Callagy Law Arizona: March 2016

Friday, March 25, 2016

Workers’ Compensation Coverage Required for New Jersey Employers

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.

The State of New Jersey Department of Banking and Insurance requires that New Jersey employers post notice of workers’ compensation insurance coverage or qualification as a self-insured employer. The only New Jersey employers except from the requirement of workers’ compensation coverage or the qualified self-insurance are those covered by Federal programs. Moreover, this requirement extends to out-of-state employers under certain circumstances. These situations include out-of-state employers who hire employees to perform work in New Jersey. Also included are out-of-state employers who have entered in employment contracts in the state of New Jersey. Finally, New Jersey employers must provide information to their employees regarding the procedures to be followed in the case of a worker related incident. Such information must include the following: (1) Where to seek medical treatment; (2) The proper procedure for reporting an injury while working; and (3) Information explaining workers’ compensation insurance coverage and benefits. Employees and managers should be made aware of this information upon being hired and during the course of employment.

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.

Workers’ Compensation Coverage Required for New Jersey Employers

Thursday, March 24, 2016

Glossip v. Gross—The Supreme Court and Capital Punishment

In 2015, the Supreme Court addressed the constitutionality of Oklahoma’s lethal injection procedure administered to those sentenced to death. In 2014, Oklahoma executed Clayton Lockett. Lockett awoke during the procedure and was not pronounced dead until forty minutes later. The Oklahoma lethal injection process called for the use of three drugs, the first being a sedative called midazolam. The failure of midazolam apparently was the reason for the inmate’s suffering. Oklahoma implemented a new system, while still using midazolam as the initial drug.

Charles Warner and 20 other death row inmates argued that the use of midazolam violated the Eighth Amendment and constituted cruel and unusual punishment. Warner and three other plaintiffs tried to postpone their executions but were denied. In Glossip v. Gross, Richard E. Glossip and the other two death row inmates requested another trial.

On June 29, 2015, the Supreme Court ruled 5-4 against Glossip. Justice Samuel A. Alito Jr., joined by four other justices, concluded that midazolam works sufficiently and its use during executions is permissible. Therefore, the executions in Oklahoma may continue as is. Justice Alito stated that due to the lack of an alternative method, the challenge set forth was weak. Justice Sonia Sotomayor, joined by three other justices, however, argued that Oklahoma’s method for execution couldn’t be trusted, as it might fail to keep an inmate unconscious. These four justices believed that Oklahoma’s lethal injection process should have been deemed unconstitutional.

Interestingly, Justice Stephen G. Breyer and Justice Ruth Bader Ginsburg argued against the death penalty altogether. They claimed that the death penalty should be unconstitutional because it is an irreversible punishment. Justice Antonin Scalia and Justice Clarence Thomas responded to Justice Breyer and Justice Ginsburg by advocating for the law of our Founding Fathers. Justice Scalia argued:

Time and again, the People have voted to exact the death penalty as punishment for the most serious of crimes. Time and again, this Court has upheld that decision. . . . Capital punishment presents moral questions that philosophers, theologians, and statesmen have grappled with for millennia. The Framers of our Constitution disagreed bitterly on the matter. For that reason, they handled it the same way they handled many other controversial issues: they left it to the People to decide. By arrogating to himself the power to overturn that decision, Justice Breyer does not just reject the death penalty, he rejects the Enlightenment.

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Glossip v. Gross—The Supreme Court and Capital Punishment

Wednesday, March 23, 2016

Facility Fees vs. Physician’s Fees

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

In the heavily regulated world of PIP (personal injury protection), it is important to distinguish between facility fees and physician’s fees, to ensure that, as a medical provider, you are receiving the appropriate form of reimbursement.

In New Jersey, auto insurers are required to provide a minimum of $15,000 in PIP coverage to everyone they insure. In practice, the amount tends to be much higher as the default option for PIP coverage is typically $250,000. To guard against endless PIP claims leading to ever increasing insurance premiums, the Department of Banking and Insurance (DOBI) promulgates fee schedules which essentially cap the amount of reimbursement providers can receive for the treatment they perform.

What is important to be mindful of is that there are many different kinds of healthcare providers and, in recognizing this concept, DOBI has set forth various different fee schedule rates.

