Primary Care Coding Alert

Question: I overheard fellow coders discussing the 2005 physician fee schedule's new rate. How will this affect my family physician who has a mix of Medicare and private insurance patients?

Ohio Subscriber

Answer: The 2005 physician fee schedule will impact more than just your Medicare patients. Although Medicare creates the physician fee schedule, the rule impacts private payers, as well. Over 75 percent of commercial insurers use the fee schedule in some fashion to determine physician reimbursement.
 
Good news: You'll enjoy a small increase - 1.5 percent to be exact - in the 2005 conversion factor (CF) to $37.8975 from the 2004 CF of $37.3374.
 
How it works: To calculate how much a service or procedure pays approximately, multiple the code's relative value units (RVUs) by the CF.
 
Editor's note: How much Medicare will specifically pay for the code also depends on the geographic adjustment factor for your area and whether a facility - such as a hospital - or non-facility - such as an office - provided the service.
 
Example: Code 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) contains 1.39 RVUs in the non-facility setting and pays $52.68 (1.39 x $37.8975) in 2005. In 2004, the office visit had 1.41 RVUs and paid $52.65 (1.41 x $37.3374).

 - Answers to You Be the Coder and Reader Questions provided by Pamela J. Biffle, CPC, CCS-P, ACS-DE, approved PMCC instructor, product development director of Custom Coding Books in Bellevue, Wash.; Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN); Linda Walsh, MAB,  senior health policy analyst with the AAP Division of Health Care Finance and Practice.