Surgery Estimate of Usual & Customary Billed Charges SAMPLE REPORT For more information or to order an estimate please contact: Mark Guilford m.guilford@accumedintel.com (303) 495-5191 Prepared For: Glenn & Glenn Law Firm 3015 Shattuck Ave Berkeley, CA 94705 Date of Issuance: July 28, 2016 HIPAA NOTICE OF PROTECTED PERSONAL HEALTH INFORMATION The information in this report contains federally protected personal health information. This report is for the explicit use of the patient identified herein. Any unauthorized use or dissemination of this report would constitute a violation of HIPAA Privacy Laws carrying a $50,000 fine per violation, up to an annual maximum of $1.5 million. The receipt and use of this report acknowledges these restrictions.
This report is a full estimate of usual and customary billed charges ("U&C Charges") for the patient's upcoming surgery. In the development of this report, AccuMed identified 372,619 historical records of providers performing procedures related to this surgery. For information on data sources, assumptions, and methodologies including the calculation of U&C Charges please reference the appendices. Transforaminal Lumbar Interbody Fusion w/ Decompression - One Level (L4 - L5) U&C Charges Pre Op Bill #1 Initial Evaluation Bill #2 Radiological Exam - Technician x,xxx Bill #3 Radiological Exam - Imaging Center x,xxx Bill #4 Pathology xxx Day of Surgery Bill #5 Anesthesiologist x,xxx Bill #6 Neuromonitoring x,xxx Bill #7 Surgical Assistant x,xxx Bill #8 Surgeon xx,xxx Bill #9 Hospital xxx,xxx Post Op Bill #10 Radiological Exam - Technician xxx Bill #11 Radiological Exam - Imaging Center xxx Bill #12 Pathology xxx Bill #13 Follow Up Appointment xxx Bill #14 Physical Therapy w/ Eval (1st Visit) xxx Bill #15 Physical Therapy (x 11 Visits) x,xxx Total Usual & Customary Charges:,xxx Within 15 miles of Campbell, CA Records are pulled from the Pacific West region and within a 15 mile radius of Campbell, CA for HCUP and CMS data, respectfully. PAGE 2 OF 14
Summary of Itemized Bills This section lists the bills that should expect to receive over the course of his treatment. Each bill details specific procedures and their U&C charge in the patient's area. Pre Op 1 Initial Evaluation Initial appointment with doctor to review medical history, perform examination, and discuss upcoming procedure. 99204 1 Outpatient visit of new patient Pre Op 2 Radiological Exam - Technician X-ray and MRI of lower lumbar. 72072 1 X-ray of lumbar, min 4 views 72146 1 MRI of lumbar spine; w/o contrast xxx Pre Op 3 Radiological Exam - Imaging Center Equipment use for X-ray and MRI of lower lumbar. 72072 1 X-ray of lumbar, min 4 views 72146 1 MRI of lumbar spine; w/o contrast x,xxx Pre Op 4 Pathology Complete blood panel. 85025 1 Complete blood and platelet count $ xx 80053 1 Comprehensive metabolic panel xx PAGE 3 OF 14
Anesthesiologist Anesthesia during surgery. Day of Surgery 5 00670 1 Anesthesia for extensive spine and spinal cord procedures Day of Surgery 6 Neuromonitoring Monitoring of the spinal cord and nerves using electroencephalography and electromyography. Includes both technical and professional components. 95861 1 Needle electromyography 95938 2 Short-latency somatosensory evoked study of upper and lower limbs (1 unit technical, 1 unit professional) G0453 8 Continuous intraoperative neurophysiology monitoring from outside the OR (15 mins per unit) x,xxx xxx Day of Surgery 7 Surgical Assistant Assisting surgeon during procedure. 22633 1 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique 63047 1 Laminectomy, facetectomy and foraminotomy x,xxx 22840 1 Posterior non-segmental instrumentation x,xxx 22851 1 Application of intervertebral biomechanical device(s) xxx 38220 1 Bone marrow; aspiration only xxx 20937 1 Bone autograft for spine surgery xxx PAGE 4 OF 14
Surgeon Lumbar fusion with laminectomy; physician. Day of Surgery 8 22633 1 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique 63047 1 Laminectomy, facetectomy and foraminotomy x,xxx 22840 1 Posterior non-segmental instrumentation x,xxx 22851 1 Application of intervertebral biomechanical device(s) x,xxx 38220 1 Bone marrow; aspiration only xxx 20937 1 Bone autograft for spine surgery x,xxx $ xx,xxx Day of Surgery 9 Hospital Facility, inpatient stay, durable medical equipment and surgical supplies. 459, 460 PR 8162 1 Spinal fusion except cervical (weighted average of codes),xxx,xxx Post Op 10 Radiological Exam - Technician X-ray of spine after surgery. 72100 1 X-ray exam of lower spine Post Op 11 Radiological Exam - Imaging Center Equipment use for X-ray of spine after surgery. 72100 1 X-ray exam of lower spine PAGE 5 OF 14