The simplest example of different providers receiving different amounts of reimbursement for the same treatment performed is a physician versus a facility. It is somewhat intuitive that a facility charge is distinct from a physician charge and the fee schedules put forth by DOBI take this into account.

What further confuses this issue is the fact that, even within the category of facility charges, there are several different types of facilities. This too is accounted for by DOBI which distinguishes between various types of facilities.

For the most part, a facility charging a fee for medical services that it hosted, fits into one of three categories: a hospital, an ambulatory surgical center (ASC), or “other” (pretty much anything else).

The fee schedule rates for these various charges can be found on the DOBI website using the following link: http://www.state.nj.us/dobi/pipinfo/aicrapg.htm. Exhibit 1 contains a column titled “physician’s fees” and a separate column titled “ASC fees.” Thus, it is pretty simple to search and find the proper reimbursement for a physician charge or an ASC facility charge.

With respect to the “other” facility category previously mentioned, meaning facilities that are neither an ASC nor a hospital, the facility fees can also be found in Exhibit 1- they are listed in the physician’s fee column but they include the TC modifier (technical component). So, for example, let’s say a patient undergoes an X-ray of the jaw which is billed under CPT Code 70100. The “physician’s fee column” lists this CPT Code twice- once with the 26 modifier and once with the TC modifier. (To be complete, it also lists it a third time without any modifier which represents a global fee but that is beyond the scope of this article.) Assuming the CPT Code is being billed twice, once by a physician and once by a facility, the physician would bill with the 26 modifier and receive the corresponding fee schedule reimbursement, while the facility would bill with the TC modifier and receive payment accordingly.

Finally, we get to hospitals which are truly a category of their own. Hospitals have their own fee schedule known as the Hospital Outpatient Surgical Facility or HOSF fee schedule. (This fee schedule can be also be found using the link posted earlier.) However, the HOSF fee schedule, as the name indicates, is really only applicable to cases of outpatient surgery. Thus, if the previously cited example of a patient undergoing an X-ray took place in a hospital, the hospital would not be reimbursed for the X-ray pursuant to the HOSF unless the exam was in connection with outpatient surgery (such as pre-op testing).

So how is a hospital to be reimbursed for facility fees that are not associated with outpatient surgery? Callagy Law takes the position that hospitals are not subject to any fee schedule for (non-surgical) treatment provided to hospital outpatients. Such charges are subject to the hospital’s usual and customary rate. Insurance carriers tend to be in acknowledgment of this in the way that they reimburse emergency room visits, typically billed under one of the 9928X treatment codes. However, when it comes to other hospital treatment such as diagnostic testing, even when performed in conjunction with emergency room encounters, carriers tend to apply the TC rate of the physician’s fee schedule referred to earlier. Callagy Law has had an enormous amount of success in arbitration reversing these applications of the TC rate which are inapplicable to hospital outpatients.

It is important to remember that an insurance carrier’s determination as to how a claim should be paid is not necessarily correct. If you suspect that a claim was not paid correctly, or you simply are uncertain, be sure to reach out to Callagy Law, PC.

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.

Learn More About Callagy Law Here:

Facility Fees vs. Physician’s Fees

Friday, March 18, 2016

In Support of the National Health Services Corp.

This blog will focus on taking a closer look into the National Health Services Corps (NHSC).

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.

Inner-city and rural populations in America often lack access to quality, primary health care. Indeed, these “underserved” communities, defined as having 2,000 or more persons per one physician, suffer the consequences of an ongoing trend toward over-specialization of physicians and young doctors flocking to more lucrative practices in more exclusive metropolitan areas. Like so much else in poor rural communities and under-privileged inner-city America, health care needs to greatly improve.

This trend toward over-specialization of physicians and physicians seeking more lucrative metropolitan practices began in the 1950’s. In response, the United States government, under the Nixon Administration, began the National Health Service Corps (NHSC), an organization providing scholarships and other financial aid incentives to entice young physicians to practice in these underserved communities. Although the program was relatively successful, budget cuts and decreased enrollment in the program during the 1980’s limited the program’s effectiveness, leaving too many rural and inner city communities still underserved.

In defense of the physician community, it is understandable how this situation has developed. The average indebtedness of medical school graduates is now over $160,000, and, as a result, the lower paying primary care fields are not high on the career wish-list of medical school graduates.

