Chapter 23 — Further Reading

The pattern from Chapters 20 through 22 holds here and is at its strongest. The relative value file, the fee schedule rules, the GPCI tables, and the transparency files are all free. You can price every service in American medicine from public documents, and the only barrier is that most people have never tried.

Tier 1 — Verified canonical sources

The Medicare Physician Fee Schedule relative value file, CMS. Free, published with each year's final rule. Work, practice expense (facility and non-facility), and malpractice RVUs for every code, plus the six indicator columns Chapters 17 through 19 used. This one file has now appeared in five consecutive chapters and it is the single most useful free document in professional billing.

The GPCI tables, CMS. Free. Work, practice expense, and malpractice indices by payment locality.

The annual Physician Fee Schedule proposed and final rules, published in the Federal Register. The proposed rule appears in summer with a comment period; the final rule around November. The final rule's responses to comments explain the changes — the same structure as Chapter 22's LCD responses.

The Medicare Physician Fee Schedule Look-Up Tool, CMS. Free, and it does the arithmetic for you by locality. Use it to check your own calculation, not to replace learning it — a coder who can only use the tool cannot evaluate a contract.

Medicare Claims Processing Manual (Publication 100-04), Chapter 12 — physician fee schedule payment rules, including the site-of-service differential.

The place of service code set and CMS's place of service guidance. Free. §23.5's table is a subset of a published list, and the telehealth entries in particular have changed repeatedly.

Hospital price transparency requirements and CMS's implementation guidance, including the required contents of the machine-readable file and the shoppable services display.

Hospital price transparency machine-readable files themselves, published by individual hospitals. These contain payer-specific negotiated rates, which makes §23.6's contract-pricing exercise possible against organizations other than your own — a genuinely new capability in this industry.

Good faith estimate requirements under the federal surprise billing framework, for uninsured and self-pay patients.

Financial assistance policy obligations applicable to nonprofit hospitals, including limitations on amounts charged to eligible patients.

OIG guidance on charge uniformity, discounts to uninsured patients, and routine waiver of cost-sharing. §23.7's compliance callout is a summary of this material, and the routine-waiver guidance in particular is worth reading in the original.

Tier 2 — Attributed, specifics unverified

Material on the RVU update process, including how specialty society surveys are conducted and how the multispecialty committee's recommendations are developed and transmitted to CMS. Understanding this explains a great deal about why the values look the way they do, and the process is more transparent than most people assume.

Physician compensation literature on work RVUs as a productivity measure. A large and practical literature, relevant to anyone in a management track, and the reason work RVUs have a life outside claim payment.

Commentary on the annual conversion factor debate. Reading a couple of years' worth makes the budget-neutrality mechanism concrete in a way §23.4 cannot.

Chargemaster management literature and the practical guidance on CDM review cycles. Thin relative to its importance, which is part of why §23.8's decay mechanisms persist.

Charge capture literature, including reconciliation methodologies. §23.9's four comparisons are described more fully here.

Revenue cycle benchmarking publications reporting collection rates, days in accounts receivable, and denial rates. Read them with §23.10 in mind — a benchmark for a metric with an arbitrary denominator is a benchmark for very little.

Analyses of hospital price transparency compliance and file quality. Directly relevant to §23.8's observation that a difficult file is a statement about the underlying object.

Journalistic and academic work on chargemaster prices and the uninsured. Uncomfortable and worth reading; it is also what your patients have read.

Tier 3 — Illustrative and constructed

All RVU, GPCI, and conversion factor values in this chapter, and every figure derived from them. Labeled as constructed teaching figures throughout — verify current values in the fee schedule.

The Northfield-versus-Medicare comparison table in §23.6, including the 128.55% blended rate. The arithmetic is exact; the underlying allowed amounts are Account 10-4471's constructed figures.

The charge-to-Medicare ratios in §23.7 — 191.67%, 237.04%, 330.88%, 466.67%.

Northgate's constructed charge-setting history and the Q6 resolution.

Case Study 1 in its entirety — the acquisition, the unchanged default, and the payer's discovery. Constructed; the mechanism is ordinary.

Case Study 2 in its entirety — the practice, the six years at 98.5%, and the due diligence team's three findings. Constructed; all three findings are among the most-discussed topics in revenue cycle management.

Three things worth doing

Price ten codes you bill, from the relative value file, by hand. Two steps each. Then check them against the look-up tool. When they match, you own the arithmetic — and you can evaluate any contract expressed as a percentage of Medicare for the rest of your career.

Then price your own contract. Top twenty codes by volume, percentage of Medicare for each, weighted by volume. An afternoon, and it will tell you something your organization does not currently know.

And run the signed-note-with-no-charge query. One join. It is the highest-yield query in this chapter, and Case Study 2 is six years of nobody running it.