Pathology Post-op blood panel. Post Op 12 85025 1 Complete blood and platelet count $ xx 80048 1 Comprehensive metabolic panel xx Post Op 13 Follow Up Appointment Follow-up appointment with physician. 99213 1 Examination for existing patient, of moderate complexity. Post Op 14 Physical Therapy w/ Eval (1st Visit) Six weeks of rehab twice a week. First visit includes a full evaluation. 97001 1 Physical therapy evaluation 97110 2 Therapeutic procedure to develop strength, ROM, and flexibility xxx Post Op 15 Physical Therapy (x 11 Visits) Six weeks of rehab twice a week. 97110 2 Therapeutic procedure to develop strength, ROM, and flexibility PAGE 6 OF 14
Provider Locations Within 15 Mile Radius of Campbell, CA PAGE 7 OF 14
Appendix A References & Data Sources Current Procedural Terminology (CPT) "CPT" is a registered trademark of the American Medical Association. CPT codes and descriptions are copyrighted by the American Medical Association and used herein for explanatory purposes only. Professional and Center Data The data contained in this report related to professional providers, durable medical equipment, ambulatory surgery centers, and diagnostic testing facilities is sourced from publicly available databases; the Centers for Medicare & Medicaid Services' ("CMS") Medicare Provider Utilization and Payment Data: Supplier Public Use File (" Supplier PUF") and Referring Durable Medical Equipment, Prosthetics, Orthotics and Supplies Public Use File ("Referring Provider DMEPOS PUF") for calendar years 2012 and 2013. The databases are based on Medicare's submission data and contains information on services and procedures provided to Medicare beneficiaries. The databases detail the provider, the place of service, the specific Healthcare Common Procedure Coding System "HCPCS" code (which includes Common Procedural Terminology "CPT" codes) that was billed, and the submitted charge amount for that code. According to CMS, this database was made available to the general public to make the healthcare system more transparent, affordable, and accountable. AccuMed also relies on the American Medical Association's CPT codebook, the American Society of Anesthesiologists ("ASA") Crosswalk book, and www.findacode.com a prominent website used by medical billing and coding professionals to most accurately code the medical procedures. The ASA Crosswalk book provides the anesthesia code that would be billed by the anesthesiologist during a surgery for a given physician's CPT procedure code. Hospital Data The data contained in this report related to hospitals is sourced from the National Inpatient Sample of the Healthcare Cost and Utilization Project (the "HCUP NIS"), which is sponsored by the Agency for Healthcare Research and Quality (an Agency in the US Department of Health and Human Services). The HCUP NIS database contains information from a sample of approximately 20% of all inpatient discharges from HCUP-participating hospitals. The information contained in the database includes, among other data elements, primary and secondary diagnosis codes, procedural ("PR") codes, Diagnosis Related Group ("DRG") codes, and total hospital charges for each patient. The NIS groups its data into nine regions nationally. The hospital billed charges in this report reference all relevant data from the Pacific West region which consists of Alaska, Washington, Oregon, California and Hawaii. Additional information on HCUP's data and methodologies can be found here: https://www.hcup-us.ahrq.gov/nisoverview.jsp Information on HCUP's data partners that contributed to the database can be found here: http://www.hcup-us.ahrq.gov/db/hcupdatapartners.jsp PAGE 8 OF 14
Inflation Data When necessary, the billed charges in the databases are inflated to represent present day costs. These inflation rates are sourced from the Bureau of Labor Statistics' ("BLS") monthly CPI Reports for Medical Care. Professional providers' billed charges are inflated according to BLS' Medical Care: Professional Services rates. Facilities' billed charges are inflated according Medical Care: Hospital and Related Services rates. The following table summarizes these rates: 2013 2014 2015 2016 (YTD May) Facility 3.90% 4.50% 4.00% 1.20% Professional 2.10% 1.70% 1.90% 1.71% Information on BLS' monthly reports can be found here: http://www.bls.gov/cpi/cpi_dr.htm#2015 PAGE 9 OF 14