Fortunately, the NHSC has seen a recent “renaissance” under the administrations of George W. Bush and Barak Obama, with increased funding (the NHSC received a $240-million-dollar grant this past October) and enrollment (NHSC membership doubled from 2008 through 2011). While primary care physicians are still paid less than specialties, such as urology or cardiology, the prospect of graduating with limited or no medical school debt appears to be enticing enough to newly-graduated physicians that we could soon begin to see a significant decrease in the number of underserved communities across the United States.

There still exists the additional problem of access to specialized care in these communities, but establishing a base of rural and inner-city primary care physicians is invaluable. It seems apparent that the continued growth of the NHSC is vital to making sure that, one day, every American has access to quality health care, regardless of location or background.

Callagy Law writes content that we hope may be applied to your professional and personal lives. Business law and personal needs can walk hand in hand. Callagy Law is aggressive, intelligent, and a results driven law firm, located conveniently in Paramus, NJ, with offices nationwide. President and Founder, Sean Callagy takes pride in having high standards of his firm, above and beyond the norm of traditional law firms. Contact us today here with any questions you have regarding your matters. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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In Support of the National Health Services Corp.

Thursday, March 17, 2016

Workers Compensation Claims & Statute of Limitations Part II

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.

As discussed in Part I, injured employees generally have either two years from the date of an accident, or two years from the last payment of compensation to file a worker’s compensation

claim, and employees who suffer an occupational injury have two years from when they knew or should have known that they developed an illness or injury related to their employment.

However, a question arises as to what is the applicable statute of limitations that applies to the medical provider’s claim for reimbursement in workers compensation in those cases where the medical provider was under-reimbursed for rendering authorized treatment to an injured worker, medical providers are entitled to file a claim in the workers. Notably, the medical provider is not filing a Claim Petition but rather a Medical Provider Claim.

Attorneys for medical providers argue that the carrier’s authorization to provide reimbursable treatment created the contract between the carrier and the medical provider to provide reimbursable treatment. Medical Providers then rely upon the six-year statute set forth in N.J.S.A. 2A:14-1, which applies to all actions of a contractual nature, express or implied, and all actions to recover on an account, for the proposition that medical claim providers are permitted Medical Provider Claim within six years of the breach.

In Medical Diagnostic Assocs. v. Hawryluk, 317 N.J. Super. 338, 349 (App. Div. 1998), certif. denied, 160 N.J. 89 (1999), the Appellate Division addressed the issue of the statute of limitation for Medical Provider Claims in workers compensation cases and clearly held that the six-year period applied to the medical provider’s claim stating:

Finally, we deem it appropriate to discuss the statute of limitations issue in the event the Division determines that the employee’s claim is not compensable. Plaintiff asserts that if medical providers are not allowed to bring suit in the Law Division, there is the potential that their claims will be barred by the statute of limitations. The statute of limitations is six years. See N.J.S.A. 2A:14-1. We note that there is no statutory provision tolling the statute of limitations on the medical provider’s claim while an employee’s claim is pending in the Division. We are satisfied, however, that if a medical provider’s suit is transferred to the Division, as we hold today, the complaint will have been timely filed. In future cases in which the medical provider proceeds directly in the Division the statute of limitations will be tolled during the period that the matter is pending in the Division.

Ibid. (emphasis added)

In Hawryluk, the Appellate Division transferred the medical provider’s claim to the Division and held that the statute of limitations for the claim was six years. In Univ. of Mass. Mem’l Med. Ctr. v. Christodoulou, 180 N.J. 334, 345 (2004), the Supreme Court overruled Hawryluk on the necessity of transferring the medical provider’s claim to the Division for a judgment of non-compensability before a Superior Court action could be filed, but did not alter its holding with respect to the statute of limitations. Although the Legislature subsequently amended N.J.S.A 34:15-15 to give exclusive jurisdiction to the Division for medical provider claims, eliminating the Superior Court option, there is no reason to suggest that the Legislature also intended to change the statute of limitations.

Therefore, it appears statute remains six years, as it does in all collection cases of a contractual or quasi-contractual nature for a medical provider to file a Medical Provider Claim in the workers compensation arena.

To view part one, please click here.

