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Facility and Physician Payment Rates
Code of Ethics
The Ambulatory Payment Classifications organize CPT codes into groups that are assigned a fixed reimbursement amount. This effects Medicare payment in the hospital outpatient setting. The cost of devices and supplies are included in this bundled payment.
Ambulatory Surgery Centers can be free-standing or connected to a hospital and must meet certain regulatory guidelines to be certified as ASC's. These are settings of care that provide beneficiaries with surgical services that do not require overnight hospital admission and generally cannot be done in a physician's office.
+ Category lll codes
Temporary codes for emerging technology, services, or procedures that require further analysis before being given Category 1 Code or not. As these codes are assigned to emerging technologies, some payers may deny or delay payment.
The Centers for Medicare and Medicaid Services is the federal agency responsible for administering healthcare benefits to over 80 million beneficiaries of Medicare and Medicaid. It was formerly known as the Healthcare Finance Administration or HCFA.
The type and range of benefits - services, procedures, medical items - for which an insurer will pay. Coverage will vary from payer to payer.
Current Procedural Terminology. A coding system used to describe services and procedures provided by physicians. Produced, maintained, and revised by the American Medical Association, it is updated annually. CPT codes are 5 digit codes and represent the 1st level of HCPCS codes or approximately 90% of HCPCS.
textDurable Medical Equipment has a long duration of usefulness and is usually rented or used in the home. Items include oxygen tents, wheelchairs, and hospital beds.
textDurable Medical Equipment, Prosthetics, Orthotics and Supplies. Fee schedule that sets payment to facilities and physicians for these items.
Diagnosis Related Groups are a classification system used to identify distinct types of hospital inpatient cases and are the foundation for Medicare's inpatient payment system. There are currently 508 DRGs that classify patients into clinically cohesive groups that demonstrate similar resource consumption by hospitals.
A billing and reimbursement method in which a physician charges for each medical service or unit provided to a patient.
+ Global Period
A defined period of time (0 to 90 days) during which all medical services related to a similar condition or diagnosis are included in the payment for the initial surgery.
Healthcare Finance Administration's Common Procedural Coding System- the federal government's 3 level coding system. The standardize coding for the Medicare and Medicaid programs has been adopted by the majority of 3rd party payers. Level 1 is CPT codes. Level ll codes are National codes for services and supplies not found in CPT i.e. durable medical equipment, injectable medications and ambulance services. Level ll codes are 5 digits and begin with letters A-V. Level lll codes are local codes approved by CMS for use only in a state or region and begin with the letters S,W,Y and Z.
+ HCFA 1500
The Universal Claim Form 1500 is the form used to record charges and submit a claim to a payer. Virtually all third-party payers accept this form either as a paper claim or in electronic format.
Health maintenance organization is a type of insurance plan that pays physicians a capitated or fixed rate per month for every member enrolled in the plan.
Hospital Outpatient Prospective Payment System is Medicare's system for paying hospitals for services rendered to beneficiaries in the outpatient setting. These payments are based on Ambulatory Payment Classifications (APC) that group similar procedures based on resource utilization.
International Classification of Diseases-Ninth Revision. Developed by the World Health Organization in Switzerland, it is used by virtually all third-party payers in the US to describe patient condition. ICD-9 is separated into diagnosis and procedure codes.
Inpatient Prospective Payment System is Medicare's system for paying hospitals for services rendered to beneficiaries in the inpatient setting. These payments are made based on a patient's assignment into one or more Diagnosis Related Group (DRG).
A federal and state funded medical assistance program administered by each state that provides health benefits for those who cannot pay or are indigent.
+ Medicare Part A
The part of the Medicare program that covers the cost of inpatient care and related post-hospital services including skilled nursing and home health care.
+ Medicare Part B
Also called supplemental insurance, it is the part of the Medicare program that covers physician services, outpatient care, lab tests, durable medical equipment, and certain other services.
+ Pass-through codes
Codes assigned to new or innovative drugs, biologics or devices whose costs are not insignificant. Developed in order to gather information on costs so that a technology could be appropriately placed into outpatient payment group. These products were given C-codes for a period of not less than 2 but not more than 3 years. (C codes are also used to identify device categories when CMS sets their yearly payment rates.)
Resource Based Relative Value Scale. Used to set physician professional fees.
+ Revenue Codes
Internal accounting codes developed by the American Hospital Association (with input from private payers and CMS) that are used to group categories of service such as lab services, nuclear medicine, med/surg supplies.
The Uniform Bill (UB)-04, also known as Form CMS-1450, is the updated (replaces the UB-92) uniform institutional provider hardcopy claim form suitable for use in billing multiple third party payers. This is the only paper claim form accepted by CMS from institutional providers (hospitals, skilled nursing facilities, home health agencies, etc...) excluded from the mandatory electronic claims submission requirements set forth in the Administrative Simplification Compliance Act (ASCA).
C. R. Bard, Inc does not guarantee that Medicare or any public or private payer will cover any products or services at any particular level and specifically excludes any representation or warranty relating to reimbursement. Laws, regulations, and payer policies concerning reimbursement are complex and change frequently, and service providers are responsible for all decisions relating to coding and reimbursement submissions. Accordingly, C. R. Bard, Inc. strongly recommends that you consult with your payers, reimbursement specialist and/or legal counsel regarding coding, coverage and payment matters.
Facility and Physician Payment Rates
Code of Ethics
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