Bio-Med Reference

Medical coding and finding healthcare costs

In case anyone is interested, here’s a synopsis of my shpiel on medical coding and finding healthcare costs from last week's reference meeting. This can also serve as a cheat sheet if you get a code question at the desk. Feel free to correct or update anything I got wrong/missed/mangled!

Liz

Coding Systems

ICD-9-CM – International Classification of Diseases, 9th revision, Clinical Modification.
Reference WB15 I57 2001
• Codes for diagnoses and procedures
• Mainly used to keep data about activity in hospitals
• Developed and maintained by the Centers for Medicare and Medicaid (CMS)
• Format:
nnn.nn (Diagnosis codes) – example: 039.48
nn.nn (Procedure codes) – example: 39.48

CPT-4 – Current Procedural Terminology, 4th ed
Reference W39 C976 2005
• Codes for procedures
• Used for reimbursement from public and private health plans
• Developed and maintained by the American Medical Association (AMA)
• Also known as HCPCS Level I
• Format: nnnnn – example: 57894

HCPCS Level II – Healthcare Common Procedure Coding System
Reference WT39 M489
• Codes for services and supplies not covered by CPT codes
• Examples: ambulance services, durable medical goods, orthotics, etc.
• Used for reimbursement from public and private health plans
• Developed and maintained by the CMS
• Alphanumeric format: xnnnn – example: L5020

DRG – Diagnosis Related Groups
Reference WB15 D778 1998
• Codes for diagnoses, based on ICD-9-CM diagnosis codes – 511 different groups
• Used for reimbursement:
a. Idea that clinically similar patients (demographic, diagnostic, therapeutic attributes) would consume hospital resources in a similar fashion
b. Hospitals reimbursed a flat rate based on DRG – what hospitalization is expected to cost – also known as Prospective Payment System (PPS)
• Maintained by the CMS
• Format: nnn – example: 127

Resources to find cost data

Most of the cost data you’ll find is related to a procedure (linked to a CPT code.) The CMS has a fee schedule of what they will reimburse for a procedure, and they have assigned each procedure a number of Relative Value Units (RVU) to reflect the difficulty of a procedure as related to other procedures. Other variables are factored in, such as the geographic area (procedures are generally more expensive in certain parts of the country.)

• Medical fees in the United States: nationwide charges for medicine, surgery, laboratory, radiology and allied health services
Reference W80 M489 2005
o Lists current RVUs and Medicare reimbursement amounts.
o Includes privately-collected data on what physicians are actually charging (50th, 75th, 90th percentile)
o Arranged by CPT code

• Physician’s Fee and Coding Guide
Reference W80 AA1 P5 2005
o Lists current RVUs and Medicare reimbursement amounts.
o Arranged by CPT code

• The DRG handbook: comparative clinical and financial benchmarks
Reference WX16 D778
o Detailed financial and statistical information about the top Diagnosis Related Groups
o Arranged by DRG number

(Biomed reference quick links -> Government Resources ->)
• Physician Fee Schedule
o Most current, but divided into about 10 PDFs so it’s difficult to search
• Medicare Outpatient Payment
o Outpatient procedures only, a bit out of date (data for 2004), but in one PDF so easier to search

Information about more abstract costs (i.e.: What does a smoker cost a health plan?) is best found in Medline. Use the economics subheading (/ec) with the condition and the “Cost and Cost Analysis” MeSH.

Posted by biomedref at July 25, 2005 02:18 PM