Healthcare According To Ernie – CMS Data


As I prepare to author Chapter 4 I have begun the tedious task of digging out a lot of data.  The first set is the CMS reimbursement amounts by CPT code.

For those of you that aren’t up on the finer points of medical billing CPT is an acronym for Current Procedural Terminology.  This is a system setup by the AMA for referring to medical procedures in a common way.  CMS uses CPT codes to process claims from Medicare/Medicaid.  The reimbursement rates for each CPT code are also tied to a given geography so when you lookup what CMS will pay for a particular procedure you’ll get different answers for say Miami Florida than you do for say Saint Petersburg Florida.

That being said, I looked up all the procedures from my list provided to me by Bayfront Medical Center.  To make things more legible I entered all that information into an Excel workbook adding in the reimbursement amount and calculating the difference.  A couple notes about this process:

  1. Not all the CPT codes provided by Bayfront returned reimbursement amounts.  This could be because CMS doesn’t reimburse anything for that procedure or because the code provided is part of a code family.  I looked into CMS claim filing and there is a literal mountain of regulation and guidance around how to get reimbursed.  You need to know not only what the right codes are but also in what order you need to claim them to be successfully reimbursed.
  2. Not all the codes provided by Bayfront appear to be CPT codes.  The medication I received all have codes that start with J and I couldn’t find anything on those at the time I wrote this post – I’m going to keep looking.
  3. The next thing for this exercise will be to add a column for BCBS MA and their discount, payer and patient responsibility amounts.

CMS Remibursement Overview

As you can see, Bayfront submitted $11,264.14 for payment to BCBS MA.  Based on the information provided CMS would only reimburse $610.53.  I’m sure I will find more values from CMS as I continue to dig deeper on this but some of the variances are truly staggering – for example the CT scan.  $3,702.41 requested, $215.09 from CMS – seems extreme.

As always, stay tuned for data as it comes in…and of course please let me know if you like this thread, have questions and of course I welcome your comments.