Wiki 2011 ER/Trauma Visit

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Jessica_Johnson

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I have a patient who is questioning the following and since I have limited Facility experience can I ask for some reference help? Here are the services charged:

1. CPT 94760
2. CPT J1170
3. CPT J2405
4. CPT J2550
5. CPT 71020
6. CPT 96372
7. CPT 99291
8. CPT G0390

My questions are as follows: 1. Where within the Medicare website would I find the 2011 fee schedule to print off for this patients review? 2. When billing a trauma /trauma alert is this identified by a revenue code? If so, can I please have a clarification of this? Where might I find reference materials to support this? 3. What coding and billing guidelines would mandate how this patient is billed if they fall in a class of "self-pay"? 4. Does Medicare set the standard for all facility billing and coding?

May I ask that the answers be "specific" and not just www.cms.gov? I appreciate any help you can afford with this?

Thank you!
 
A lot to ask for....

I think you might be asking for a bit too much. Let me try to tackle a couple of parts. The Fee Schdule is on the site, just look around. Self pay should not be billed any differently than insured patients. You will have to be more specific with your question. Are you asking about whether a discount can be applied to self pay patients.?
And as you might have seen on this site with questions about facility ED Level coding, there are no specific guidelines on how to code ED facility levels. There are 13 general principles, but they won't really help you with determining the ED Level. Take a look at a couple of strings on here about facility ED coding. And do a bit of internet research and you will see some of the methodlogies that are out there.

Jim S.
 
More Specifics /Questioning ER Fees

Jim , Thank you! In regards to your statement that self pay should not be billed any different than insured ..where can I find specific reference material that would support this statement. The patient I am speaking of is a self pay but has been charged over 300% more than the Medicare allowable. In reviewing the Medicare fee schedule I am rather taken back at the fees that the facility has charged. I am aware that a self pay discount can be applied by the facility. Obviously I am concerned as to why this patient was outrageously charged and how I can help her with reference.

Best,
Jessica
 
Actually not that High

Jessica,

I know it might seem outrageous, but 3X of Medicare is pretty standard pricing. Most facilities use either a multiple of the fee schedule or RVUs that pretty much come out to a multiple of the fee schedule. The reason they do it that way is pretty much they always have. A long time ago when many payors paid either 100% of charges or 80% it made some sense. The other argument that is somewhat valid is that Medicare fees have been held artificially low for a long time. But then why use Medicare fees as a basis for pricing? And the answer is that Medicare provides the best information.
Price sensitivity for healthcare services has become a big issue these days with pretty much most the insured having responsibility of some of the bill. What I've seen many facilities do is offer a pretty liberal discount after billing for self pay patients. Also if this person really is a hardship case, the hospital should have hardship guidelines to offer the patient either free or deeply discounted fees.

Jim S.
 
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