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DebbieP

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Please help! I trying to see if our Medicare reimbursement is correct. I can't come up with the correct formula. Is it time units (every 15 mins equals 1) + base units (given by CMS) X conversion factor? I hope someone can help me with this.
 
Debbie,

You are correct. Keep in mind that time units for Medicare are calculated in tenths of a unit. For example, if your total anesthesia time was 72 minutes, then your time units would be 72 minutes/15 minutes = 4.8 units (not 5 units). Regardless, for Medicare, you report total minutes on the claim form, not units. If the anesthesiologist performed the service, then yes, your calculation is correct.

The reimbursement is different if the anesthesiologist provided medical direction or supervision. It would be helpful to review Chapter 12, Section 50 of the Medicare Claims Processing Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf Other payers may have different reporting requirements and may calculate the units differently. Some payers allow extra units for qualifying circumstances, physical status modifiers, special positioning, and field avoidance (Medicare doesn't).

I hope this helps!

Sincerely,

Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC
 
Jennifer,

You stated you report total minutes on a Medicare claim not units but the reimbursement is based on the units or minutes? Does Medicare convert it to base units + time units X CMS conversion factor. Thanks so much I will go review Chapter 12.
 
DebbieP said:
Jennifer,

You stated you report total minutes on a Medicare claim not units but the reimbursement is based on the units or minutes? Does Medicare convert it to base units + time units X CMS conversion factor. Thanks so much I will go review Chapter 12.
Click to expand...

Debbie,

Per Medicare guidelines (in Chapter 12) :), you report minutes on the claim form. Medicare will convert the minutes you report to units and apply the reimbursement formula: (base units + time units) x conversion factor. If you are validating Medicare reimbursement, you need to know that Medicare calculates units to 1/10 of a unit, not rounded.

Does that make sense?


Jennifer M. Connell, CPC, CPCO, CPC-P, CPB, CPMA, CPPM, CPC-I, CENTC
 
Rounding

In knowing that Medicare time units are calculated to 1/10th of a unit, do you know what rounding method is used? Based on research with other payers, we are learning this can vary. So far, we have seen the following rounding methods: Down @ 7 up @8 Down @ 4.99 up @ 5.00
 
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