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Workers Compensation Claims & Statute of Limitations Part II

Monday, March 14, 2016

“A personal and professional perspective from an employee of Callagy Law” – Mark H. Winters, Jr., paralegal

Personally, the field of PIP represents a step in my career that allows me to take part in something important, something helpful, and something that can help work within a broken system for the greater good. Professionally, working in PIP at Callagy Law has exposed me to some of the brightest attorneys, who quite frankly I feel have revolutionized arbitration on a number of pertinent issues, all without cost to the clients.

In explanation of my enthusiasm in PIP, it is relevant that the first eight (8) years of my legal career I was involved largely in consumer collections litigation, a particularly dreary aspect of law. Spending so much time in that field, it begins to cloud your overall perspective on the very nature of law, people, and even yourself. Luckily, in June 2014, I took the opportunity to work in the PIP department at Callagy Law.

Now, at first, I was not even clear on what working in PIP would mean, or if anything could improve my jaded outlook of the law. However, integrating myself into the world of PIP was almost therapeutic. This was an opportunity to do something good, for the first time in my career representing the “good guys,” and it was exiting to find that the remainder of Callagy Law was likewise enthused. For, after all, who does it feel better to help than those who dedicate their lives to helping others?

Notably, in PIP we get to represent a huge variety of doctors and institutions, each of whom are essential for an immeasurable amount of car accident victims. Throughout the days and weeks, we handle cases involving everything from initial Hospital Emergency Room visits, to the initial stages of treatment (ie. chiropractic, physical therapy), then moving along to more advanced and complicated treatment providers, including specialized dental practitioners, pain management physicians. Whether it is underpayment of services, or an outright denial of necessary treatment, we argue on behalf of the treating doctors, who typically provide the patient with the necessary care even at the risk of insurance denials. It is here that my job comes in, helping those doctors get payment for the services they rendered to their patients in good faith.

In fact, one thing I did not know before starting in PIP, and what actually may make Callagy Law unique among PIP practitioners, is that we even represents pharmacies who issue prescribed medications that insurance companies nevertheless fail to pay for. I have even seen reimbursements awarded to psychologists and counselors whose post-traumatic stress therapies are denied prematurely. So, yes, I found that even such apparently ancillary providers such as pharmacies, dentists, and psychologists can benefit from an attorney’s PIP services.

In short, while I was feeling quite negative about the field and practice of law before starting in PIP, working for the benefit of the medical field to encourage fair payment, and in recovering the amounts unjustly denied, means something to me, to this firm, and, I like to think, our clients as well.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

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Friday, March 11, 2016

Let’s Call It What It Is—An Implied Assignment of Benefits

An Assignment of Benefits (AOB) in the world of No-Fault Law, also known as Personal Injury Protection (PIP), is critical in order for a medical provider to be reimbursed by a PIP insurance carrier. Indeed, a contractual relationship exists between the patient (insured) and the carrier (insurer), but no such relationship exists between the carrier and the medical provider. The AOB is what transfers, or “assigns,” the patient’s rights to receive PIP benefits to the medical provider. Without it, the medical provider would have no legal right to claim reimbursement from the carrier.

So, why and how is it that very often claims are allowed to go forward when there is no signed AOB, or the AOB that is presented is sufficiently defective as to render it not truly an effective legal instrument to transfer rights, or it is executed by someone who clearly would not have the right to effectuate such an assignment. These instances often present themselves in the context of Emergency Room (ER) treatment, where the niceties of signing intake forms and other consents do not exist because of the traumatic nature of the events, injuries and treatment. The atmosphere by its very nature is emergent and therefore warrants consideration beyond the standard practices found in by-choice, pre-scheduled doctor visits and procedures.

In these situations, PIP arbitrators, known as Dispute Resolution Professionals (DRPs), at times do allow the claims to go forward when there is no AOB, or it is signed by hospital personnel, or it is signed by a stranger to the patient’s policy, or it is somehow otherwise defective. They do this in recognition of fundamental fairness and equity, because there is no dispute as to the carrier’s liability. There is only the defect of the nonexistent or defective AOB. Though it is rarely recognized as such, the legal conclusion being drawn by these DRP’s is that an implied AOB exists.

In effect, even though the patient has not signed an AOB, which would expressly and unequivocally transfer to the ER doctors and hospital the right to recover PIP benefits, the circumstances dictate that the patient implies an assignment when they accept treatment under the circumstances. Indeed, hospitals are required by law to treat anyone who comes into the ER, regardless of their ability to pay and regardless of insurance. Therefore, it seems only fair that in the circumstances of ER treatment, medical providers should be able to pursue PIP carriers in arbitration regardless of a written AOB, because an assignment is clearly implied from the circumstances.

