Episode 21: CPT Codes and How You Get Paid in Medicare
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Amy: [00:00:00] Hello, amazing listeners. Welcome back to Mastering Medicare with Alex and Amy. Hello. Hello. Hello. Hello. So today we are gonna be talking about something that always comes up. If I'm consulting for somebody, Alex gets it if he's consulting. This is a topic of great interest to pretty much everybody who is a doctor, nurse practitioner, a pa.

It's how do we get paid through the Medicare system? Isn't that interesting, Alex? Yeah. How the money flows is everything. How the money flows is everything. So we're gonna be talking today about how we get paid through what are called C P T codes and hick picks, codes. [00:01:00] This is really interesting. So Hicks Codes and C P T codes are basically a list of codes that have been attributed to every possible thing that can be done in medicine.

It means equipment, it means evaluation and management. In the office setting it means doing surgeries. It means all of those things have a code attached to them. And then when you submit that code to Medicare, Medicare has something called like a Medicare. Approved rate or whatever it is exactly. I can't remember off the top of my head, but that is the way that we get paid.

And Medicare basically divides all of these things into procedural codes and management codes and equipment codes. And then what happens is if you're a provider with Medicare, you send it to Medicare and then within 14 days they pay you. So we're just gonna go through this and this is gonna be an informative.

Educational podcast today because we've just had so many [00:02:00] questions about this. And then moving forward, we're gonna have some guests come on that have created their own codes that have worked with the American Medical Association to, you know, give values to those codes. And I think it's just gonna really, I think it's gonna hit a sweet spot for a lot of people, cuz people who are in the startup world are really trying to figure out how to get money.

Through the Medicare system because they have great ideas and they just don't understand quite how to get paid if they're gonna be looking at working with original Medicare or even Medicare Advantage. Yeah, and before we dive deep into that, let's mention back to the audience that we did launch our.

Aging Here newsletter, which you can visit@www.aginghere.com. It's our twice weekly newsletter on everything to do with the aging in place market, especially the business and operations of aging in place. And we are, we want this to be a community. If you have [00:03:00] articles or ideas or stories that you want shared in the newsletter, you can reach out to us at info.

At Aging here.com. And also I, if you're interested in being interviewed for mastering Medicare and you think you have an interesting story or, or a deep dive topic, Reach, reach out to us@infomasteringmedicare.net. So a Amy back to the CCP T topic. I see a lot of folks get confused between CPT codes versus ICD 10 codes.

Can you ah, give the the critical minor? Great. Yeah. So let me start off by telling you what CPT stands for. It stands for common Procedural terminology, and I think it's important to kind of go back to where these all came from. If we don't think about the history of them, then they kind of don't make sense, even vis-a-vis Hick Picks or ICD 10, cuz they're all distinctly different.

So the common procedural terminology codes came about many, many years ago. It turns out that there's only a limited number of things that we do in [00:04:00] medicine, right? Like we examine people, we do surgery on people, but each one of them has a little bit of a micro difference to it. And it became interesting for some really smart people to start saying, all right, how do we actually delineate each of these activities?

How do we describe the work that is done by. Medical professionals, and in doing so, they came up with this astronomically complex way of. Describing all of them. I mean, in fact, in emergency medicine, Alex, there is a specific code for if you fix a one centimeter laceration mm-hmm. A three centimeter laceration, a five centimeter laceration, and each of these C P T codes has become the way that we communicate back and forth about what we do, what is the work that we do as medical professionals.

Right. And this is, this is. Unbelievably interesting that somebody sort of took the time to kind of describe all of [00:05:00] these, and then they got divided up into whether or not it's a procedural, like an actual procedure, like a surgery or if it's an evaluation and management code. So back in the 1960s, early seventies, this sort of began to happen where people tried to articulate using a.

Numerical representation for what the stuff was that we did at that point in time. None of it was linked to payment. It was just a way of describing how many different types of things that we did. And so a lot of these have five digit codes. The C p T codes specifically start with like 99 this and 99 that, and there's, there's a lot of codes out there right Over time.

The ama, which manages these codes began working with the federal government and saying, we not only have this list of codes, but we need to be able to describe how we might get paid for those codes. And then the whole idea of RVs came into play. [00:06:00] Hmm. And VUS are relative. Value units, and this is actually truly how doctors get paid so that if you, there's a C P T, that code that you submit to Medicare, there's a value that is given to that thing, and then Medicare pays based on that.

