drbowen wrote on Tuesday, July 18, 2006:
This is what would be referred to as a “managed care module.” For this to work correctly, the practice needs to enter several different “allowables” for each CPT code where each “allowable” represents the pre-negotiated fee for a particular CPT code. The system compares what is being entered against what was actually charged and what is the allowable fee.
As an example, a very common CPT in primary care 99213 (established patient, expanded visit).
Cash fee: $75
Medicare: $50.18
Citna: $63.04
BlueIns: $62.32
UltimateHC: $54.17
etc.
We have at this time 13 different fee schedules x approximately 8,000 CPT codes each.
The common insurance ploys that need to be monitored are underpayment, undercoding and bundling.
In an underpayment Citna would “innocently” pay $58.25.
An undercoding means that BlueIns changes the code from a 99213 to a 99212 and pays us the correct amount for a 99212. A typical example is that the primary ICD-9 code used does not “justify” the higher charge. A common example, charging a 99215 with a diagnosis of “influenza” is likely going to be downcoded to 99213.
It is illegal to “unbundle” laboratory charges. If I have a big chemistry analyzer that runs 150 different automated chemistries and I run a “SMAC 24”. I am supposed to bill for 24 automated tests using the appropriate code for this.
If my laboratory has three separate smaller machines that run a SMAC 12, a liver panel, a lipid panel as three separate tests. (24 tests total) I can charge a SMAC 12, a Liver panel and a lipid panel as separate tests. This is legitimate because I actually own three separate machines that do the work. This involves more reagents and more maintenance than the SMAC 150 machine described above.
In bundling, UltimateHC bundles my three tests together and pays me for the SMAC 24 because the reimbursement is lower. This is also illegal but harder to fight since they have a lot of good lawyers and the difference in fees is relatively small ($3-4). This doesn’t break the piggy bank of the physician but to UltimateHC $3 x 1 million claims a years ends up being a nice bonus on the bottom line.
Of course Acme US Healthcare pays $4 (yes, 4.00 dollars) for a CBC, CMP (14 tests), lipid panel, TSH and urinalysis. This battery of tests is bundled together as a “general health panel”. Well, let me come clean. They do pay $6 for the phlebotomy charge.
The names of the these insurance companies have been changed to protect the innocent. Any resemblance to actual insurance companies is completely accidental.
Remember, The insurance company computers only read the first line of diagnosis codes for any CPT code. It is important to code each CPT code with the best matching ICD-9 code, line by line to try to get what is owed to you.
For this type of module to work correctly it will be necessary to enter all the separate charge schedules. Your software will have to check that the actually CPT code being reimbursed is the one you actually charged (checks for bundling and downcoding) and that the fee received is the one expected (checks for underpayment). It will need to flag the operator.
One of the ways to prevent downcoding is to check the “justification” of CPT codes to ICD codes on the front end before billing. Picking up that no reasonable insurance company is going to pay a 99215 for the flu.
Maybe the doctor should have coded hypoxemia or shock instead. After all, the patient with the flu had an oxygen concentration of 85% and a blood pressure of 75/30. The doctor performed a CMP, ECG, CXR, and CBC. Medical decision making was complex. Risk of morbidity and mortality is high. In this case the 99215 is actually the appropriate code.
Sam Bowen
