Percentage of reimbursement per CPT code.

Effective practice management includes monitoring the average percentage of reimbursement from all insurance carriers for each Current Procedural Terminology (CPT) code. This, combined with knowledge of the Relative-Value Units (RVUs) for each CPT code, can help you determine for your practice the most profitable way to charge and still remain within the appropriate guidelines. You also need to know the variable expenses associated with each CPT code.

For example, when the practice sees a return patient for a vocal fold problem that requires flexible laryngoscopy, some providers will reimburse either the Evaluation and Management (E&M) code or for the laryngoscopy. Therefore, an absolute decision about how to bill, from a financial standpoint, is dependent upon at least three variables:

* RVUs (e.g., 99213 [1.41]; 99214 [2.2]; 31575 [3.08])

* The average percentage of reimbursement for each of the possible codes

* The contribution margin (greater contribution with lesser variable costs--for example, an office visit has a greater contribution margin than an in-office procedure that requires supplies [e.g., myringotomy and tube; nasal packing]). For example, you should know how much you are reimbursed for nasal packing (supply costs) in order to determine if you should bill for an E&M code or a nasal-packing code. You should also know what number of RVUs are assigned for each of the CPT codes. Finally, the Average Percentage Reimbursement (all payers) per CPT code (see figure) will provide additional valuable information about the reimbursement you can expect from each of the two codes in your individual practice.

Otolaryngologists average 27% of their time in the office and 10 to 11% in surgery (AAO--HNS Socioeconomic Survey, 2003). With decreasing margins, it is important to analyze every aspect of reimbursement in our practices.

Figure. Average percentage of reimbursement (all payers) per
CPT code.

                    Data

                         Total
           Total Fees   Amount     Reimb
CPT Code     Billed     Allowed   rate-%

99214        244,923    174,158     71%
31575        160,394     54,835     34%
69436        148,833     36,105     24%
99243        100,190     54,727     55%
95115         93,879     74,496     79%
95027         86,310     45,661     53%
95165         72,231     66,527     92%
30520         67,575     18,446     27%
42820         65,205     24,266     37%
31237         64,800     15,185     23%
31255         63,756     13,101     21%
92511         62,775     22,741     36%
31536         57,461     13,250     23%
99244         49,140     30,440     62%
92557         44,974     20,285     45%
31267         43,706      7,104     16%
99213         40,194     26,503     66%
30200         37,544     26,107     70%
92585         35,600      9,885     28%
31238         31,050      9,525     31%
69631         28,520      7,271     25%
92543         26,631      5,684     21%
42821         26,576      8,690     33%
31276         23,000      4,831     21%
61795         22,880      4,907     21%
92547         21,750     11,476     53%
42826         19,328      4,722     24%
92567         18,564      7,852     42%
99215         15,051      9,924     66%
30802         15,000      4,114     27%
43200         14,847      2,898     20%
92541         13,688      3,259     24%
38724         13,368      3,841     29%
99245         12,285      7,572     62%

Dr. Isenberg is an otolaryngologist in private practice in Indianapolis; [e-mail]