So I thought we would just sort of start talking about the C P T codes and then we can move on to vus, ICD 10 hick picks and all this sort of stuff. We don't want this to be an overwhelming podcast, so we're gonna really try to. Keep it contained into this sort of world. So Alex, let's just say you have somebody come into your office and you sit and talk with them for 15 minutes or 30 minutes, there is a code for sitting and talking to a patient, right?

And it has a number. And if you do it, then you put it on this Medicare 1500 form, which you can find on the web. It's basically a form. Of course now it's all done electronically, but it's a form that asks for the patient's name, their Medicare [00:07:00] number what their diagnoses are that might be related to what you've done, and you submit that with the code to Medicare, and then they pay you 14 days later that, that's the simplistic way of looking at this.

Yeah. But if, let's just say that you do a craniotomy on somebody, which is basically brain surgery. There's also a C P T code. Listed for that, and then with all the little teeny tiny adjustments, like, okay, well the, you know, I made this type of incision and I, you know, extracted this much of the skull and then I did all these different things.

All of these are now described in these C P T codes. I think, you know, you know what, what I find fascinating about this is the simplicity of the model. Is, I think something that has led to the massive amount of fraud that there, there is in fee for service Medicare, right? Because you basically, as a provider, you just put on this, you know, either paper document or electronically, I, I did this c P T code for this patient who's Medicare patient, [00:08:00] and you send it and 14 days later there's money in your bank and it's like an unlimited pot of money.

Well, I mean, well that, that speaks very beautifully to original Medicare, just as a general rule, right? Because. Medicare, original Medicare doesn't have a gatekeeper, you know what I'm saying? Like you got a headache, you go to a neurosurgeon, you have, you know, a skin tag on your arm, you're gonna go to like a plastic surgeon.

So people don't triage themselves well throughout the system. But you know, in speaking to, to that exactly right, like. It's, it's just like, here's my code, here's what I did, and I'm gonna document it, you know, based on what the C P T manual tells me. I have to document it, right. And then I send it off. I mean, I think a lot of the fraud though, just to kind of contextualize is not, because maybe the documentation wasn't perfect to support that C P T code.

It's just that probably just like either never happened or never needed to happen. Right? That's fraud. Fraud is the fraud and abuse is, is. First of all, we're not lawyers, but it is. It's not necessarily because somebody didn't [00:09:00] document. Right. So the important thing also to understand about C P T codes is that there is a manual from the AMA that allows you to see exactly what Medicare wants to see in the documentation to support the medical necessity of that particular C P T code, you have to prove.

To Medicare in words. And by the way, they believe us. Whatever we write down in general, they believe that you are medically necessary. It was medically necessary to perform the evaluation management process or to do a surgery. You just put it in to the, the documentation, you send it in and then you get paid.

Well, I think this is one of the weaknesses actually about this system, that when new C p T codes get generated, like when the new RPM codes. Got p published January 1st, 2020. There wasn't a comprehensive documentation of all the requirements for the C P T code. You had to go through all sorts of different [00:10:00] sources to try to piece together.

The all the different nuances that you needed to answer. And that's been one of my frustrations, is that they generate these codes, but then they don't necessarily publish a single curated, centralized set of rules for those codes. Not only that, oh, oh, I think you are so right. I mean, I, it takes me back to when the annual wellness visit code came out.

Yeah. And they were like, okay, an annual wellness visit must be comprised of this, this, this, this, and this. Well, what do you mean by that? Like, just show me. Right, exactly. If you're gonna give me rules, don't give me half the rules. Right? Tell me exactly what rules, because there's like that gotcha moment when they're like, well, I mean that wasn't how we interpret it, interpreted it, you know, here over at cms, this is how you as an individual provider have interpreted.

I mean, the interesting thing though, Alex, is when the annual wellness visit came out, and I can't remember exactly G zero something, something, something, cuz it's a, it's a, it's [00:11:00] an interesting code an entire industry. Developed around the annual wellness visit code. Yeah. Because it was so confusing. So companies were forming that were like, we can help you do your annual wellness visit.

Cuz the interpretation of it became almost paralytic for a lot of providers. They're like, well, I don't totally understand how to do it, thus I'm never going to bill it. And yeah, it, it's actually even more interesting is if you look at all of the utilization of some of the codes that are out there many of them are never utilized.

