First, there’s these things called edits. Edits would be better called gotchas, as they function pretty much that way. Let’s say you have two different surgeries, procedure A and procedure B. You perform both procedures at the same time, and try billing them together, on two separate line items. Gotcha! Edits say you can’t do that–and if you do: a) you will not get paid for one of them, and/or b) you are guilty of fraud. You see, B is considered to be included in the payment for A (a component edit), or B is deemed to be mutually exclusive with A. The Feds publish these updated edit lists quarterly, made up of thousands of paired procedure codes–and it’s up to you to be sure you check them before submitting your claim. Otherwise, gotcha! Oh, and did I mention: many insurance companies have what’s called black box edits: they deny payment for procedure B when billed with procedure A–but don’t tell you that up front, and you don’t find out until after your claim is denied. And they won’t disclose these to you–even though you have a contract to provide services to their clients for payment. Nice.
Then there’s these things called globals. When you perform a surgery, you get paid not only for the surgery, but also for the postoperative care, for a predetermined number of days–usually 90 days for major surgery, 10 days for minor procedures like a laceration. Some simple procedures have a zero day global–which means you can charge for subsequent related care–but not for related care on the day of the procedure (”So why 0 days, and not a 1 day global?” “Quiet please, sit down”). Such post-procedure care is said to be bundled–that is, included in the package fee for the procedure or surgery. No matter if the care proves simple or complex, one visit or 90 in the postop period: same reimbursement.
This is after a explanations of how the pricing structure is basically set up in the first place. And how the Feds Fucked It ALL UP!
