Every CPT code has been assigned a relative value unit (RVU) and they are determined on the basis of the resources necessary to the physician’s performance of the service. Assigning these services in the proper sequence based on a highest to lowest RVUs can ensure proper payment. When submitting the claims, listing the codes in the wrong order may lower your reimbursements. Here are some examples which illustrates how a change in sequence may affect the way you are reimbursed.
Case 1: During a right eye cataract surgery with IOL, an ophthalmologist also performed fistulization of sclera for glaucoma;trabeculectomy ab externo in absence of previous surgery.The claim was billed as –
Line 1: 66984 RT (RVU 20.85)
Line 2: 66170-59-RT (RVU 32.13)
The payer processed the claim with a 50% reduction on the second line item and made a total payment of $1335.24.
Since CPT 66170 has higher RVU, the claim should have been billed with CPT 66170 -RT on the first line and 66984-59-RT on the second line. Then the reimbursement would have been $1533.19.
A potential loss of $197.95 per case, which could add up significantly if physician is performing multiple such cases.
Case 2: A surgeon performed an anterior discectomy and osteophytectomy at C5-6 and C6-7 with allograft fusion and zephyr plating.The claim was billed as –
Line 1: 22554 (RVU 34.17)
Line 2: 22845 (RVU 20.25)
Line 3: 20931 (RVU 3.06)
Line 4: 63075-51 (RVU 37.04) 50% reduction
Line 5: 63076 (RVU 6.86) X3
The payer processed the claim and made a total payment of $3910.16.
The RVUs in the above metioned claim suggests that the claim should have been billed like this:
Line 1: 63075 – Full payment
Line 2: 22554-51 (50% reduction)
Line 3: 22845
Line 4: 63076 x 3
Line 5: 20931
The reimbursement would be $3966.22. A potential loss of $56.065 per case, which could add up significantly if physician is performing multiple such cases.
Case 3: An Ob-Gyn performed a left Salpingo-oophorectomy and a right ovarian cystectomy. The claim was billed as
Line 1: CPT 58720 LT (RVU 20.00)
Line 2: CPT 58925-51-RT (RVU 20.51) 50% Reduction on the second line item.
The payer processed the claim with a 50% reduction on the second line item and made the total payment of $1155.73.
Since CPT 58925 has a higher RVU(20.51) then CPT 58720 RVU(20.00), the codes should have been submitted in this order
Line 1: 58925-RT $782.85
Line 2: 58720-51-LT $391.42(after 50% reduction)
Total Amount would be: $1165
A potentioal loss of $9.27 per case which could add up significantly if physician is performing multiple such cases.
When reporting multiple surgery procedures performed on the same day, on the same patient by the same physician, codes should always be listed according to their assigned RVUs.This proper sequencing is very crucial when it comes to reimbursement because if a lower RVU code is billed first, it will be reimbursed fully while the higher RVU code will be paid at a reduced rate thus lowering the overall reimbursement.