They're just not utilized. Yeah. Like there's actually, like, sometimes they'll throw a code out there that may never have a payment from Medicare just to see if people will utilize it, but it's, there's so many codes now that you, you almost have to like live in that world of coding, coding, coding. To even say, well, I've been doing this all along.

I didn't even know there was a code for that. Now I can get billed for that. And that's where the chronic care management codes came from. Extended non-face-to-face time codes have come from. But let's go back to C P T for just a second. So [00:12:00] let's just say we're working in the emergency department, Alex, and we see a patient who comes in with chest pain.

We can put down a specific type of code, which is an evaluation and management code. It requires a certain type of documentation to be done, but then the patient has a moment where they, let's just say for those of you who may know what this is, they go into atrial fibrillation. We have to give them some medications.

We can then bill on top of that original C P T code, more C P T codes that say we were dealing with critical care time and all these other types of things so that you can actually layer on when you see a patient. Multiple different codes. So in fact, what you might start off by saying, well, this is just a simple code.

I'm not really gonna get myself, you know, anything else. You have to know what the subcodes are to make your job even profitable, to make what you do, make money. You have to become a coding expert in your field. Yeah, that's, that was my assessment. I guess it's messy. Is there are rules that certain codes, for example, cannot be combined together?

Or they [00:13:00] can only be billed certain frequency of times, right? Correct, yes. Or only by certain types of providers. And again, this is where my real frustration is. You as a provider, you have to piece this all together. And then if you don't do it correctly, they can claw back your money and they can put you in jail.

So like, this is stupid, honey. Yeah. I always go, God, I will not look good in orange. Like that is always my biggest fear. And that has been my biggest fear because this is the important thing is if you are somebody that is billing Medicare, You are literally a, basically a contractor with Medicare. You are, you are agreeing to a lot of things.

It takes a lot to become a somebody that is a Medicare provider. There's a lot of pieces of paper. Alex went through those when he started his practice. I went through them. When I started my practice, you were basically agreeing to a certain amount of rules in order to get paid for by Medicare, and it's a great payer, right?

Medicare pays within 14 days, and if you get your C P T coding down, And what is sort of formerly known as a superbill, like these are the common codes that I will use in my [00:14:00] specialty. You can really create a very efficient business, but if you don't play by the rules, you can get yourself into a lot of hot water.

Now, let's go back to just a second. Who are the people that can actually bill c p t codes? Well, lots of people who are, let's just talk about, I'm not gonna talk about durable medical equipment and other people who are working in sort of as similar, but not exactly the same C P T code environment. It's generally, Physicians, PAs and nurse practitioners, they are the ones that live in the C P T world.

So they're the ones that are out there saying, okay, I did this. It's, let's say a level three code, cuz there's all these different types of codes and it's all based on time and acuity and these types of things. So if you think about that, there's not that many people that can actually go out there and build C P T codes.

There's limited other things. There's licensed social workers, some psychologists, but in general, this is an physician nurse practitioner, PA world as, as most of us are living in it. Yeah. Yeah, so, all [00:15:00] right, so we've got these C P T codes. We get a whole bunch of them, and sometimes you can add these things called modifiers and modifiers allow you to be able to sometimes bill at the same time that you might not otherwise have been able to bill for that code.

I'm gonna give you a great example. If somebody's in hospice as an example, and I hope the listeners can really appreciate this, because this is something a, a rumor I choose to wanna dispel probably on the daily. If somebody is on hospice or in hospice or whatever the preposition is that you wanna use.

If they are currently receiving part A benefits that have been redirected into the hospice for hospice care, there is a, there's misinformation that they cannot obtain medical care from anywhere else. Correct. That is simply untrue. It is simply untrue. Somebody who's on hospice has a terminal diagnosis, and in general, Medicare doesn't want you to continue to pursue curative treatment for that particular terminal illness.

But if you go and let's just say you're on hospice, but you fall and, and break your hip, [00:16:00] You can actually, a physician can absolutely get paid for that. If you are on hospice, let's say for dementia, but you have diabetes, you could go see your doctor for diabetes. Medicare doesn't love that, but you know, it, it, it's a thing.

