rbrvs - Washington Paraoptometric Section
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Transcript rbrvs - Washington Paraoptometric Section
Understanding RBRVS
What is RBRVS
RBRVS to Discover & Set Fees
RBRVS to Choose Procedure Code
(Resource Based Relative Value Scale)
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What is RBRVS?
It is how 3rd parties pay
RVU x CF = Payment
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What is RBRVS?
RVU = Relative Value Unit
All procedures assigned “relative
value”
Based on resources needed to deliver
procedure
3 types of resources
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What is RBRVS?
3 types resources:
Physician Work (PW)
Practice Expense (PE)
Malpractice (MP)
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What is RBRVS?
Each type resource assigned a
“relative value”
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What is RBRVS?
PW RVU
PE RVU
MP RVU
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What is RBRVS?
3 resources totaled =
PW RVU + PE RVU + MP RVU =
Total RVU
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What is RBRVS?
8000 CPT codes
8000
= Relative Value Scale, ie
(total)
RVUs
Resource-Based Relative Value Scale
(RBRVS)
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Examples of RVUs
RVU range 0 to 470.33
RVU of 0?
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Things Assigned “0” RVU
Category 3 CPT
0207T
(evacuation meib gland)
(Lipiflow)
S codes
(HCPCS Level 2)
S0620
(exam + ref, routine, new)
(TOS handout)
After hours office visits
Routine Exam
“Dump” codes 92499
99050
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(unlisted ophthal service/proced)
Examples of RVUs
RVU of 470.33?
CPT 37227 Revascularization of femoral
artery (for occlusive disease)
X 34.023 = $16,002
(2013)
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Examples of RVUs
Eye Codes
92004 = 4.45
(x 34.023 = $151.40)
92015 = 0.58
($19.73)
65600 = 12.07
($410.66) (tattoo)
92950 = 9.05
($307.91)
(2013)
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Facility vs. Non-Facility RVU
Facility RVU < Non-facility RVU, ie
Provider: Facility $$ < Non-facility $$
Facility: Facility & provider split pay
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Facility vs. Non Facility
Non-Facility:
Physician office
Patient home
Freestanding imaging center
Independent pathology lab
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Facility vs. Non Facility
Facility:
Hospital
Ambulatory surgical center (ASC)
Skilled nursing facility (SNF)
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GPCI
Geographic Practice Cost Index
Alters RVU for local economy
Separate GPCI for each economic area
(PW x GPCI) + (PE x GPCI) + (MP x GPCI)
= total RVU (for specific area)
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GPCI
Geographic Practice Cost Index
Medicare – Uses GPCI
Non-Medicare – May or may not use
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What is RBRVS?
RVU x CF = Payment
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Conversion Factor
Converts RVU to payment
3rd parties choose CF
Usually one CF, sometimes more
2013 Medicare CF 34.023
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Yearly RVU & CF Change
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Yearly RVU Change
RVU data updated yearly; Up & down
GPCIs may change
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Adopt RVU Change
Medicare
January 1
Adopts new RVUs & GPCIs
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Adopt RVU Change
Non-Medicare
Anytime
Year of RVU
Any year
GPCI
Used or not
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Adopt RVU Change
Non-Medicare
10 sets RVUs in past 5 years
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Yearly CF Change
Medicare
CF changes Jan 1: budget neutrality
Published Nov 1 Fed. Register
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Yearly CF Change
Non-Medicare
Pick their CF: market forces
Often higher than Medicare
Occurs anytime
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Examples
RVU x CF = Payment
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Examples
92004
Medicare 2013
4.45 x 34.023 = $151.40
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Examples
92015
Medicare 2013
0.58 x 34.023 = $19.73
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Examples
65600
Medicare 2013
12.07 x 34.023 = $410.66
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Examples
92950
Medicare 2013
9.05 x 34.023 = $307.91
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Understanding RBRVS
What is RBRVS
RBRVS to Discover & Set Fees
RBRVS to Choose Code
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Set Medical Fees
Obtain pay schedule, all contracted plans
Or calculate with RVU x CF = Payment
Identify highest payer
Set office fees above highest plan
RVU x CF = Office Fee
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Set Medical Fees
Choose your CF
Twice-yearly re-assess
Fees accurate, reasonable
Not good when insurance pays your
charge
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Set Medical Fees
Medical fees already determined
Insurance defines value
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Set Routine Fees
Market-driven
Routine service unrelated to Medical
Routine fees unrelated to Medical
RBRVS unrelated
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Control Accounts Receivable
GOAL
Collect all patient portion on day of service
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Control Accounts Receivable
3 Parts
A. Prepare Payment Schedules
B. Verify Insurance
C. Day of Service – Collect Patient Portion
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Control Accounts Receivable
A. Prepare Payment Schedules
Spreadsheet, common codes (40)
Columns
1st – U&C
2nd – Insurance Maximum Allowed
3rd – Write Off
4th - Insurance Due
5th - Patient Due
(spreadsheet example)
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Control Accounts Receivable
file://localhost/Users/alanhomestead/Docu
ments/My Documents B 3-813/Adventures 11-3-12/1
AccuFee/2013/AccuFee 2013 Files
XLSX/1 AccuFee 2013 15.4.xlsx
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Control Accounts Receivable
A. Prepare Payment Schedules
One spreadsheet per insurance (8 - 10)
If more than one plan,
One spreadsheet per plan
(1 – 2)
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Control Accounts Receivable
B. Verify insurance
Before patient arrival
Beginning of month, employer paid
premium?