For more information on AOB, please read our blog:

Why I an Assignment of Benefits So Important?

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Let’s Call It What It Is—An Implied Assignment of Benefits

Thursday, March 10, 2016

How does third-party liability affect a New Jersey Workers’ Compensation claim for a medical provider petitioner?

N.J.S.A. 34:15-40 (“Section 40”) provides that

Where a third person is liable to the employee or his dependents for an injury or death, the existence of a right of compensation from the employer or insurance carrier under this statute shall not operate as a bar to the action of the employee or his dependents, nor be regarded as establishing a measure of damage therein. In the event that the employee or his dependents shall recover and be paid from the said third person or his insurance carrier, any sum in release or in judgment on account of his or its liability to the injured employee or his dependents, the liability of the employer under this statute thereupon shall be only such as is hereinafter in this section provided.

* * *

(b) If the sum recovered by the employee or his dependents from the third person or his insurance carrier is equivalent to or greater than the liability of the employer or his insurance carrier under this statute, the employer or his insurance carrier shall be released from such liability and shall be entitled to be reimbursed, as hereinafter provided, for the medical expenses incurred and compensation payments theretofore paid to the injured employee or his dependents less employee’s expenses of suit and attorney’s fee as hereinafter defined.

(c) If the sum recovered by the employee or his dependents as aforesaid is less than the liability of the employer or his insurance carrier under this statute, the employer or his insurance carrier shall be liable for the difference, plus the employee’s expenses of suit and attorney’s fee as hereinafter defined, and shall be entitled to be reimbursed, as hereinafter provided for so much of the medical expenses incurred and compensation payments theretofore paid to the injured employee or his dependents as exceeds the amount of such difference plus such employee’s expenses of suit and attorney’s fee.

Simply, Section 40 prevents double recovery by workers’ compensation claimants by allowing the respondent carriers to assert a lien against a potential third-party lien. A petition is prohibited from recovering from both the respondent carrier and a liable third-party, thereby allowing the respondent carrier to subrogate against the third-party.

A Section 40 lien is limited to medical treatment costs and disability payment (temporary and permanent), as it does not cover the respondent carrier’s medical examination defense costs, such as Independent Medical Examinations. A respondent carrier’s recovery from a third-party under Section 40 is limited to the amount paid less petitioner’s counsel fees, which are typically one-third. Therefore, the carrier will likely be allowed to recover two-thirds of the total payments from the third-party.

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Friday, March 4, 2016

Worker"s Comp Claims|Statute of Limitations (Part I)

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.

Typically, under New Jersey Worker’s Compensation law, most claim petitions filed on behalf of an injured worker must be filed within either two years from the date of the injury or two years from the last payment of compensation, whichever is later. Payments of compensation can also include payment to a medical provider for authorized medical services. So, if an employee is injured in a work related accident and receives treatment authorized and paid for by the employer [or its insurance carrier], or receives disability benefits from the employer [or its insurance carrier] the Workers’ Compensation Claim Petition has to be filed within two years of the last payment or the last treatment received from the medical provider which was paid for by the employer or its carrier. Simply put, if an employee is injured on the job, the claim has to be filed within two years of the date of the accident or filed within two years from the last date of treatment or the last payment of disability.

In those other cases where an employee alleges that they developed an injury or illness developed over time as a result of the conditions of their employment, otherwise known as an “occupational injury”, ie: the law provides that these claims must also be filed within two years, but two years from when the employee knew or should have known that the injury or illness was connected to their employment. So for example, if an employee was to develop mesothelioma, which often may not appear for 20-50 years after exposure to asbestos, and the exposure was connected to the employee’s job, then the employee would have two years from diagnosis to file a claim.

In sum, injured employees generally have either two years from the date of an accident, or two years from the last payment of compensation to file a worker’s compensation claim, and employees who suffer an occupational injury have two years from when they knew or should have known that they developed an illness or injury related to their employment.

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Worker"s Comp Claims|Statute of Limitations (Part I)

Tuesday, March 1, 2016

A Closer Look at Revenue Codes | Callagy Law

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.

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A Closer Look at Revenue Codes | Callagy Law