And there are modifiers that physicians can put, nurse practitioners, a PA sorry, can also put on that C P T code when they see a patient that's on hospice, which is either a GV modifier or a GW modifier. So it, it's like it becomes, It's, it's an alphabet soup, right? And there are people who literally get degrees in this.

There's people who specialize in this, and there's people who like live and breathe in the C P T world. Yeah. So can you so obviously I'm familiar with the emergency medicine c p t codes, you know, 9 90 81, not through 9 92 85, but how does the hospice c P T codes work? Do they bill a C P T code every month, or how Yeah, they do.

There's a ton of c there's a ton of codes that exist in hospice. And without getting too far into it Medicare has requirements, and this is part A, remember, so hospice is [00:17:00] part A, but they also have a lot of codes. They, you know, I'm going to. Claim a little ignorance here. Not knowing if they're like C P T codes directly, but they are specifically codes that say, I saw I am a nurse and I saw this patient on this day.

I am a social worker and I saw a patient on this day. And so there are a certain number of those that you need to have in order to bill and to code. So there's a whole other set. There's a whole other set of coding. That is out there for the part A world as well in order to meet those compliance. But on the part B world, we are living in the world of C P T coding.

Right. So let me, let me jump from here cuz I think it's really clear like, you know, if you do something, you get paid for it. And I'm gonna give you some examples in the emergency room, Alex, when we would see somebody for chest pain. We would put a C P T code and then there is a value, the RVs that are on that, the total number of RVs is what determines payment.

Right. And we're gonna get a little bit into how those get [00:18:00] created because I think it's kind of confusing. What an RV is, a total RVU is actually a breakdown of three sub RVOs. And most people who work in the medical world, If they're in an RVU based reimbursement system for their own payment, they get paid based on what are known as work vus.

And we're gonna talk a little bit about that. So if we're in the emergency room and we see a patient, we evaluate them for chest pain, that might be five vus, and we get paid in 14 days after we see that patient, then we get paid. On the other hand, although they're not getting paid necessarily by Medicare, because now all the insurers use C P T codes, this is across the board.

Every insurer use C P T codes. If you deliver a baby the 40 weeks prior to all of that, you're not getting paid along the way. You only get paid when the baby gets born. So there's. Lots of different ways that people get paid for these C P T codes. And that might be like 40 C p T codes, sorry, 40 RVs that you get paid for at the end of the baby being born, even though you're, you're sort of like [00:19:00] ticking along.

I did, I saw this person. Well, you know, well baby check, well baby check, well baby check, and then the baby gets born. Then you get a big giant payment based on 40 vus. So in the ER we're doing a five RVU thing with a chest pain eval, but the obs are maybe getting. 40 vus pay worth of payment at the end of a 40 week set of 40, 40 weeks of taking care of that patient.

Right. Does that make any sense? Yeah. Yeah. I, I think examples, yeah. Keep using examples. Yeah, like that. That's pretty much how it's, so let's, let's just talk really quickly because we've now talked about the fact that these c P T codes were developed in the sixties, and then over time the federal government wanted to say, wow, this is a really great idea.

Like about all these codes. Look at all these ways that we've established how people do work. How do we start, how do we start sort of attaching dollar payments to each one of those? So we. You know, we, when I say we, providers don't always understand that each C P T code has an R [00:20:00] V U value, right? And that, that RVU value is actually broken up into three different types of vus.

And RVU U Stand is sort of based on the, this concept called R B R V S, which is the resource based relative value scale. So, What is it that is comprised of. These vus. Do you know Alex? Like can you think to yourself like what would be important if you wanted to ascribe a dollar value or amount of work to a C P T code?

Like how would you do that? I read about this a long time ago, but it was some, something to do with the amount of work involved and maybe some component of like risk and resources or something. It to, it absolutely is. So let's kind of break it down and we're gonna talk about the. First sub-component of vus, which is the work R V U, the work R V U.

It's an assessment of the labor that is required to do that particular C P T code essentially, right? So it [00:21:00] accounts for technical skill, physical effort, mental effort, judgment. Stress related to the patient outcome, but most importantly, it's about time. So the total work that is sort of, they give you like a little sub Yeah.

Amount of RVs for doing this. So it's about pre-service work, the amount of service that you do during the particular process. And then the post service work. And so you get a little vu amount and, and you have to lobby for this. The AMA has opportunities to go and say I know that you thought that doing a certain type of procedure used to be, you know, seven hours long, but now it's only three hours long.

