HOUSE BILL 2339 ADVISORY GROUP OCTOBER 10, 2017 Tashia Sizemore - PowerPoint PPT Presentation

HOUSE BILL 2339 ADVISORY GROUP OCTOBER 10, 2017 Tashia Sizemore Senior Policy Analyst Division of Financial Regulation

Follow-up from September • What does it mean when a line with a CPT code lacks a modifier? Most rows with CPT codes have no modifiers, regardless of whether the claim is facility or professional. These rows are already included. • Is the claims data at the claim or procedure level? Each claim line is a single CPT code. • Global billing. • Scope of recommendation to the legislature.

Revenue Codes Explained • What are they? • Per the AAPC: Payment codes for services or items in FL 42 of the UB-92 found in Medicare and/or NUBC (National Uniform Billing Committee) manuals (42X, 43X, etc.) • Example One • CPT Code: 23515 • CPT Code Explanation: Clavicle Fracture • Associated Revenue Codes • 0360: Operating Room Service - General • Example Two • CPT Code: 00790 • CPT Code Explanation: Under Anesthesia for Procedures of the Upper Abdomen • Associated Revenue Codes • 0250: Pharmacy - General • 0258: Pharmacy - IV Solutions • 0272: Medical/Surgical Supplies and Devices - Sterile • 0963: Professional Fees – Anesthesiologist (MD) • 0964: Professional Fees – Anesthesiologist (CRNA)

For More Information on Revenue Codes • The website used by DFR to research revenue codes listed in this presentation: https://med.noridianmedicare.com/web/jea/topics/claim- submission/revenue-codes • A website linked on the Noridian Medicare website: http://www.nubc.org/

Example One: 00142 Commercial Only Medicare Only • In-Network • In-Network • Rating Area 1 • Rating Area 1 • Revenue Code: Null • Revenue Code: Null • Number of Claims • Number of Claims Available: 2,123 Available: 9,679 • Billed Average: $680.95 • Billed Average: $700.51 • Allowed Average: $377.58 • Allowed Average: $149.24 • Paid Average*: $291.37 • Paid Average*: 144.34 *This amount may not include consumer cost- *This amount may not include consumer cost- share responsibilities (e.g. copayment, share responsibilities (e.g. copayment, coinsurance, or deductible) coinsurance, or deductible)

Example Two: 23515 Commercial Only Medicare Only • In-Network • In-Network • Rating Area 1 • Rating Area 1 • Revenue Code: Null • Revenue Code: Null • Number of Claims • Number of Claims Available: 281 Available: 23 • Billed Average: $3,490.09 • Billed Average: $3,784.39 • Allowed Average: • Allowed Average: $1,857.81 $1,017.78 • Paid Average*: $1,378.07 • Paid Average*: $957.57 *This amount may not include consumer cost- *This amount may not include consumer cost- share responsibilities (e.g. copayment, share responsibilities (e.g. copayment, coinsurance, or deductible) coinsurance, or deductible)

Example Three: 88112 • Rating Area 1 • Revenue Code: N/A • In-network pathology claims without modifiers 26 and TC • Number of Claims Available: 3,363 • Billed Average: $228 • Allowed Average: $95 • Paid Average*: $73 • In-network pathology claims with modifier 26 • Number of Claims Available: 5,532 • Billed Average: $151 • Allowed Average: $43 • Paid Average*: $37 • In-network pathology claims with modifier TC • Number of Claims Available: 216 • Billed Average: $134 • Allowed Average: $51 • Paid Average*: $45 *This amount may not include consumer cost-share responsibilities (e.g. copayment, coinsurance, or deductible)