Healthcare Payment Systems: Fee Schedule Payment Systems (Paperback)

Introduction to Fee Schedule Payment SystemsOverview of Healthcare Payment SystemsClaim Filing and PaymentOverview of Medicare Fee Schedule Payment SystemsPrivate Third-Party Payer and Commercial Fee SchedulesPayment System InterfacesHealthcare Provider Use of Fee Schedules to Set ChargesSummary and ConclusionHealthcare Provider ConceptsIntroductionPhysiciansNonphysician Practitioners and ProvidersClinicsHospitals and Integrated Delivery SystemsSpecial Provider Organizations DME Suppliers Skilled Nursing Facilities Home Health Agencies Independent Diagnostic Testing Facilities Comprehensive Outpatient Rehabilitation Facilities Clinical Laboratories Ambulatory Surgical CentersSummary and ConclusionAnatomy of a Fee Schedule Payment SystemIntroductionBasic Fee Schedule Payment FormulaBasic Architecture for Healthcare Fee Schedule Payment SystemsRelative ValuesClassification SystemsUsual, Customary, and ReasonableClaims and the Adjudication ProcessAdjudication Features for Fee SchedulesCode Sets and AdjudicationParticipating Healthcare ProvidersChapter SummaryMedicare Physician Fee ScheduleIntroductionUnderlying Code Classification StructurePayment Amounts under the MPFSElements in the Full MPFS CPT/HCPCS Codes Modifier Description Status Code Relative Value Units Professional Component/Technical Component Indicator Global Days Pre-Operative, Intra-Operative, Post-Operative Percentages Multiple Procedures Special Surgical Payment Indicators Endoscopic Base Code Conversion Factor Physician Supervision of Diagnostic Procedures Calculation Flag Diagnostic Imaging Family Indicator Outpatient Prospective Payment System Imaging CapUpdating and Modifying the MPFSGlobal Surgical Package Overview of Services Included in the GSP Pre-Operative Window Post-Operative Window CPT Modifiers Separating Phases within the Surgery Transfer of Post-Operative Care Anesthesia PackageSpecial Surgical Payment Processes Surgical Complications Co-Surgeons Team Surgeons Sequential Surgical Procedures: Separate Physicians Staged Surgical Procedures Bilateral SurgeriesFamilies of CodesNonphysician PractitionersSpecial Utilization of the MPFS Independent Diagnostic Testing Facilities Comprehensive Outpatient Rehabilitation Facilities Critical Access Hospitals Ambulatory Surgical CentersCPT and HCPCS ModifiersNational Correct Coding InitiativeModifiers Used to Bypass the NCCI Edits NCCI Coding Policies Medically Unlikely EditsGaining Extra Payment through the MPFSChanges and Change Process for the MPFS Medicare Secondary PayerUsing the MPFS RVUs to Establish ChargesSummary and ConclusionOther Medicare Fee Schedule Payment SystemsIntroductionAnesthesiology Fee ScheduleAmbulance Fee ScheduleClinical Laboratory Fee ScheduleDurable Medical Equipment Fee ScheduleConclusion and SummaryPrivate Third-Party Payer Fee Schedule SystemsIntroductionUsing Medicare Fee Schedule ApproachesUsual, Customary, and Reasonable Basic Statistical Concepts Charge Data Statistical Analysis of Charge Data UCR ChallengesEstablishing a UCR Schedule of Fee Payments Provider-Based Clinics Global Surgical Package Multiple Surgeries Bilateral Surgeries Evaluation and Management Services with Surgeries Assistants at Surgery Co-Surgeons/Multiple Surgeons Staged Surgical Procedures Surgical Families Anesthesia Services Mid-level Practitioners Physician Supervision Edits to Verify Correct Coding Extra Payments Choosing the UCR Data Challenges in Developing Fee Schedule PaymentSummary and ConclusionAppendix: Case Study ListAcronym List