A Critical Analysis of the 2012 Centers for Medicare and Medicaid Services Provider Use and Payment Database

Abstract

The release of an enormous amount of provider level claims data by the Centers for Medicare and Medicaid Services may serve as a new tool for locating potential fraud, pinpointing needs, and assessing levels of growth in care. Plastic surgeons need to understand implications of changes to Medicare, which will likely affect patient mix, physician documentation, billing, coding, reimbursement, and active participation in quality reporting.

A Critical Analysis of Medicare Claims for Otolaryngology Procedures

“…11 The RVUs, with a conversion factor and adjustment by location, subsequently determine the physician reimbursement for a given procedure. 12 The RVUs for the most frequently coded procedures among otolaryngologists are low, with a median work RVU of 0.13 and a range between 0.0 and 1.1 for the 10 most coded CPTs ( Table 2). Thus, the procedures most frequently billed for require a relatively low amount of physician work, which is not surprising as otolaryngologists provide a significant number of ambulatory services relative to physicians in other specialties.…”

“…11 The RVUs, with a conversion factor and adjustment by location, subsequently determine the physician reimbursement for a given procedure. 12…”

“…Each CPT code is preassigned relative value units (RVU), which quantitatively assess the amount of time, skill, building space, equipment, practice expenses, and liability required for the service 11 . The RVUs, with a conversion factor and adjustment by location, subsequently determine the physician reimbursement for a given procedure 12 …”

“…In general, office‐based procedures are favorable for physicians seeking greater autonomy and increased revenue. With regard to Medicare payments, nonfacility RVUs are higher, and reimbursements are substantially greater than those of facilities to cover the increased nonfacility practice expense 12 . This is due to the fact that in an office setting, the practitioner is generally paying more for the cost of overhead, staff, equipment, and supplies than in a facility setting 11 .…”

Radiation Oncology Physician Practice in the Modern Era: A Statewide Analysis of Medicare Reimbursement

“…The POSPUF datafile contains information on nearly all Medicare Part B services provided by individual physicians. Analysis of Medicare spending using POSPUF data has been detailed for multiple specialties, including ophthalmology, plastic surgery, urology, general surgery, and radiation oncology [12][13][14][15]. However, to our knowledge, an analysis of Medicare claims data by radiation oncology practice structure has not been previously reported.…”