Wiki Do you still submit CPT charges, highest to lowest, in RVU value?

[skseyes1]

Hi all! I am working with an orthopedic practice and they are questioning if they still need to post their charges based on their RVU value from highest to lowest? Everything is submitted electronically through Waystar clearinghouse. I think they still need to have their CPT charges ranked since your reimbursement goes down. Please help me to confirm this or tell me it is no longer necessary to submit charges in this manner. I am not referring to ASC charges, but physician charges in a clinic setting.

Thank you for your help!
Susannah

 

[csperoni]

It shouldn't be necessary in this day and age. I am not aware of any payor who does not use a computer system to process claims, which should automatically pay the highest value at 100%, and then subsequent surgeries at their reduced rate.
Notice my use of the word SHOULD. Which means maybe 0.001% of the time, you will come across something that was paid in the order you listed them instead of the correct value order.
In my opinion, depending on how much time/energy/effort it takes for you to list them high to low RVU, it's just really not important. When posting surgeries, I do always post high to low, but that is more by habit than necessity. Many of my colleagues do not, and I cannot recall the last time I saw a claim paid incorrectly due to the order submitted. Perhaps years.

 

[amyjph]

Even though systems are electronic and the 51 is pretty much obsolete; I would still list them correctly in RVU order. When looking at the case or service if there are multiple lines it makes more sense this way. You can also more easily see if something is missing and/or other problems if they are in RVU order. There may also be an internal reason to do this with data analytics and other spreadsheets or info that may be pulled internally from your EHR/EMR. If it was up to me, I would not recommend just haphazardly adding codes out of order. I feel like the standard should be kept and followed. I also don't necessarily trust multiple procedure reductions to be applied correctly 100% of the time. Also, when training newer coders and for people who are learning, it is much easier to teach it in RVU order.

I also think of post-claim adjudication and what the EOB or ERA looks like, look at it from a payment posting perspective and from the eye of a customer service rep or someone else helping a patient with a bill, etc. The dollars will usually start higher and go down from there.

Especially in ortho, think of it if you had a big spine case and it was listed like this (not saying these are correct or would be billed together, just as an example):
20936
63052
22842
22853
22633
22830
22614
This would just be off kilter, could lead to entry errors, diagnoses linkage errors, and code first rules may or may not apply. It just does not make sense to me to do this. Maybe if it is a different specialty, but not orthopedics.

Or, even office procedures with E/M? Can you imagine looking at a billing screen like this? Totally weird.
J1010
99214
20610

 

[csperoni]

Even though systems are electronic and the 51 is pretty much obsolete; I would still list them correctly in RVU order. When looking at the case or service if there are multiple lines it makes more sense this way. You can also more easily see if something is missing and/or other problems if they are in RVU order. There may also be an internal reason to do this with data analytics and other spreadsheets or info that may be pulled internally from your EHR/EMR. If it was up to me, I would not recommend just haphazardly adding codes out of order. I feel like the standard should be kept and followed. I also don't necessarily trust multiple procedure reductions to be applied correctly 100% of the time. Also, when training newer coders and for people who are learning, it is much easier to teach it in RVU order.

I also think of post-claim adjudication and what the EOB or ERA looks like, look at it from a payment posting perspective and from the eye of a customer service rep or someone else helping a patient with a bill, etc. The dollars will usually start higher and go down from there.

Especially in ortho, think of it if you had a big spine case and it was listed like this (not saying these are correct or would be billed together, just as an example):
20936
63052
22842
22853
22633
22830
22614
This would just be off kilter, could lead to entry errors, diagnoses linkage errors, and code first rules may or may not apply. It just does not make sense to me to do this. Maybe if it is a different specialty, but not orthopedics.

Or, even office procedures with E/M? Can you imagine looking at a billing screen like this? Totally weird.
J1010
99214
20610

I had to chuckle when I looked at your second example. In our EHR system, there are some codes that are automatically added as the order is entered (like an in office urine dip or blood draw). The physician codes their E&M after the system has already added the codes from the order, so I see ALL THE TIME:
81003
99213
and it does make me internally cringe. But it doesn't create incorrect payments, so I'm not going to train my staff to spend hours each day just to re-order the CPTs.

 

[amyjph]

I had to chuckle when I looked at your second example. In our EHR system, there are some codes that are automatically added as the order is entered (like an in office urine dip or blood draw). The physician codes their E&M after the system has already added the codes from the order, so I see ALL THE TIME:
81003
99213
and it does make me internally cringe. But it doesn't create incorrect payments, so I'm not going to train my staff to spend hours each day just to re-order the CPTs.

I hear you. I think it also might depend on the specialty, type of service, and the EMR/EHR being used. It also depends on if codes are being entered manually or being pulled in from entry in the EHR to the billing system. If it takes too much time, and too many resources that could be utilized more efficiently or in a better way, and it doesn't hurt anything, I agree with you. I just cannot bring myself to enter codes in the "wrong order".

When I worked on the provider side, our surgeries were all manually entered while the office stuff was populated from the EHR, so it would generally come over in order by the system. If someone is manually doing i, why not do it correctly? But, like you said, if it takes so much time to "fix" or re-enter, that does not make sense.

 

[sls314]

My claims have to be manually entered, so I put them in RVU order. Probably out of habit, but also because it would look weird to me to see the services out of order.

If ARIA (rad onc EMR) would talk to eCW and I could stop manually entering physician claims, I'm not sure if I'd care about the RVU order. I'd just be so thrilled to have the manual entry part of my workload go away!

 

[CBLENNIE]

It shouldn't be necessary in this day and age. I am not aware of any payor who does not use a computer system to process claims, which should automatically pay the highest value at 100%, and then subsequent surgeries at their reduced rate.
Notice my use of the word SHOULD. Which means maybe 0.001% of the time, you will come across something that was paid in the order you listed them instead of the correct value order.
In my opinion, depending on how much time/energy/effort it takes for you to list them high to low RVU, it's just really not important. When posting surgeries, I do always post high to low, but that is more by habit than necessity. Many of my colleagues do not, and I cannot recall the last time I saw a claim paid incorrectly due to the order submitted. Perhaps years.

Sadly, I work for a payer who doesn't have software that automatically determines the highest value procedure to allow as primary and then automatically reduce the remaining procedures (when appropriate). Additionally, we determine the primary procedure as the procedure highest allowance based on the provider's fee schedule or our plan's maximum allowance. We don't base it on RVUs. We are an outlier in the industry I know, but we are a small plan compared to national plans, although we are the largest plan in our state.

 

[csperoni]

Sadly, I work for a payer who doesn't have software that automatically determines the highest value procedure to allow as primary and then automatically reduce the remaining procedures (when appropriate). Additionally, we determine the primary procedure as the procedure highest allowance based on the provider's fee schedule or our plan's maximum allowance. We don't base it on RVUs. We are an outlier in the industry I know, but we are a small plan compared to national plans, although we are the largest plan in our state.

Thanks for the input & perspective from the payor!! I've been billing surgeries by RVU as long as I have been coding. I do recall a situation (probably 15 years ago at this point), where the payor (BCBS) did pay the highest RVU at 100% then remaining at 50%. However, our fee schedule was not based on RVUs and they underpaid by a few hundred dollars. I had to write several appeal letters and do the calculations for them before we received the correct reimbursement. The payor SHOULD be paying the highest value (even if not the highest RVU) at 100%. But it's literally been a handful of times over 20 years, and the last time had to be at least 3 years ago.

 

[skseyes1]

Thank you everyone for your advice! I appreciate it!!