactive, using play equipment, non-verbal communication, in an inpatient hospital, partial hospital or residential care setting, approximately 20 to 30 minutes face-to-face 2.42 98 117 133 84.70 90824 with medical evaluation and management services 2.84 112 135 152 99.40 Medicine + Add-on Code, Modifier 51 Exempt. Moderate Sedation a Modifier 63 Exempt # Resequenced Code Revised Code New Code 2011 Optum Data only 2011 FAIR Health, Inc. CPT only 2011 American Medical Association. All Rights Reserved.