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Simple office visits: |
| | Example
1.
Dr. Smith sees Mr. Jones for a follow-up visit lasting 15 minutes
and an expanded problem focused history and examination are completed.
Dr. Smith bills $120.00 using CPT® code 99213 and includes a chart
note documenting the services provided. The RVU for CPT® code
99213 is 1.67 and the applicable conversion factor is $64.79. The
maximum allowable under the fee schedule is $108.20 (1.67 x $64.79).
Dr. Smith is paid the fee schedule amount of $108.20 for the services
provided. |
| | |
| | Example
2.
Ms. Smith, PA, sees Mr. Jones for a follow-up visit lasting 15 minutes
and an expanded problem-focused history and examination are completed.
Ms. Smith bills $82.00 using CPT® code 99213-81 and includes
a chart note documenting the services provided and that the services
were provided by a physician assistant. The RVU for CPT® code
99213 is 1.67 and the applicable conversion factor is $64.79. The
maximum allowable under the fee schedule for a physician is $108.20
(1.67 x $64.79). The maximum allowable under the fee schedule for
a physician assistant is $91.97 ($108.20 x 85%). Ms. Smith is paid
$82.00 for the services provided.
|
| | |
| Services
at an ASC: |
| | Mr. Jones is
in need of arthroscopic knee surgery and Dr. Cotter provides it at an ASC. Dr. Cotter and the ASC will each bill. Dr. Cotter bills and is paid for performing
the surgery. The ASC bills and is paid for providing the facility for the surgery.
Dr. Cotter bills $2500.00 using CPT® code 29880. The RVU for CPT®
code 29880 is 17.66 and the applicable conversion factor is $86.44.
Dr. Cotter is paid $1526.53 (17.66 x $86.44) for performing the surgery.
The ASC bills $3100 using CPT® code 29880-SG and provides a copy of the operative report. The ASC group number assigned by the Division 009 rules
for CPT® code 29880 is 6, and the maximum allowable fee under Oregon workers' compensation for group 6 is $2108.00. The ASC is paid $2108.00 for providing
the facility used by Dr. Cotter for the surgery. |
| | |
| Outpatient
Physical Therapy: |
| | Dr. Cotter
prescribes physical therapy for Mr. Jones. Mr. Jones goes to Salem Hospital for his therapy. The hospital bills a total of $129.00:
$30.00 for CPT® code 97032 (RVU is 0.44);
$51.00 for CPT® code 97140 (RVU is 0.71); and,
$48.00 for CPT® code 97110 (RVU is 0.76).
The applicable conversion
factor for each of these CPT® codes is
$65.79.
The maximum allowable under the fee schedule for:
CPT® code 97032 is $28.28 (0.43
x $65.79);
CPT® code 97140 is $46.05 (0.70 x $65.79); and,
CPT® code 97110 is $49.34 (0.75 x $65.79).
Salem Hospital is paid $122.33
($28.28 + $46.05 + $48.00) for the outpatient therapy services. On the final reimbursement, $48 is paid for services under CPT® code 97110 since it
is the lesser of the fee schedule and the actual charge. |
| | |
| Emergency
Room visits: |
| |
Example
1.
Mr. Jones goes to the emergency room at Providence Portland Medical
Center on July 14, 2008 and is examined by Dr. Meyer. Providence bills:
$250.00 using revenue code 0981 and CPT® code 99284 (RVU is 3.17)
for services provided by Dr. Meyer and $335.00 for the use of the
emergency room, using revenue code 0450 and also using CPT® code
99284 as required by Medicare for a total of $585.00.
The
charges for the physician's services ($250.00) are subtracted from
the billed total ($585.00) and paid using the applicable conversion
factor ($64.79) and RVU. The adjusted cost/charge ratio is applied
to the remaining balance of $335.00 ($585.00 - $250.00). The adjusted
cost/charge ratio for Providence Portland Medical Center (see Bulletin
290) is (0.512).
Providence Portland Medical Center is paid:
$205.38 (3.17 x $64.79) for services provided by Dr. Meyer; the adjusted
cost/charge ratio(0.512) is multiplied by the remaining balance of
$335.00 for a payment of $171.52. Providence Portland Medical Center
is paid a total of $376.90 ($205.38 + $171.52) for the services provided
to Mr. Jones. |
| | |
| |
Example
2.
Dr. Hill sees Mr. Jones at Willamette Falls Hospital emergency room
on July 14, 2008. Dr. Hill orders x-rays. Willamette Falls bills:
$335.00 for use of the emergency room using revenue code 0450 and
CPT® code 99284; and,
$110.00 using revenue code 0329 and CPT® code 72110-TC2
for taking the x-rays for a total of $445.00.
Willamette
Falls is paid:
The adjusted cost/charge ratio of 0.564 for Willamette Falls Hospital
is multiplied by the balance of $445.00 for a payment of $250.98 for
services provided on July 14, 2008.
Dr.
Hill bills $250.00 using CPT® code 99284 (RVU is 3.17) for the
services he provided in the emergency room on July 14, 2007. Dr
Hill is paid $189.53 (3.17 x $59.79).
Dr. Scott bills $55.00 for interpreting the x-rays using CPT®
code 72110-263
(RVU is 0.42). Dr. Scott is paid $28.56 (0.42 x $ 68.00) for the
report interpreting the July 14, 2007 x-rays.
2"TC" is
the modifier used for the technical component of a service
3
"26" is the modifier used for the professional component
of a service.
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|
|
Medical
Fee Dispute Request:
|
| | When a dispute about fees exists between a provider and an insurer, a provider,
insurer, or injured worker may request review by the director. A request for review must be submitted to the director within 90 days of the date the aggrieved
party knew or should have known that the dispute existed.
Use these forms to request review:
Medical
Fee Dispute Resolution Request (Form 2842)
Medical
Fee Dispute Resolution Worksheet (Form 2842a) |
