06/25/2002    Todd Rotwein, DPM

Austin/Akin Bunionectomy Payment

Query: Austin/Akin Bunionectomy Payment
From: Todd Rotwein, DPM

Do any of my learned colleagues have suggestions
about handling the current problem with
insurance carriers' allowances for code 28299.
It seems that they are usually paying less for
it than for its primary component, 28296. I am
referring to ideas other than appeals to the
carriers' philanthropic natures.

Todd Rotwein, DPM
Hempstead, NY
drdpm@aol.com

----------------------------

[Codingline-L] Response:

Beginning January 1, 2002, CPT defined (via
illustration) CPT 28299 as the proper code to
use for an Austin-Akin-type bunionectomy (distal
1st metatarsal and proximal hallux phalanx
osteotomy).

Medicare assigned CPT 28299 21.03 RVUs -
facility. At the same time, Medicare assigned
CPT 28296 (a component procedure of CPT 28299)
19.11 RVUs - facility. Not a significant
amount of difference (the equivalent of an adult
entrance ticket to Disneyland) considering, as
you stated, CPT 28296 is the "primary component"
of CPT 28299.

It is no secret that many, but certainly not all
managed care companies use Medicare CPT values
to establish their own provider fee schedules.
If you have one or more managed care plans that
are paying less for CPT 28299 than CPT 28296, it
is because,

1) They have not updated their fee schedules for
2002 values;

2) They are aware of the 2002 values and really
don't care to update
the fee schedules.

Both reasons are to the financial advantage of
the payer. While you might wish to open
discussions, file complaints, etc. over this
issue, managed care plans may simply argue that
you signed their contract agreeing to their fee
schedule. Since many managed care companies
feel that the methodology for establishing and
assigning fees are "internal" company matters,
you find yourself, figuratively, hitting your
head against a wall. If, however, your managed
care contract specifies that the managed care
fee schedule is based on the current Medicare
CPT RVUs, you would be in a good position to not
only get the payer to change their fee for the
procedure, but retroactively get them to
reimburse you for previously claimed procedures
which were improperly paid.

It goes without saying if your contract states
that the rates are based on the current Medicare
RVUs per procedure (not the current Medicare
conversion factor-RVU value of the procedure),
and the payer refuses to adjust that fee
schedule allowance, you should file a complaint
with your state agency governing the managed
care plan.

[Codingline-L] Expert Panelist: Harry Goldsmith,
DPM

Other messages in this thread:

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06/26/2002    Martin G. Miller, DPM,Harry Goldsmith, DPM

Austin/Akin Bunionectomy Payment ( Harry Goldsmith, DPM )

RE: Austin/Akin Bunionectomy Payment ( Harry
Goldsmith, DPM )
From: Martin G. Miller, DPM
In response to your answer to Dr. Rotwein's
question about the decrease of payment for 28299
v. 28296, you mentioned only managed care
contract issues. Although many of your readers
are in that category, neither Dr. Rotwein nor I
subscribe to managed care plans. We would like
to know your thoughts on our recourse
for "normal" insurance plans. Filing an appeal
seems to just go around in circles with most
carriers without any resolution.

Martin G. Miller DPM
mgmiller@optonline.net

----------------------------

The following response is a personal opinion:

I apologize for only responding using Medicare
and managed care as examples. Let me start
over...

The 2002 CPT defined (via illustration) CPT
28299 as the proper code to use for an Austin-
Akin-type bunionectomy (distal 1st metatarsal
and proximal hallux phalanx osteotomy).

This is fact, published in CPT which is an
established-authoritative-universally-available
coding and reimbursement book and guideline.
Unless the non-managed care insurance plan you
are dealing with has a written policy unique to
that insurance company, you would be expect to
bill using CPT coding, rules, and guidelines.
It is your obligation to check with the payer to
confirm their "rules".

It is no secret that many, but certainly not all
non-Medicare payers use Medicare CPT values to
establish their own provider fee schedules or
fee-for-service procedure/service (profiled)
allowances. The valuation of individual
procedure or service codes within a fee schedule
is determined by the premium package cost,
employer generosity, employee contributions,
deductible amounts, copays, etc. Some non-
managed care payer fee schedules run from
being "great" pays (I'm sure they must be out
there, although I haven't seen "greatness" on a
consistent basis) to unbelievably poor pays.

