Billing Flashcards
Difference in Direct vs Incident to professional billing for outpatient care
Direct - Physician is not required to see the pt
Incident to - Professional fees reimbursed at 100% of physician schedule but the physician must be involved and physically see the pt.
Direct - NP is reimbursed at 85-92% of physician schedule
Hospital or ER professional billing categories
Direct
Split/Shared
Hospital or ER professional billing categories that involves you consulting a physician
Split/shared
In split/shared billing what can the physician not say in their note
what is correct
“I have personally seen and examined…..I agree….” - this is fraud
“I was asked by Julie Kuzin, PNP to see this patient regarding the development of empyema.” They will then include “substantive” elements from their face to face experience with the patient ….”
Admission CPT codes
99221 - minor
99222
99223 - highest complexity
what is wRVU
Work RVU - a way to quantify productivity
what is tRVU
total RVU - this is what is used to calculate the allowable charges
RVUS are numbered based on the code which is what determines the charge.
CPT consultation codes
99251 - level 1 99252 99253 99254 99255
subsequent care CPT codes
99231
99232
99233
Discharge CPT codes
99238
99239
conversion rate CPT formula
$28.35 x total RVU = allowable charge
(for 2021 - $34.8931)
CMS.gov
Problem focused (billing)
HPI requirement
ROS requirement
Past, family and social History requirement
Brief HPI (1-3)
ROS (No requirement)
PFSH (no requirement)
Expanded Problem focused (billing)
HPI requirement
ROS requirement
Past, family and social History requirement
Brief HPI (1-3)
ROS - Problem pertinent
PFSH (no requirement)
Detailed (billing)
HPI requirement
ROS requirement
Past, family and social History requirement
Brief HPI - 4+
ROS - Extended (2-9)
PFSH - Pertinent (1-3)
Comprehensive (billing)
HPI requirement
ROS requirement
Past, family and social History requirement
Brief HPI - 4+
ROS - Complete 10+
PFSH Complete (2-3) or (3-3) for new
