Alicia: Alright! This is one where there can be so much explanation there, but again, put a little website on there that really expands it.
Q: Reimbursement, is it based on ICD-9-CM or CPT diagnosis or procedures?
A: The example I found was: How does the physician get paid for what they do? Well, physicians at this time are paid / reimbursed by what they do for the patient. These are called procedures and include the evaluation and management of the patient which is the exam and decision in treatment. Testing that is done is considered a procedure as well.
Let’s say we have a brand new physician:
Dr. X case 1: Mrs. S is a 68 y/o female on Medicare who and presents to the clinic as a new patient with fever and sore throat. He performs a history of physical exam, he performed a rapid strep test, and he gives a diagnosis of viral pharyngitis. And then he recommends, in addition, that she takes Robitussin-DM.
CPT Coding – Video
So, here’s our brand new physician, he’s so excited to see his very first patient. Now, what did he provide? What services did he provide? Three main components for all visits to the physician: 1) Provider Visit – History/Physical/Medical Decision Making, the Physician Performed Procedures; 2) Testing/Non-Physician Performed Procedures – Immunizations, if any of those will be given, will be in that; 3) Office Work – nurses and the front desk and stuff like that.
What services did the physician provide? Again, your doctor-patient encounter, and all tests and procedures you performed on the patient are considered “procedures.” Each “procedures” has a CPT Code, and for Mrs. S’ visit there’s a CPT Code for the Physician Visit itself, and that’s considered an E/M code. Now, a CPT Code for the nurse’s work, that’s a little bit different. But, CPT Code for the procedure, this rapid strep test, there’s a code for that.
This was based on explaining to a physician how they got paid, that’s why I got those, was very unique.
Mrs. S’ Visit
- Physician Visit – CPT 99202
– Mind you, I don’t know how old these are, and I did this location I found this, so I didn’t look up each code. But let’s say it’s 99202.
- Nursing Work – CPT – (Office) – that didn’t get a code
- Rapid Strep – CPT 87880
- All Linked to ICD-9 Code 462 (Pharyngitis)
The doctor gets paid based on the CPT coding that are given, and the ICD-9-CM code supports the reason for the CPT codes. You can’t have one without the other, and that’s really the key.
So, at this time and this may change in the future, because in the past it was different; it happened based on different instances like for home health and stuff like that on what was wrong with the patient, versus what is are being done to the patient. And that’s how HCC coding is done too, it’s by what is wrong with the patient. But at this time, your CPT code on what you did to the patient has to be supported by the diagnosis and then they can get paid that’s why you have to do both, and it goes back to those relative value units that we were talking about.
And this website that’s listed here, if you go to that website that’s where I got this information and it goes into depth as it explains to a physician how he gets paid, and it goes into detail about the relative value units and much, much more. There was just so much information, I was shocked, and really actually quite excited and I bookmarked it because it’s going to make great
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