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Codes, Tests & Money

Codes, Tests & Money. Dan Imler. CPT. Specifies a given patient encounter within an office setting specific (relevant to the issues being addressed) for the current visit John comes in for a regular visit and has a otitis media You bill: 093828 – Otitis Media uncomplicated.

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Codes, Tests & Money

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  1. Codes, Tests & Money Dan Imler

  2. CPT • Specifies a given patient encounter within an office setting specific (relevant to the issues being addressed) for the current visit • John comes in for a regular visit and has a otitis media • You bill: 093828 – Otitis Media uncomplicated

  3. E & M (Evaluation and Management) • Determines to what level of activity the doctor went to address the patients issue • John comes in for a regular visit and has a otitis media • You bill: 098439 – Level 1 patient visit • ICD-9 – Another name for E & M and also includes procedures

  4. DRG (Diagnosis Related Group) • Specifies an inpatient hospital diagnosis • Prices based on a working groups opinion on the “average” cost associated with that diagnosis • John is admitted for high white count, pneumonia and ends up having ALL • Hospital bills – ALL & complex PNA • Hospital Bills – via E&M code off your notes

  5. Charges • It seems like the hospital will bill from it’s own list of prices for all of the CPTs, DRG, meds, etc for the patients inpatient stay. But no, wait a second… • RVRBS – Working group figures out what the cost of a inpatient stay should be for a given diagnosis. Basically it is what Medicare or government body said it is willing to pay. • Thus, the hospital has a fixed revenue for a given diagnosis. Incentive is to get them well using the least amount of resources possible (best thing would be to have them leave AMA, ship them to a different hospital or they die!) Dr. Doe who is conservative and indecisive ordering a lot of tests is BAD for the hospital. “Good doctors”, make good, quick decisions with few tests • The hospital gets a fixed reimbursement but has unlimited expenses AND THE DOCTOR IS IN CONTROL (i.e. daily CBC or CBC vs. H & H, daily CXR, Chem7) • Final bill is sent to the insurance group (i.e. $15,000 for ALL), but they spent $27,000! Luckily the hospital has contracted with the hospital to pay a certain percentage of the final bill (i.e. 135% -> $20,250!) But the hospital still loses $ 6,750!!!!! • Ah, but there are “co morbid conditions”. So you better document all those other things that are going on! Thus, you don’t just send one DRG you send several, John also had his complicated PNA, and… • But then to complicate things even more, charges don’t really = costs. For example, the hospital may charge $1 for an asprin, but when you by 2 billion asprin at a time each one only cost you $0.05!

  6. Guess the Price 450 bed Midwest Hospital Not for Profit (non-house-staff) • URINE PREGNANCY TEST • OXIMETRY EVAL • CT ABDOMEN-WO • MRI ABDOMEN WO • ED VISIT LEVEL 1 W/PROC • ED VISIT LEVEL 2 W/PROC • ED VISIT LEVEL 3 W/PROC • ED VISIT LEVEL 4 W/PROC • ED VISIT LEVEL 5 W/PROC • IV THERAPY 1ST HOUR • BASIC METABOLIC PANEL • Daily BMP x 7 days • CBC W/O DIFF • HEMOGLOBIN $15.69 $46.69 $1066.18 $1654.8 $49.06 $112.8 $195.66 $387.4 $581.67 $161.65 $127.81 $1131.55 $42.35 $18.55

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