As simple as it sounds, if you want to get paid for what you do, you must speak the language of coding. In order to fully understand coding and reimbursement, and to be able to speak that language, you must understand how the coding system works and how and why values are set forth for every service you do.

By and large, coding is created for the Medicare system, and thus, many federal directives dictate coding polices and reimbursement-related issues. Providers are frequently underpaid by payors for services rendered. The cause of these low reimbursement rates doesn’t always lie with the payor, however. It may be the result of improper coding and documentation by the provider.

By understanding how the coding process works, you can more easily develop your coding and fee schedules for your office to assure maximum reimbursement.

Let’s address the three major points your office must be aware of in order to assure proper reimbursement:

1. understanding Current Procedural Terminology® (CPT®) Coding and Resource Based Relative Value System (RBRVS);
2. properly coding for the services you render; and
3. assuring your level of documentation will support the services you rendered.

The CPT coding system is updated and published annually by the American Medical Association (AMA), and the term CPT is a registered trademark of the AMA.

Many practitioners are unaware that this coding process is overseen and approved by the U.S. Department of Health and Human Services (HHS). Most coding is developed for Medicare purposes. For example, when it was determined there was a need for specific Chiropractic Manipulative Treatment (CMT) codes, the process was begun in 1996. These codes were created for reimbursement within the Medicare program. The simple creation of these codes increased Medicare reimbursement for doctors of chiropractic by more than 50% from the old A2000 code.

As you know, the CMT codes are now the primary codes used for average day-to-day encounters with patients. The process was begun and adopted for Medicare, but the codes are widely accepted by most all insurers. The process includes assigning a value to the codes, known as the Resource Based Relative Value System (RBRVS). This system assigns three values to each code: a work value, a practice expense value, and a malpractice value. The application of each of these, when multiplied by geographic equivalents and a yearly conversion factor, determines the Medicare reimbursement value for each code. These are the values you receive at the end of each year from your Medicare carrier to let you know what your fee schedule will be for the next year.

The work value of a code represents the “work per unit of time” in general, and is based not only on the amount of time spent with the patient, but also the amount of work, physician skill, and judgment required during the visit. This constitutes the majority of the value of the code.

The second value is known as practice expense. This value fluctuates annually, and is primarily the reason you may see a few cents increase or decrease in your Medicare fees on an annual basis. This value includes things such as the cost of your physical plant, your staff, electricity, supplies, etc.

The final value is a malpractice value. This number is dependent upon the risk of the service.

The reason all these facts are important is that in many ways, the Medicare system drives reimbursement. Although the private payors have their own fee schedules, one need only to look at the recent flood of denials associated with the Medicare Correct Coding Initiative (CCI) edits to see how Medicare initiatives can drive reimbursement within the profession.

Although Medicare allows only the CMT codes to be reimbursed in the program, it has set edit checks coupled with the CMT codes to deny other services rendered on the same date, such as massage, manual therapy, or neuromuscular re-education. These are known as mutually exclusive services. Logic dictates that this should not be an issue, since Medicare does not cover these other ancillary ser-vices. However, many private payors have adopted these edits as the basis for their own systems, and this practice has driven a startling reimbursement trend.

More and more payors are trying to inch toward CMT being the only covered service for doctors of chiropractic. It is clear to see how this Medicare coding system can affect your reimbursement in the private payor arena. More and more payors are adopting the Medicare RBRVS fee system to determine their reimbursement guidelines. For this reason, it behooves you to be intimately aware of the connections between Medicare and the private payor system, and to understand how this coding system can affect you in your daily practice.

It’s also imperative