Callagy Law Arizona: A Closer Look at Revenue Codes

The purpose of this post is to help assist those with questions they have concerning their business or medical practice. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.

Revenue codes represent variable services, including supplies and services that may not always have a constant reimbursement rate or amount.

The Court in Cobo, citing 24 NJR 1348 stated, “The provider, in submitting the billings, makes the initial determination as to what his or her usual, customary and reasonable fee is….thus, the scheme envisions that the health care provider will set its own customary fee, not the insurer or the insurer’s auditor.”

Usually, a Claimant will establish its usual and customary fees for the relevant CPT Codes in dispute by submitting its bills and copies of Explanation of Benefits to show that insurance carriers have reimbursed them pursuant to same.

In some instances, the billing codes in dispute are REVENUE Codes, not CPT Codes.

Medical coding and billing is a complex procedure in and of itself. That is where the Revenue codes come in. Revenue codes are typically 3-digit or 4-digit numbers that are used on hospital bills to help insurance carriers identify different type of services, the type of supplies used and the department in which services were rendered to the patient. Thus, any charge on a bill for medical services must have a Revenue code attached.

It is significant to note that with Revenue codes, the services are more generalized, and the pricing may vary per each billing instance. These prices vary based upon what actual services and/or supplies were involved in that particular instance. As such, these codes may not always have a constant reimbursement rate or amount, unlike CPT Codes.

For example:

REV Code 0111 represents general Medical/Surgical services.

REV Codes 250, 258, and 259 represent general “Pharmacy” medications, the prices of which vary depending on what medications are dispensed, in what quantity, and in what strength/form (liquid, tablet).

REV Codes 270 and 279 represent miscellaneous medical and surgical supplies, dispensed as needed throughout the course of this patient’s surgery, as needed. The cost varied depending on the actual items, brand, size, etc.

REV Code 312 – general, variable Lab/Histology diagnostic studies.

REV Code 320- general, diagnostic radiology- billed depending on the actual function of the study, i.e. Body part, number of films, etc.

REV Code 360 – general code for OR Services, billed at the appropriate rate, pursuant to the actual services which become necessary and appropriate throughout the course of the operation. Thereafter, the billed amount is established accordingly.

If and when the reimbursement of these different Revenue codes are in dispute, proofs of usual and customary rate (“UCR”) are available to demonstrate consistent billing practices by the provider. These proofs are either in the form documentation of billing and paying the exact service or supply at the same number of Units, or representing average payments for similar items in the same category.

Conclusively, Revenue Codes play an integral part in the medical billing process and it is important to recognize that the reimbursement of these codes may vary depending on the supplies and/or services rendered to the patient.

We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $185,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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A Closer Look at Revenue Codes | Callagy Law