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

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Feb 06, 2024 23 likes •95 views

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

SLIDE 1

HOUSE BILL 2339 ADVISORY GROUP

OCTOBER 10, 2017

Tashia Sizemore Senior Policy Analyst Division of Financial Regulation

SLIDE 2

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.

SLIDE 3

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)

SLIDE 4

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/

SLIDE 5

Example One: 00142

Commercial Only

In-Network
Rating Area 1
Revenue Code: Null
Number of Claims

Available: 2,123

Billed Average: $680.95
Allowed Average: $377.58
Paid Average*: $291.37

*This amount may not include consumer cost- share responsibilities (e.g. copayment, coinsurance, or deductible)

Medicare Only

In-Network
Rating Area 1
Revenue Code: Null
Number of Claims

Available: 9,679

Billed Average: $700.51
Allowed Average: $149.24
Paid Average*: 144.34

*This amount may not include consumer cost- share responsibilities (e.g. copayment, coinsurance, or deductible)

SLIDE 6

Example Two: 23515

Commercial Only

In-Network
Rating Area 1
Revenue Code: Null
Number of Claims

Available: 281

Billed Average: $3,490.09
Allowed Average:

$1,857.81

Paid Average*: $1,378.07

*This amount may not include consumer cost- share responsibilities (e.g. copayment, coinsurance, or deductible)

Medicare Only

In-Network
Rating Area 1
Revenue Code: Null
Number of Claims

Available: 23

Billed Average: $3,784.39
Allowed Average:

$1,017.78

Paid Average*: $957.57

*This amount may not include consumer cost- share responsibilities (e.g. copayment, coinsurance, or deductible)

SLIDE 7

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)