The Medicare Code
An estimated 42.5 million Americans received health care
through Medicare in 2005. Medicare is the U.S. Government's health
insurance program offered to citizens and permanent residents who are at
least 65 years old. Most individuals are automatically enrolled in the
free Medicare Part A program on their 65th birthday, and have the option
to enroll in Part B, which requires a monthly premium. People younger
than 65 who meet certain specific requirements are also eligible for
Medicare coverage.
Medicare spending is estimated to grow by 7% per year, so how will the
system keep up? The money issues are the responsibility of the
government. As far as patient care and recordkeeping goes, Medicare has
a form for every situation, and will likely create more. The system also
has a Medicare code for every conceivable medical condition and drug.
A brief overview of how a Medicare code works and
some examples are given below.
A Simple Example
The Medicare code is comprised of alphanumeric characters, which
means it can contain both letters and numbers. Every treatment a
patient receives under Medicare has an associated Medicare code.
When a provider requests reimbursement from Medicare for patient
services, it must provide the unique Medicare code for each medical
service or product provided.
The Medicare system generally reimburses a specific amount for each
medical procedure. That amount is associated with a Medicare code.
When a medical provider's reimbursement request reaches the system,
each Medicare code on the request is matched to the reimbursable
amount for that code. Medicare then totals all the individual
reimbursable amounts related to each Medicare code, and computes a
total reimbursement for the provider.
Of course, this is a greatly oversimplified example and does not
take real-world conditions into account. Not all medical items have
set reimbursable amounts, and not all are automatically covered
either. The point is that without the Medicare code list, the system
would grind to a halt.
Healthcare Common Procedure Coding System
The Healthcare Common Procedure Coding System (HCPCS) is a
collection of codes that represent procedures, supplies, products
and services which may be provided to Medicare beneficiaries and to
individuals enrolled in private health insurance programs. The codes
are divided into three levels, or groups, as described below.
Level I is a Medicare code list containing descriptors used by the
American Medical Association's current procedural terminology. Each
Medicare code is a 5 number representing both physician and
non-physician services.
Level II is comprised of a list of each Medicare code and descriptor
used by the American Dental Association's current dental
terminology. Each Level II Medicare code is a 5 character
alphanumeric code comprising the D series.
The Level III Medicare code list includes codes and descriptors
developed by Medicare carriers for use at the local level. These are
5 character alphanumeric codes representing both physician and
non-physician services not already represented by a Level I or II
Medicare code.
Conclusion
These are simply three levels each type of Medicare code. The degree
of complexity of the Medicare code system is enough to give one a
migraine headache. And there's a Medicare code for a migraine: J3030
(prescription Imitrex (tm) with a dosage of up to 6 mg administered
via subcutaneous administration). The doctor and pharmacy visits to
get the Imitrex (tm) would generate even more Medicare codes. Maybe
we're better off not knowing.
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