The Centers for Medicare and Medicaid Services (CMS) is the government agency that provides insurance coverage for people ages 65 and older, those under age 65 with certain disabilities, and people with end-stage renal disease.1 The CMS is the national insurance plan that sets the standard for insurance coverage, which most private insurers follow. Embedded in the CMS rules and regulations are the current procedural terminology (CPT) codes for billable procedures that nurses perform. The CPT codes are required to process claims.2 Being familiar with the rules and regulations of insurance reimbursements goes hand in hand with getting coverage for services delivered. Knowledge of how the billing process works gives direction to the billing process.
Understanding reimbursement from the CMS is essential to understanding how this government agency handles insurance claims. A Medicare administrative contractor (MAC) is the contracting entity that's responsible for the receipt, processing, and payment of the CMS fee-for-service claims.3 In addition to providing core claims processing operations for both Part A (hospital) and Part B (private practice), MACs are the primary contacts for physicians and staff and perform functions related to appeals, provider outreach and education, financial management, provider enrollment, reimbursement, payment safeguards, and information systems security.3 MACs are private entities that hold the government's CMS contracts throughout the United States. There are 15 MACs throughout the United States, providing services for various geographic locations.
The CPT codes that are submitted for reimbursement are provided by Medicare and correlate with the procedure performed.1 The American Medical Association (AMA) publishes a book each year with information about codes and updated guidelines covered for reimbursement. This manual is vast, and interpretation of the manual can be exhaustive, but understanding how to apply it to the billing process is the key to getting reimbursed.4
In the healthcare industry, the CPT code is the standard for which services rendered are linked to reimbursement.5 The exact definition of each CPT code is in the AMA manual, and the codes must be adhered to for reimbursement criteria to be met. However, the manual can be deceiving; just because a code is in the manual doesn't mean you can get paid for it. Reimbursement differs depending on your MAC provider and geographic location.2 Most of the CPT codes that are used in a particular practice can be found on the office fee ticket or “super bill.” After the CPT code is found in the AMA manual, it's correlated with the website to see if reimbursement is possible. (See Table 1.) Accurate coding reflects the level of adherence to federal coding guidelines.6
This all seems relatively easy, right? Find the code, submit for payment, and then get paid. In reality, it's not so seamless. Actually it's anything but easy. MAC fee schedules are updated quarterly, so what may be reimbursed one quarter may be denied another. Also, the CMS is constantly reviewing claims, meaning denials aren't uncommon.7 The CMS has the right to review any chart at any time and freeze a provider's claims, which can be devastating to a practice.7
Utilize the resources available for finding the right CPT code for payment. Your CMS provider, along with the CPT manual, is your basic guide. (See Table 2.) The billing department within a private practice is the backbone of the reimbursement process. Don't overlook the representatives from various companies that are presenting information and products to your practice. If the representative has a product related to a procedure, he or she will provide you with the billable CPT code that correlates with the product.
Remembering to bill for the nursing services you use on a daily basis is key to reimbursements. Our days are so busy working with our patients that we sometimes overlook the task of submitting our work. As nurses, we're geared toward the patient's needs and often overlook the business end of nursing. Optimize your billing process with group lessons in a classroom setting for single CPT codes. This can increase revenue while providing the same services to patients. For example, holding a group lesson for six individuals in 1 hour is reimbursed sixfold for just that session. It's interesting to note that patients have expressed satisfaction with being part of a group, rather than having separate, individual training sessions.
Implications for nurse managers
With labor being the largest portion of any nursing budget, there's a natural and understandable tendency to decrease staff in times of economic uncertainty.8 Budgetary constraints loom overhead. As nurses, we need to identify sources of continued revenue that can't be captured by the nonnursing staff. When it comes to the billing process, it's often difficult to identify the actual direct and indirect care of nursing.9
To understand the financial aspect behind services provided by the nursing staff, nurse managers need to be aware of the guidelines and standards set by the federal government. To be competitive and sustain operations within a healthcare setting, managers need to understand the financial data and implications of the billing process. Educating the nursing staff about charting acuity to support codes that are submitted to a healthcare provider for reimbursement is imperative.10
Nursing is a valuable asset to any healthcare facility or healthcare provider, whether nurses work in a large forum or private practice. Nurses need to be proactive when it comes to ensuring their financial future in the American healthcare system, especially during these difficult economic times.
4. American Medical Association. CPT 2011 (CPT/Current Procedural Terminology (Professional Edition))
. Chicago, IL: American Medical Association Press; 2011.
5. Contino DS. Get a grip on billing and reimbursement. Nurs Manage
6. Vonderheid SC, Pohl JM, Tanner C, Newland JA, Gans DN. CPT coding patterns at nurse-managed health centers: data from a national survey. Nurs Econ
. 2009;27(4):211–219; quiz 220.
7. Gallagher L, LaMarche N. Interventional cardiology current trends in Medicare compliance. In: Diagnosis Related Guideline Symposium
. Neptune, NJ: Jersey Shore University Medical Center Press; 2010:1–15.
8. Dunham-Taylor J, Pinczuk J. Financial Management for Nurse Managers: Merging the Heart with the Dollar
. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers, LLC; 2010.
9. Welton JM, Zone-Smith L, Fischer MH. Adjustment of inpatient care reimbursement for nursing intensity. Policy Polit Nurs Pract
10. Contino DS. Can room and board lead to hidden revenue? Nurs Manage