Or it used to be one hour long, but now it's six hours long. So there's a lot of. In fighting and year over year, the amount of VUS that are attributed to different c p T codes is, is under constant. There's like negotiation every single year, year over year. Oh yeah. It's massive cuz the [00:22:00] slightest change times millions of patients is gazillions of dollars.

Right, right. Oh, and not only that, but since mo, many physicians are actually reimbursed because there's so many employed physicians and they use work RVU models for physician compensation, this becomes really important, like how you argue for the component of an R V U, that is the work. R V U literally could potentially affect how many dollars a physician brings home.

Oh yeah. And, and not only that, I think there's, if you wanna see which specialties have the greatest influence in Congress or whoever decides this all you have to do is see which specialties procedures have the highest RV values. Which Right. They're the lobbyists. Yeah, they're the lobbyists. It used to be like the ortho pods and a couple of the other specialists.

But we would, we would joke in the, in the er. You know, the ER handshake was you know, you, you do a rectal exam and we're all trained that you know, there's a [00:23:00] couple things you you're supposed to do on every single patient, and we don't actually do that. Right. But a rectal exam was always kind of part of that.

And it turns out that, you know, rectal Disimpaction is like one of the highest paying procedures you can do one of the highest VU procedures in emergency medicine. And it's kind of crazy that certain procedures For some reason ha have massive VUS contributed to them more than the entire ER visit by itself sometimes.

And though that often has to do with the, the risk of doing that procedure. Yeah. Medicare and, and the ama in their, in their great wisdom in the development of the RVU based system does take into account. This is maybe not gonna be very time consuming, may not require a lot of work, but the downside and the risk might be very high.

And so it actually, there's a different part of the RVU system that gives it a high, A higher total rvu. Yeah. But why is this all important? Because VUS in and of itself doesn't get a doctor paid. It's how those [00:24:00] RVs trans. Late in $2. Yes. So there is a conversion factor and there's a Exactly. A lot of fighting about the conversion factor year after year after year.

This is not a small thing, so I actually you know, it's funny because it doesn't change like by massive amounts, but like even a two to 4% change and I think in 2023 it's somewhere is around $33. Yeah. And I actually don't have the exact number in front of me, but. Every time that the rv, the total dollars amount changes in that conversion factor where you say, okay, if you did a five vu procedure this year, you're making this, the next year you might be making 4.5% more.

Right? The next year you're making 2% less. So this has become a really big thing. And this is not just argued in some back offices. This is, comes through, oh yeah. Our government. Yeah, absolutely. So let's get to practical advice. So let's say you wanna, people always ask like, oh, well how much can you get paid for [00:25:00] doing X?

So how can people look that up? So, all right, so the nice thing is that Medicare has a lookup tool. So you can Google search under c m s. And you would basically look for the physician fee schedule and there is a physician fee schedule menu, and there's a lookup tool where you can actually put the C P T code in if there's any modifiers, if you're knowledgeable about modifiers, you can put those in and then you click.

And it will tell you how much you get paid for that C P T code or hick picks code. And we can just understanding that those are basically synonymous with each other how much you get paid in different regions. Remember that geography is important under the Medicare. Under the Medicare rules if you live in a place that is has a higher cost of living, generally the reimbursement for different c p T codes will also be higher.

And there's other different types of codes that will allow you to get paid more if you're in a facility because they understand that doing [00:26:00] certain codes in a home or in a doctor's office, in a outpatient surgery center, in a in a hospital, All of those incur different types of fees. I think it's really important that people know that that is out there.

So any of you start up, people who are looking to kind of like sort of wrap yourselves around original Medicare C P T codes and what those rates look like. And also, by the way, the MA plans utilize those same. Reimbursement rates in many ways for calculating the total cost of care of a patient. You can look these up online and you can sort of see like, wow, if I the Telemed code seem to be of great interest to people.

You can look up to see if somebody bills a certain telemed code. Whether it's an rpm, an rtm, any sort of these types of codes, how much could I create and then what is the value of my product? What is, yeah. You know, how, how, how can I utilize this information to create a business around it? Okay. So couple quick points I wanna point out.

