SCCM Resource Library-Overview of Payment and Coding Systems

Pdf Summary

Chapter 1 of the Current Procedural Terminology (CPT) 2020 by the American Medical Association (AMA) offers an overview of coding systems critical care practitioners use for reimbursement of services. The AMA developed CPT as a standardized method for describing medical procedures performed by healthcare professionals. Annually updated, these codes are crucial for billing and insurance claims, yet their usage does not guarantee complete reimbursement.<br /><br />CPT codes, organized in an Evaluation and Management (E/M) section, include modifiers for specific circumstances, such as specialized services. Critical care codes in this section are unique, involving time elements. Coding rules, defined by systems like CPT and the Healthcare Common Procedure Coding System (HCPCS), are separate from payment rules, established by the Centers for Medicare & Medicaid Services (CMS) and third-party payers, determining the reimbursement of coded services.<br /><br />HGPCS Level I consists of CPT codes, whereas Level II is for products, supplies, and non-physician services, standardized to facilitate billing outside the physician's practice. Healthcare professionals adhere to CPT-4 codes for insurance claims, while the RBRVS and RUC processes guide payment scale adjustments considering physician work, practice expenses, and liability insurance.<br /><br />The RUC, composed of healthcare professionals from diverse fields, collaborates with the CPT Editorial Panel to propose payment-related recommendations to CMS. Engaging in surveys and data analysis, the RUC measures the relative value of medical codes for reimbursement policies. This process, influential in non-government-funded healthcare, enables adaptive and justified compensation structures.<br /><br />The AMA's consultative work on coding and billing systems, continuously revised to reflect healthcare dynamics, is essential for resource management and provides a framework to ensure payment equity amidst complex medical service environments. Understanding these systems is crucial for healthcare providers to navigate and secure reimbursement effectively.

Asset Subtitle

Administration, Professional Development and Education, 2021, 3:20:00

Asset Caption

This is a complimentary chapter from the textbook, Coding and Billing for Critical Care 8th Ed), titled "Overview of Payment and Coding Systems." Physicians are required to use a variety of coding systems to obtain reimbursement for services rendered. This chapter provides critical care practitioners with an overview of these coding and payment systems.

Meta Tag

Content Type Book Chapter

Knowledge Area Administration

Knowledge Area Professional Development and Education

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Billing and Documentation

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Economics

Year 2021

Keywords

Billing and Documentation

CPT 2020

American Medical Association

critical care coding

reimbursement

Evaluation and Management

HCPCS

RBRVS

RUC

CMS

medical billing

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