Procedure Selection

Basics

Select the medical billing codes for which you want to view reimbursements.

Use the search bar to lookup any alphanumeric medical billing code.

Not all payers negotiate rates for every single billing code code classification system or for every individual code within systems. Procedure Selector interfaces with PriceMedic’s Payer Data Catalogs to display a comprehensive breakdown of different types of billing codes included within the selected payer’s transparency data.

The Code Types list underneath the procedure search bar displays the count and category of all of the medical codes available to query for the payer you have selected. You can hover over each code type for a brief explanation of their typical usage.

Billing codes that match your search will be displayed in the table. Preview the payer’s procedure description, the billing classes associated with the code in the selected payer’s data (institutional or professional), as well as any billing code modifiers that the selected payer has associated with the billing code.

If you’ve saved Billing code lists specific to your organization, toggle to the Billing Code Lists tab at the top to select from them.

Add a billing code or list by clicking on its row in the table. Selected Procedures are displayed the right hand column You can remove a billing code by clicking the ❌ or Clear All within the Selected Procedures Section along the right hand side.

Select Next Step - Regions to proceed.

Billing Code Filters

Access filtering options for billing codes by selecting Show Filters to the right of the search bar.

Within the Filters pop-up you can pare down billing code search results based on the following requirements:

Billing Codes Types

Filter billing codes by their classification system, such as CPT, HCPCS, or ICD-10 codes.

Code Type	Description
CPT	5 digit numeric or alphanumeric codes maintained by the American Medical Association corresponding to the procedure or service rendered; also includes Proprietary Laboratory Analyses codes
CSTM-ALL & Local	Payer defined custom billing codes for the service or procedure described in the Payer Procedure Description field
HCPCS Level II	4 digit alphanumeric codes designed to identify products, supplies, and services not included in the CPT system; HCPCS codes reference generic drugs only
ICD-10-CM	3 digit alphanumeric codes to identify medical diagnoses and conditions based on classifications developed by the World Health Organization and modified by the National Center for Health Statistics
MS-DRG	4 digit numeric codes developed by the Centers for Medicare and Medicaid Services to categorize and reimburse inpatient hospital services. Compare with APCs
APC	4 digit numeric developed by the Centers Medicare and Medicaid Services in the United States to categorize and reimburse outpatient services provided by hospitals and other healthcare facilities such as Ambulatory Surgical Centers
NDC	10 digit, 3 part numeric identifiers for all commercially distributed drug products maintained and assigned by the FDA; NDC codes are specific and unique to the labeler (manufacturer, distributor, or repackager), dosage and route, and formulation
RC	4 or 5 digit alphanumeric codes maintained by the American Hospital Association to provide a broader classification of billable services such as Room and Board or Operating Room Services

Billing Code Modifiers

Filter billing codes by additional two-digit codes that provide more information about the service or procedure.

Modifier	Description
22	Increased procedural service
23	Unusual anesthesia
24	Unrelated E&M service during postoperative period
25	Significant, separately identifiable E&M service on the same day
26	Professional component
27	Multiple outpatient hospital E/M encounters on the same date
32	Mandated services
33	Preventive service
47	Anesthesia by surgeon
50	Bilateral procedure
51	Multiple procedures
52	Reduced services
53	Discontinued procedure
54	Surgical care only
55	Postoperative management only
56	Preoperative management only
57	Decision for surgery
58	Staged or related procedure during the postoperative period
59	Distinct procedural service
62	Two surgeons
63	Procedure performed on infants
66	Surgical team
73	Discontinued outpatient procedure prior to anesthesia
74	Discontinued outpatient procedure after anesthesia
76	Repeat procedure by same physician
77	Repeat procedure by another physician
78	Return to the operating room for a related procedure
79	Unrelated procedure by the same physician during postoperative period
80	Assistant surgeon
81	Minimum assistant surgeon
82	Assistant surgeon (when qualified resident unavailable)
90	Reference laboratory
91	Repeat clinical diagnostic laboratory test
92	Alternative laboratory platform testing
95	Synchronous telemedicine service
96	Habilitative services
97	Rehabilitative services
99	Multiple modifiers
AA	Anesthesia services performed personally by anesthesiologist
AD	Medical supervision by a physician: more than four procedures
AS	Assistant surgeon services provided by PA or advanced practice RN
CR	Catastrophe/disaster related
CT	Computed tomography services
EY	No physician or other licensed health care provider order
F1	Left hand, second digit
F2	Left hand, third digit
GC	Service performed in part by a resident under the direction of a teaching physician
GQ	Via asynchronous telecommunications system
GT	Via interactive audio and video telecommunication systems
GZ	Item or service expected to be denied as not reasonable and necessary
KX	Requirements specified in the medical policy have been met
LT	Left side
RT	Right side
RR	Rental
TC	Technical component
NU	New equipment purchase
UE	Used equipment purchase

Negotiation Arrangements

Filter billing codes by how the payment is structured between the payer and provider.

Arrangement	Description
Fee for service (ffs)	Negotiated dollar values the payer agrees to reimburse the provider for each billing code
Capitation	A fixed amount paid per patient by the payer to the provider (often Health Maintenance Organizations and Accountable Care Organizations) for a predetermined period of time, usually monthly, for the provider to provide all healthcare services required by the patient during the covered period
Bundle	An all-in negotiated reimbursement for related services or procedures that are typically performed together that may not equal the sum of the Fee-For-Service rates of all of the services or procedures included in the bundle. Example: a bundle could be used to bill for all of the procedures and services associated with a colonoscopy such as anesthesia, professional services, and post-anesthesia care

Billing Classes

Filter billing codes by whether they apply to institutional settings, professional services, or both.

Class	Description
Institutional	Billing codes that apply only to services rendered in hospitals, nursing homes, or ambulatory surgical centers. Also known as facility fees
Professional	Billing codes that apply only to services rendered by physicians or other health care professionals
Both	Codes payers have listed in association with both professional and institutional billing classes

Negotiated Types

Filter billing codes by how the reimbursement amount is determined and calculated.

Type	Description
Negotiated, Derived, and Fee Schedule	Negotiated, Derived, and Fee Schedule are used almost interchangeably according to the preference of the payer. In general, they all represent the total dollar amount to be remitted to the provider for a procedure or service through a combination contributions of the payer and patient
Percentage	Payer agrees to reimburse the provider the a percentage of their billed charge or charged amount
Per Diem	Represents the negotiated daily rate to be reimbursed to the provider usually for ongoing services such as an inpatient or rehabilitation care