Yeah. So yeah, if you go into Google and just write C M S C P T code lookup tool, [00:27:00] the first link is the one you should generally follow. Yep. You'll have to accept a few things. You will see this you will see that you need to decide which Mac. You are kind of looking up, as Amy said that there's slight differences in payments based on region.

Medicare is actually administered through these medic, these max, which are the Medicare administrative contractors. Right? So the government doesn't really do anything. They're private companies. That They're private. Yeah. They contract everything. So all of this is actually done at, like in our mid, mid-Atlantic region.

The Mac is novitas. So you, you can choose or see the payment by Mac and then Amy talk, remind people that this, like in a Part B payment, you're actually not getting that whole amount. Yep. Right. I think that's so critical. So explain that. Absolutely. So let's just kind of like go back through this.

You've got these C P T codes, you get RVs that are related to them. There's a [00:28:00] conversion factor, so you get a total amount that Medicare is willing to pay. It sort of slightly differs by geographic code, but the person who is performing that service Has a different Medicare allowable rate, meaning a physician is the one that is the, the only person that can quote unquote, potentially collect a hundred percent of the Medicare allowable rate.

So if Medicare says, Let's say Alex does something and then the code is 9 9 9 9 9, okay? So that's the code. And you put into this lookup tool 9 9 9 9 9, and it says a hundred dollars. We know that Alex can potentially make a hundred dollars from this. However, Medicare is not gonna pay that a hundred dollars.

They're gonna pay pay 80% of that a hundred dollars, right? And the other 20% is going to come out of the patient's pocket. Comma, or [00:29:00] through their secondary or co-insurance, right? So, All of the dollars that are here under the Part B system are just potentials. Like Alex could do 9, 9, 9, 9 9, and say, I'm gonna send a bill to Medicare for a thousand dollars on my C M s 1500 form.

I'm gonna tell him I want. Thousand dollars for this. Medicare's gonna go, haha, no such thing. We have a C P T code with RVs that map out to a Medicare allowable cost of a hundred dollars and here's your 80 bucks. Right, and good luck in getting your other twenties. So that total amount, you see it gets decrement if it's performed by an A P P, right?

Like an NP or a pa, an NP, or pa. And the amount that it gets decrement is by 85%. So the total allow, the Medicare total allowable cost goes down by 15%, right? So, If it's a hundred dollars for Alex, it's [00:30:00] only $85 for his np. And the NP would then potentially only collect 80% on that $85. Right, right. So it, it starts to go down pretty rapidly.

And you have so, and there's rules that you have to try to collect the patients. Correct. You cannot just write it off. Correct. You can't just be like, well, it's fine. You have to try to collect it jumpsuits for that. And you have to, and I don't remember exactly how many times you have to attempt, but at least once you have to try to get that secondary payment either through their secondary insurer, and I'll talk about that in just a second.

Or from the patient themselves. It's important to understand that if you are a Medicare provider and you have accepted the Medicare allowable rates in general, patients have what is known as coordination of benefits, which means, let's say that we send a to Medicare, cuz you only have to bill Medicare.

And Medicare supposedly goes through and says, Ooh, I wonder who their secondary insurer is. That's coordination of benefits. So even if they're [00:31:00] secondary, Is through Blue Cross Blue Shield, and Alex doesn't take Blue Cross Blue Shield. He sends the bill to Medicare. For, you know, the Medicare allowable rate, he gets paid 80 bucks.

Medicare then pushes that over to the secondary payer, and then the 20 bucks, the remainder of those a hundred bucks goes to Alex through Blue Cross Blue Shield, without him having to actually be specifically a Blue Cross Blue Shield provider. Right? So you can only be a provider for Medicare and still get paid by private insurers under the Medicare rules.

Right? Awesome. That is such great information. But let's go back to ICD 10 codes just in the last few minutes here. Yeah, because I think it's really important to understand how C P T codes are a distinct way that we map the activities, the professional activities that we perform. I. Those get mapped into RVs, VUS have a value ascribed to them, and then people get paid based on that vu, which becomes, you know, that times the conversion factor is the Medicare [00:32:00] allowable rate, which has some geographical malleability.

And then from there people get paid based on the 80 20 rule or the detrimental 15% for being a non-physician provider. 80 20 rule. Right. So ICD 10 codes, let's just jump into those really quick because I think it's important that you can't have one without the other. You can't have C P T coding. Yeah.

