Comment by aintgonnatakeit
2 years ago
Let’s do wrist x-ray and keep it simple. I’m sure I’ll mess up the formatting here.
When you get an x-ray, you would expect to see 3 claims (again, simplifying).
—— One is the x-ray tech taking the picture. That gets a professional claim with a CPT code and is straightforward.
—- One is the interpretation by a radiologist of the imaging. That is a professional claim with a CPT and a modifier.
—- The last depends on the place of service. If it’s in a hospital, or at an outpatient facility, or at an ASC, then you get a facility claim to go with it.
Next, under what circumstances did the x-ray occur? Was it during an inpatient stay? If so, the payor might pay based on a DRG, which is basically a bundle of all the services that occur during the stay. How do you decide how much of the cost to allocate to the various parts of the x-ray? There are more variations on this.
Next, how are the providers contracted? Are they participating providers? Par vs non-par have different payment rates.
Next, was the service in-network or out-of-network, defined by the patient’s insurance benefits?
Does the patient’s PCP participate in a capitated arrangement (fixed fee to the PCP’s office per month)? If so, what is the allocated cost for the service based on the submitted encounter?
What about fees for network rental? Sorry, this one is esoteric, but it’s another factor.
And so forth and so on. It’s a mess.
I'm the author. When I write articles I have to make a choice: make them readable by the public, or detailed enough to satisfy the experts. I try to strike a balance, but I can't have both.
Please take a look at the CMS Price Transparency Guide https://github.com/CMSgov/price-transparency-guide and familiarize yourself with the schema. You can also take a look at the federal ruling: https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-...
The metadata you're talking about is specified in the files themselves. I've limited my search to fee-for-service (non-capitated, non-derived, non-bundled) institutional claims.
You can write to me if you have more questions. alec@dolthub.com
Forgot one. The doctor who looked at the X-ray practices under one ID on Sundays, another ID MWF, and another T,Th,Saturday. In each case he’s also part of a different provider group. He might still have more than 9 TINs or NPIs under which he bills, all with different rates. How much does it cost to have this doctor interpret your x-ray?
I think you're far off base here. An X-Ray will never come on more than 2 claims. It only has two parts, an interpretation and a facility fee. You are right it is confusing. It is true that billing context (as part of a grouper/stand alone) needs to a part of the publication of the files. However, that has nothing to do with the author raising valid points of inconsistency that can make the data unusable.