MEDICAL BILLS


Official Medical Fee Schedule


There are seven separate fee schedules that comprise the OMFS:
  • Physician's Services (PSFS)
  • Inpatient Hospital Services (IHFS)
  • Hospital Outpatient Departments & Ambulatory Surgical Centers Services (HOPD/ASC)
  • Pharmacy Services (PFS)
  • Pathology and Laboratory Services (CDLS)
  • Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
  • Ambulance Services (AFS)

Coding

  • CPT (Current Procedural Terminology)

    • -Codes identifying medical services and procedures

  • ICD Codes (International Classification of Diseases)

    • -Diagnostic codes

  • HCPCS (Health Care Procedure Coding System)

    • -Codes identifying supplies, injections & some service procedures

 

The following examples indicate, in small measure, the minefield that a lay person will encounter when trying to understand and settle provider's invoices.

 

Physical Medicine limited to the provider's authorized scope of practice.

 

Providers: Physical Therapists - Chiropractors - Acupuncturists.

 

Cascade, as applicable to Physical Medicine CPT code/s, is a staged reduction in compensation for multiple procedures/modalities and is paid within the framework of a series of ground rules.

 

Physical medicine, per session, normally one hour, is limited to two procedures and two modalities.

 

Multiple procedure/modality payment calculation:-
  • The highest rated (RV) procedure code is paid at 100% of the listed value.
  • The next highest rated (RV) procedure is paid at 75% of the listed value.
  • The highest rated (RV) modality is paid at 50% of the listed value.
  • The next highest rated (RV) modality is paid at 25% of the listed value.
Examples:

 

(2 procedures / 2 modalities)
CPT code RV     Unit value     Cost        Cascade Provider Invoice 
97250 7.2   *    $6.15    =    $44.28 @100% = $44.28               $55.00
97110 5.4   *    $6.15    =    $33.21 @75%   = $24.90               $39.50
97018 3.0   *    $6.15    =    $18.45 @50%   = $9.22               $23.00
97014 3.0   *    $6.15    =    $18.45 @25%   = $4.61               $23.00
  Total cost:               $114.39 Total:         $83.01                $140.50
Reimbursement: $83.01      
(3 procedures / 1 modality)
CPT code RV     Unit value     Cost        Cascade Provider Invoice 
97250 7.2   *    $6.15    =    $44.28 @100% = $44.28               $55.00
97110 5.4   *    $6.15    =    $33.21 @75%   = $24.90               $38.00
97018 3.0   *    $6.15    =    $23.40 @0%     = $0.00               $29.00
97014 3.0   *    $6.15    =    $18.45 @50%   = $9.22               $23.00
  Total cost:               $101.80 Total:         $78.04                $145.00
Reimbursement: $78.04      
(1 procedures / 3 modalities)
CPT code RV     Unit value     Cost        Cascade Provider Invoice 
97250 7.2   *    $6.15    =    $44.28 @100% = $44.28               $55.00
97024 3.0   *    $6.15    =    $18.45 @75%   = $13.83               $23.00
97018 3.0   *    $6.15    =    $18.45 @50%   = $9.22               $23.00
97014 3.0   *    $6.15    =    $18.45 @0%     = $0.00               $23.00
  Total cost:               $99.63 Total:         $67.33                $124.00
Reimbursement: $67.33      
Surgery

 

Cascade, as applicable to Surgery CPT code/s, is a staged reduction in compensation for multiple procedures performed at the same session and paid within the framework of a series of ground rules.

 

There are exceptions to this general rule with the use of Modifiers along with detailed surgical reports.

 

Modifiers play a significant role in CPT surgical codes and are critical when paying surgical bills.

 

Multiple surgical procedures payment calculation:
  • Major (highest valued RV) is paid at 100% of the listed value.
  • Second (second-highest valued RV) is paid at 50% of the listed value.
  • Third (third-highest valued RV) is paid at 25% of the listed value.

 

For some Arthroscopic procedures on the same joint at the same session, the highest valued RV code is paid at 100% of the listed value with the second and subsequent codes paid at 10% of the listed value.

 

Unbundling:

 

Unbundling is the use of one or many CPT/HCPCS codes along with or without the primary procedure code on invoices to maximize reimbursement. Codes are billed inappropriately along with or without the primary procedure. Reimbursement for the primary procedure includes the services represented by the inappropriate codes which represent the basic procedures required to accomplish the primary procedure.

 

Examples:

 

(Diagnostics codes MRI's)
CPT code                                     Description                                     RV       Payment  
72158       MRI Spinal Canal Lumbar w/o & w/ contrast material 71.7               $896.25
Code 72158 not billed but unbundled as follows.....
CPT code                                     Description                                     RV       Payment  
72148       MRI Spinal Canal Lumbar without contrast material 51.2               $608.00
72149       MRI Spinal Canal Lumbar with contrast material 60.8               $722.00
  Payable: code 72158  =  $896.25    
(Diagnostics codes Cat Scans)
CPT code                                     Description                                     RV       Payment  
74170       Cat scan abdomen w/ & w/o contrast material 40.3               $478.56
Code 74170 not billed but unbundled as follows.....
CPT code                                     Description                                     RV       Payment  
74150       Cat scan abdomen without contrast material 28.8               $342.00
74160       Cat scan abdomen with contrast material 33.4               $396.63
  Payable: code 74170  =  $478.56    

 

(Medicine-Polysomnography) Code 95810 billed and unbundled as follows.....
CPT code                          Description                          RV      Payment   Provider Invoice 
95810       Sleep staging plus testing parameters 92.9          $386.84          $1400.00
94762       Noninvasive ear/pulse oximetry 4.9            $0.00            $225.00
99090       Analysis of info stored in computer   -            $0.00            $350.00
99199       Video & audio monitoring  BR            $0.00            $450.00
99070       Application kit   -            $0.00            $107.00
97650       Education & training 3.5            $0.00             $97.00
  Payable: code 95810  =  $386.84