If you don't tell Medicare what is wrong with the patient. Yeah. So ICD 10 codes are the, and the 10 means they've obviously had previous nine versions of international classifications of disease. And just as there is many, many things that a physician can do in activities a physician can perform, there's only a limited number of ways that people can get sick.

Right. And every one of those ways of getting sick and having a pathology has been ascribed a code. And those are the ICD 10 codes. And by the way, there's manuals that are available for both of these C P T and ICD 10 codes. And by the way, just to make me feel old, I believe when I [00:33:00] started it was, was it an ICD eight code or ICD nine?

I don't remember When we were in med school. Was this ICD nine coding, right? You? Well, I'm a little bit younger than you. So no comment. Okay. But yeah, just to, yeah, no comment. So, Go ahead. Like they update it and they add. Okay, so ICD 10 codes is basically all the different ways that you can get sick. And so somebody, I always like to do this in my practice, and I, I was talking to you about this, Alex.

One of the things that I really enjoy doing is looking at lists of ICD 10 codes and then like trying to create a narrative from that ICD 10, like that list of ICD 10 codes. So, If you see a bunch of codes and they're just codes, right? Like a whole bunch of codes and I've memorized a lot of them cuz I work in the, I work in sort of clinical medicine quite a bit.

It's like a narrative. I can say. This is an elderly man who has a longstanding history of hypertension and chronic kidney disease who just had a recent fall and has a history of UTIs. Like you can almost turn these lists. [00:34:00] Into narratives, and that's what Medicare likes to be able to do. They like not to turn into narratives, but they like to be able to say, what is everything that is wrong with this patient?

Right. And in hospice, as an example, we have extensive ICD 10 lists when people come onto hospice. When I was in just part B practice it was very important to say. Why the patient was being seen. What is the medical necessity of why you're seeing a particular patient? So the ICD 10 codes basically give credence to the visit so that you can build I the C P T code and thus get paid.

Yeah. So the C p T code is what you did, the ICD 10 code is, is you. Is why you why I did it, right? So like, I wanna, I'm wanna read off some of my favorite ICD 10 code. Oh, here we go. Okay. Okay. W five 55.21 is bitten by cow. W 5 6 5 2 x a is struck by other phish. Initial encounter. So there's both initial encounters and subsequent encounters.

So V 97 [00:35:00] point 33 XD is sucked into jet engine subsequent encounters. So not just first, this is somebody who's so klutzy like stop. Like, stop. So w stop getting away from the engine of this W 61, 62 xd. Struck by duck. Subsequent encounter, like this is just ludicrous. I remember this. Yeah. These are, yeah, water skiing, but like being hit by the actual front of the water skiing, not the back of the water ski hit by boom.

Yeah. Yeah. All that. So yeah, pretty much anything you could imagine, although people are coming up with stuff that still has not been captured, but by ICD 10 codes. Okay, great. What, what else do folks need to know here? So, basically I think what p people need to know is that we're gonna actually take this particular podcast and we're gonna expand on it because I think how people get paid and how money moves around has really been a driving force for us.

I mean, in addition to lots of other things, how the money [00:36:00] flows and yeah, we all know that codes describe what we do. The C P T codes, the hick picks, codes. Describe what we do. The ICD 10 codes, describe why we're doing it. And I think we're just gonna kind of like keep exploring that. I think we're gonna have somebody on who's gonna talk about remote monitoring, different types of remote monitoring.

I think the E N M, which is the evaluation management codes, are gonna deserve a little bit of a deeper dive. And I think people who do procedures like surgeries are gonna need to. Come on. So if there's any surgeons out there that want some time in the limelight and understand billing and coding and ICD 10 and c p t coding in your l l neck of the woods, please give us a call.

We would love to interview you. I think it's just how the money moves. Now. We have been talking a lot about value-based care, and Alex, I'm gonna kind of now start questioning you a little bit. How do C P T codes and ICD 10 codes work? In a value-based environment, especially if you're not tracing the exact amount of things that you [00:37:00] do back to a dollar amount that you receive.

Cuz now in value-based care, like the calculus is different. Well I, I would say it's not that different in that it so, In the MA world, it's just like any other private insurance. They have contracts. The health plans have contracts with providers that they will pay certain amounts for certain C P T codes and when those providers are their own employees, as some of them are they will have their own model for that, where the physician could be on a pure hourly, and it doesn't matter which c P T codes they submit, they're still gonna, the provider's gonna get paid the same amount.

