How does the doctor get paid?

We all know that doctors make alot of money (so we say) but how do they get paid? I mean I’ve never written a check for a doctor after my visit luckily. WHen it comes to healthcare one has to look at it as a business, becuase in reality……it is.

WHne it comes to coding for providers the importance of selecting the proper code will cover the procedure performed,diagnoses, and the supplies used for the client. The health care service coding system is monitored by the Centers of Medicare and Medicaid Services (CMS) which overlook CPT codes, ICD-9 codes, and HCPCS these are under the sets under the Health Insurance Portability and Accountability Act (HIPAA). The main coding used for providers are the ICD- 9-CM codes which stands for International Classification of Diseases, 9th revision, Clinical Modification. Providers use these three to 5 digit alphanumeric codes to encompass their specific encunter with the patients.

ICD-9-CM codes are three-to-five digit numeric and, in certain cases, alphanumeric codes. The first three digits in a code signifies the general illness. Some are followed by a decimal point and more digits ares added to ensure the specificity of the encounter these following codes are the subcategory and subclassification to discribe the etiology and the manifestation of the illness. Notice the example below:

“123 — {Disease} (The first three digits make up the category)

• 123.0 — {Disease} in Chest (The zero after the decimal point is the subcategory. It relates an important designation about the disease.)
• 123.00 -… uncomplicated
• 123.01 — … with complications in cardiac system
• 123.02 — … with complications in digestive system (the last digit is the subclassification. This gives even further information about the designation outlined in the subcategory. If we were to select 123.02 as our code, we’d read the full code as “{Disease} in chest, with complications in the digestive system.”

The code is organized by 3 volumes- the first is the tabular volume including the disease and descriptions with their correct codes. This encompasses 17 chapters with E-codes and V-codes which hold the feilds of the disease. For example Ch 1 encompasses the infectious diseases from 001 to 139. Ch. 2 encompases endocrine nutritional and metablic diseases and immunity disorders 240–279 and so on until Ch 17. Volume 2 is the alphabetic index used by coders to look up general terms for accuracy and medical terms describing the illness.The third volume is the alphabetic and tabular index of procedures, used by hospitals. This contains procedural codes that hospitals report to insurers. Typically not used by physicians and insurers.These are submitted to Section 111 claim through electronic file submission.

When using the ICD-9-CM codes are used in the medical report which includes patient demographics, medical history, current symptoms, diagnosis, procedures the doctor performs, and prescriptions and treatment. The coder takes the information in the report and when looking at the diagnosis codes provided by the ICD-9 codes otherwise the symptoms are observed for coding when the doctor can’t find a possible diagnosis. These ICD-9 codes may contain conventions such as brackets, parenthesis, “excludes”, “includes”, “see also”, “use additional codes” and many more. These are extra information for the coder and tell the coder which code is the corect ones to use. These make the difference on insurance claims.

In regards to re-imbursment one looks at the Resource-Based Relative Value System where providers are reimbursed for cognitive and E/M services are increased but procedure reimbursments are decreased. So primary care physicians get an increase but specialist get a decrease. The work the physicna is considerd for is the time,mental effort, and physcian skill.However they get reimbursed for 55% of the physcian’s cost. Practice expenses like staff cost,rent utilities,supplies are reimbursed at 42% of the physcian’s cost. Malpractice insurance at 3% of the physician’s cost. The total physican’s work is look at through the intraservice work, preservice work, and post service work- which varies whether the patient was seen in a clinic or a hospital.