Health Care Reimbursement
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Common Acronyms
Some common acronyms used in health care services reimbursement.
APC (Ambulatory Procedure Classification): OPPS uses this to classify procedures. Each APC incorporates HCPCS codes considered to have similar resource consumption and similar clinical attributes.
CPT (Common Procedure Terminology): Similar purpose as HCPCS, but used for billing to other payers besides Medicare (especially commercial insurers).
- Procedure coding system from AMA, for physicians
- It's the basis for Medicare's coding system
- Commercial insurers may accept/consider CPT codes NOT included in the HCPCS codes; e.g., HCPCS does not include the code for an office visit to follow up on a surgical procedure or hospital stay (99024), but commercial insurers may consider making separate payment for such a visit
- Relative importance of the distinctions between CPT and HCPCS (and therefore commercial insurance and Medicare) depends on whether the typical patient for a certain kind of procedure is likely to be a Medicare patient (as with prostate surgery) or not (as with a vasectomy or normal delivery).
DRG (Diagnosis-Related Groups or “Diagnostic-Related Groups”): Inpatient payment is based on these
HCPCS (Healthcare Common Procedure Coding System): The officially recognized procedure codes, with the finest level of detail and specificity that is recognized
IRP (inexpensive and routinely purchased): The cost of a piece of durable medical equipment (DME) does not exceed $150
OPPS (Outpatient Prospective Payment System): For hospital outpatient departments
PFS: Medicare’s physician fee schedule
Important Regulatory Agencies
Center for Medicare and Medicaid Services (CMS). Administers the Medicare program, coordinates with state Medicaid programs, develops regulations for all aspects of Medicare and Medicaid, conducts and reports on research into the cost effectiveness of treatment strategies, determines coverage, sets prices, etc.
Food and Drug Administration (FDA). Issues approvals, recommendations, research, and other information about which devices, drugs, and foods are safe and effective. Its rulings and advisory statements typically inform insurance coverage decisions. NOTE ESPECIALLY THE APPROVALS AND CLEARANCES TAB.
United States Patent and Trademark Office (USPTO). Publicly accessible database of all patent applications and decisions. The Johns Hopkins community also has access to two proprietary patent searching databases:
- Derwent Innovations Index
- LexisNexis Academic (which includes many other features unrelated to patent searching)
Classification and Coding Systems
- ICD-9 Diagnosis Code Lookup (Keyword)
- ICD-9 Diagnosis and Procedure Codes List
- ICD-10 Diagnosis Code Lists (Downloadable files for ICD-10-CM codes to be used for discharges occurring from October 1, 2018 through September 30, 2019 and for patient encounters occurring from October 1, 2018 through September 30, 2019)
- ICD-10-CM
- ICD-10-PCS (Procedure Coding System) (Downloadable files for 2019 ICD-10-PCS codes to be used for discharges occurring from October 1, 2018 through September 30, 2019)
- ICD-10 and ICD-11 -- What's new in ICD-11 (WHO site)
Healthcare Common Procedure Coding System (HCPCS) Overview
- Level I HCPCS Procedure Codes (Same as CPT Codes--Get from Web search or AMA Website)
- AAPC Website (Freely available, no reimbursement figures--but can get these from Medicare/CMS website's Physician Fee Schedule Lookup Tool)
- Level II HCPCS Procedure Codes (Medical equipment and supplies coding system for payment)
- Explanation
- List of Codes (from Medicare/CMS website)
- List of Codes (from HCPCSData.com, a free proprietary website)
HCPCS codes caveat: These codes are generally identical to CPT codes; however, the Medicare-generated HCPCS coding system only includes codes that are reimbursed by Medicare. In other words, they are not a complete substitute for CPT codes, which are a proprietary product of the American Medical Association.
- Medicare Severity Diagnosis-related Group (MS-DRG)
- Medicare --> Prospective Payment Systems --> Hospital Outpatient --> Adendum A and B
Ambulatory Payment Classifications (APCs)--Addendum B translates HCPCS procedure codes to APCs, and Addendum A shows payment amounts for each APC.