Ask Deductible, Co-Pay, Co-Insurance %
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Control Accounts Receivable
B. Verify insurance
Co-Pay, Co-Insurance may vary with
office call
surgery
test
specialty
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Control Accounts Receivable
B. Verify insurance
Deductible
Amount
Amount not met
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Control Accounts Receivable
B. Verify insurance
Medicare – application allowing access to
Medicare claim and eligibility information.
Deductible balance
If Medicare Advantage
(can see pending claims)
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Control Accounts Receivable
B. Verify insurance
Medicare, claim & eligibility information
Noridian – Endeavor: online
(Jursdctn F-WA,OR,ID,MT,ND,SD,WY,AK,UT,AZ,CA,HI,NV)
Novitas – IVR:
Interactive Voice Response 855-252-8782
(Jursdctn L-DE,NJ,PA,MD,DC, Arlington & Fairfax county, city of Alexandria)
Palmetto – OPS:
Online Provider Services, or IVR
(Jursdctn 11/M-WV,VA,NC,SC)
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Control Accounts Receivable
B. Verify insurance
Medicare, claim & eligibility information
CGS – CSI: (online) Claim Status Inquiry, or IVR
(Jursdctn 15-OH,KY)
WPS – C-SNAP:
(online) CMS Secure Net Access Portal,
or IVR
(Jursdctn 8-IN,MI)
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Control Accounts Receivable
C. Day of Service – Collect Patient Portion
Deductible –
Co-Pay –
found before patient arrive
found on insurance card
Co-Insurance -
found on spreadsheet at checkout
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Control Accounts Receivable
C. Day of Service
Write off un-collectable
A/R very accurate
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Control Accounts Receivable
C. Day of Service
Patient portion of A/R = small fraction of
monthly production
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Catch Mistakes
Check daily production sheet
No 2nd write off, unless explained
(eliminate double write-offs)
Insurance paid wrong?
Office prediction wrong?
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Weekly Meeting
Short stand-up review of A/R
Review Patient-Portion,
30 + 60 + 90 days
How did account get on A/R
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Results
Firmly controlled A/R
Few statements
Refund checks
Cash flow optimal
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Understanding RBRVS
What is RBRVS
RBRVS to Discover & Set Fees
RBRVS to Choose Code
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Office Visit 99 or 92
How many codes?
Ophthalmic – 4
EM – 10
7 New, 7 Established
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Office Visit 99 or 92
Ophthalmic vs EM New Patient (2013)
99205 5.99
$217.89
92004 4.45
$151.40
92002 2.44
$83.02
99204 4.84
$176.49
99203 3.18
$116.77
99202 2.19
$80.85
99201 1.29
$47.91
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Office Visit 99 or 92
Ophthalmic vs EM Established Patient (2013)
99215 4.2
$153.68
92014 3.71
$126.23
92012 2.57
$87.44
99214 3.14
$115.25
99213 2.14
$78.74
99212 1.29
$47.91
99211 0.6
$22.54
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Office Visit 99 or 92
MEDICARE
New
Est
99205 99215
99204 92014
92004 99214
99203 92012
92002 99213
99202 99212
99201 99211
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Office Visit 99 or 92
Choose office visit:
The one that pays the most
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Office Visit 99 or 92
Choose office visit:
Note: 92012 > 92002 !
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Office Visit
Billed Level 5?
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99 Codes
file://localhost/Users/alanhomestead/Docu
ments/My Documents B 3-813/Adventures 11-3-12/O S/Presentations/Repository of My
PowerPoints/1 Topic Modules/99/99 Aug
13.ppt
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