But then you asked about non-managed care plans -
which mean the payer allowance, ultimately,
shouldn't matter much to your office. You see,
whether or not the payment is great is the
patient's problem - it is their insurance, not
yours. In a non-managed care (non-Medicare,
etc.) patient, you should be charging your
established fee for the procedure(s) or service
(s) performed at the time you performed the
service.

Bizarre, you say. Unheard of. What a
concept? What a novel idea? If I charge the
patient what I'm worth, why would they come to
me? Well, they'll come to you because you're
nice...and you're worth it, dammit.

Trust me. My grandfather told me about this.
There was a time when doctors actually made it a
policy to collect their fees before the patient
left the office. I know, I was also
dumbfounded. The patient's claim was either
filed, as a courtesy for the patient or the
patient was handed a "superbill" (You remember
superbills? They came out about the same time
as leisure suits) with instructions to staple it
to their claim form and mail it to their
insurance company. Either way, it was the
patient that would get reimbursed. You
see...you've already been paid...your fee in
total. Happy days.

So you say, you don't understand, that YOUR
patients cannot afford to pay you at the time
you render medical services. Okay, so you are
resign to finance (staff time, mailing/telephone
expenses, Prilosec for all) those patient's
medical services despite that fact that in a non-
managed care world you are not required to do
so. I would recommend you give these non-
managed care patients the option to finance
their medical expenses on their VISA,
MasterCard, Discover (they'll get a little
something back...), or AMEX cards. Not only
will the patients be able to pay off the charged
amount at their leisure, but they'll get
frequent flier miles, too. I believe that is
worthy of a little sign next to the frosted
glass ("Ask about our Miles For Your Bunions
Program. Companions fly free."). By using
their bank or charge cards, your bill is paid
(minus a small amount for the card company), and
the patient will be the recipient of a
reimbursement check from their insurance
company. They can then apply the entire check
against their credit card statement finance
charge...

You asked about "filing an appeal seems to just
go around in circles with most carriers without
any resolution". In a non-managed care world,
if you received your money at the time of
service, you and your staff can - with a genuine
smile on your faces - assist the patient in the
filing their appeal with their insurance
company. Isn't it amazing how patient letters
of appeal seem to "work" where if a physician
signed the same letter the response would
be, "Dear Dr. ___, We had a former weatherman
review your claim, and, quite candidly, you were
so close...better luck next appeal."

I can tell you if I had any patients, I know I
would collect the money at the time of service...

To be fair, though, let's look at the "other
side" - those arguments commonly made by doctors
who read opinions of others not in their
position:

"If I ask my patients to pay me at the time
services are rendered, either I'll have as many
patients as Goldsmith or I'll be the primary
contributor to the success of the podiatrist
down the road"; "How do I explain to patients
that the fees they're seeing aren't really my
fees, it is what I charge their insurance
company"; "Patient always respond that that is
what they have insurance for"; "My patients
cannot afford to pay me upfront". Well,
doctor, all I have to say is that your patient
just bought 6 fake palm trees and a 55 gallon
drum of Head and Shoulders at Costco (substitute
Sam's Club, as appropriate) for $425.87. I
believe they could have paid for that
matrixectomy and waited to get reimbursed.

So, you don't WANT to ask your patient to pay
for your professional services at the time they
are rendered. You'd rather do the patient a
favor by billing the insurance company,
accepting assignment and waiting, right? If
that is the case, I would assume the only
reasons you didn't sign managed care contracts
were that 1) you couldn't get on the plans
and/or 2) you intend to balance bill the
patient - eventually - more than the managed
care standard fee schedule allows. At this
point, you just shifted who gets reimbursed,
from the patient to you. By that generous act,
YOU get to wait until the non-managed care payer
decides to pay you. And you get to enter into
the "appeals" fray since you haven't received
your money. My question is, "if all you have
to show from the appeals process is wasted staff
time, increased expenses, and heightened
emotions, won't you have to eventually turn to
your patient and (finally) ask for the
balance? At that point, the patient usually
says "You didn't bill it right" or you get your
statement back with "forwarding order
terminated" or your staff calls only to
hear "the number you have called is no longer in
service". And now principles of "advanced"
collection take over.

In my opinion, if the patient is not "managed
care" and the doctor is not planning on asking
them to pay the charges at the time of service,
that physician might as well sign up with
managed care. The advantage of managed care is
that even though you get less money, they
promise you that you'll make it up in volume...

Obviously, Dr. Miller, the above is written with
a lighthearted flair. What was your question
again?

Harry Goldsmith, DPM
Cerritos, CA
hgfca@gte.net