Mm-hmm. And in those situations, this, you know, the C P T codes Not just function as a payment mechanism, but also as a data and reporting and analysis mechanism. Arguably that piece of it is potentially just as important, if not more important. All these risk-bearing entities [00:38:00] need a source of truth for what's happening to whom and when.

And all of that data, it, the, through the claim, the claims data is the ultimate source of truth, right? So, so even in a model where you as a provider are being paid not necessarily through the c p T codes you are still submitting C P T codes because that is how you capture what happened to the patient and why.

So. Anyways. Yeah, well that's important because it just, yeah, I, I just think it validates why understanding this, this part of the medical system is so critically important. It's just even in a value-based environment, if I am, I'm a company and I'm gonna give you $500 to take care of this patient in a given month, and you get to keep whatever is left over at the end.

There is a huge data gathering component where you have to be able to say, Well, how do I know what I'm gonna get to keep? But you still have to be a coder. You still have to learn to code even in a P P M model, all [00:39:00] of that. Yeah, absolutely. And then maybe we should talk about the fact that there are certain C P T codes that are not paid, and there are purely for data gathering purposes.

Correct. And people don't always know about them. And that's, and that's actually what's really interesting is that Medicare will, sometimes, it's kind of like when you're taking the SATs, you're like, is that a fake question? Like I can't tell if they're using it for next year's test. But yeah, they'll put out a code to see if people start utilizing it.

But it's never really occurred to me to be like, Hey, listen, I'm gonna take the time to code for that, even if I'm not gonna get paid. Cuz like, well, that already took like five seconds out of my life that I may never get back. But I do believe that. There are a lot of codes for people who are in this world following it day after day.

There are a lot of codes, like Alex said, that are kinda like test codes to see if people will utilize them. And if they get a certain amount of them, then they will try to work towards getting RVs ascribed to them, getting them paid under the Medicare rules and, and that that's pretty exciting. Yeah, so I think that's another thing.

I think [00:40:00] this, yeah, the same thing happens on ICD 10 too, by the way. There's a lot always new codes, right? Like Medicare just came out, the whole list of these ICD 10 codes, which are basically Z codes for the social determinants of health. Yeah. They're beautiful codes, right? It addresses all of these different things, which is, they're not like person is person has a heart attack, but it might be person has trouble getting food, right?

And so there's a whole bunch of these types of codes. So on the value-based side, there's. In addition to, in like an internal operational data analysis and reporting value to the CPD codes, there is also a quality angle to it. Mm-hmm. Which is all these health plans are competing with each other for members, whether that's MA or you know, or in the, in the private commercial space.

And they get, they, they have a grade, right? They have star ratings with Mm. The Kaiser plans five star, and this other one's three star. So which one are you gonna choose while we are probably gonna go to the five star one, right? Mm-hmm. Mm-hmm. So how are those measured? Many of the. Quality measures that get [00:41:00] aggregated together into the five star are measured automatically cer through the presence or absence of certain codes in the claims data for the, the existing members.

Right? So, so a lot of, in the value-based space, a lot of providers are under tremendous pressure to capture the right codes so that the health plan under, or the risk repairing entity under which they operate can meet the quality, their quality goals. Not only that, but H C C scoring is related entirely almost to ICD 10.

Oh yeah. Quality, quality coding. Yeah. So, yeah. So it hits them on revenue side as well. Yeah. So there's, yeah. So you got risk. Right. Revenue, risk and revenue, it's the same. The only differences in the Part B world, you do not have like risk per se, but there's always like, you can't bill this if you don't do that and in, and if you don't have this ICD 10 code, you can't do this.

And so it, it does they all, the interplay of C P T and ICD 10 coding is, is pretty much paramount. [00:42:00] And I'm not sure that everybody is always so skilled in it. I didn't learn it in med school. Did you learn it in med school? I mean a little bit. No med school? No, no, no, no, no, no. Not at all. Med school. No, no.

Just residency. Okay, let's wrap this up. So everybody, all right, great. Visit us at aging here, uh.com and sign up for a newsletter. Send us ideas, stories, et cetera, info aging here.com. Reach out to us@infomasteringmedicare.net.net and thank you so much. Thank you so much.