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HMSBeagle

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When you get a quote for a procedure at the AMA CPT code, is that what the physician gets paid for a procedure, visit, study etc? I see there are two quotes, one for Facility and another one for Non facility. What does this mean and how does it work? If say you are doing a CABG you bill for the CABG only or do you also bill for harvesting the vessels?
 

edfig99

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When you get a quote for a procedure at the AMA CPT code, is that what the physician gets paid for a procedure, visit, study etc? I see there are two quotes, one for Facility and another one for Non facility. What does this mean and how does it work? If say you are doing a CABG you bill for the CABG only or do you also bill for harvesting the vessels?

a cpt code discussion in allo? really? ok...
i'm not an expert in this area, but this is my understanding:

when you see a fee schedule with associated CPT codes, you are seeing what the physician will CHARGE for a given procedure (which is NOT the same as what the physician would get paid).

The non-facility quote is the amount the physician would be reimbursed if they performed that procedure in their own office. You'll probably notice the quote is a lot more money than the facility quote. That's because the non-facility quote reimburses the doctor not only for the work s/he performed, but also for the materials, supplies, equipment, etc. utilized.

The facility quote is the amount the physician would be remibursed if they performed in a facility, i.e. a hospital. The hospital would then bill separately for the "technical component" -- room, equipment, supplies, etc.

The amount a physician will actually be reimbursed depends on their insurance contracts. They could charge and get reimbursed for everything they charged (i.e. an uninsured patient) or some percentage of what they charged (because they agreed to do so when they contracted with Plan X), and the patient may or may not be responsible for the rest. They could get reimbursed a teeny fraction of what they charged by the insurance company with the patient owing the rest if they are an 'out of network' doctor.

Re your CABG example, I'm not a CT surgeon but my guess is that they will submit all the relevant procedure codes for everything that was done at the time of surgery and each procedure will get reimbursed appropriately, or they'll be bundled together and reimbursed at some lower rate. I don't have my CPT book in front of me so I can't give you a more detailed answer.

hope this is helpful.
 
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