Appendix B Methodologies Overview AccuMed builds reports with the mission of arriving at the true cost of treatment for a typical patient receiving care in a specific geographic region and at a specific point in time. This mission guides all decisions made by AccuMed in assembling each report. AccuMed takes great care to let the data speak for itself. The company does not make independent assumptions nor does it opine on a patient's current state of health, diagnosis, or prognosis. It relies on notes provided by the patients' doctors for these assessments. AccuMed does not review the patients' financial resources or health insurance benefits available to pay for medical care. Reports only analyze billed charge amounts, representing the total cost of the procedures before any third-party contracted rates would apply. Usual and Customary Billed Charges AccuMed approaches "usual and customary" by defining each term separately and applying these definitions to its analyses: Usual - A charge is considered usual if it is a provider's typical charge for a given procedure. AccuMed only uses provider data if the provider has treated a minimum of eleven patients for that specific procedure. Not only does this establish a usual charge for a procedure but it ensures patients' protected health information in our database remains protected. Customary - A charge is considered customary if it would include a significant percentage of procedures performed by providers within a reasonable distance from the patient. AccuMed has determined "a significant percentage" to include 8 out of 10 procedures (or the 80th percentile using the nearest rank method). This determination is consistent with health insurance industry standards. Further, if local data is unavailable for a specific procedure (e.g. due to its rarity, the remoteness of the patient, etc.), we enlarge the radius for that code until sufficient data is available to arrive at customary charges. All charge data must be deemed to be both usual and customary if it is to be included in AccuMed's report. Bundling a Course of Treatment MedVantage reports often cover the entire course of treatment for a patient; from the first evaluation through the last rehab appointment. A course of treatment for a procedure is built using HCPCS and DRG codes that relate to specific procedures the patient is expected to undergo during their treatment. In assembling these bundles, AccuMed consults with the patient s providers and their billing departments, reviews published literature, and consults with certified billing and coding specialists. The resulting code bundle is representative of a typical course of treatment a patient is expected to undergo. AccuMed does not opine on a client's medical condition in order to determine potential complications or outlier procedures. If atypical procedures are included in an estimate it is because the client's doctor specifically mentions that procedure has a likelihood it could be performed. Furthermore, AccuMed does not include treatment of postoperative complications (e.g. infection of a surgical wound) as these again are atypical. PAGE 10 OF 14
Billed Charges AccuMed analyzes billed charges in the report. As mentioned above, patients' financial resources and health insurance benefits are beyond the scope of this report. As such, billed charges are the appropriate metric as this is the universal cost of treatment regardless of the payer. AccuMed arrives at the usual and customary billed charges by searching its historical databases for each occurrence of a HCPCS code billed by a type of provider the patient will likely seek treatment from (e.g. physical therapy from a physical therapist). The data is then filtered to include only providers within a preset radius around the patient's home address. If there are no occurrences of that code in the selected radius, the radius is enlarged for that code and noted in the report. It then calculates the 80th percentile using the nearest rank method to return a statistically reasonable value of billed charges for that procedure that is considered usual and customary. Billed charges for DRG and PR codes are performed in a similar fashion with the exception that these codes are broken out into nine regions nationwide with all the data for the applicable region being included in the percentile calculation. PAGE 11 OF 14
Appendix C Supporting Code Detail For an expanded appendix showing all calculations leading to U&C Charges, beginning with raw data as it appears in the database, please contact AccuMed for a Trial Ready version of this report at 844.307.4487 or info@accumedintel.com. Bill # Code Description Data Source Radius (miles) Total Patients U&C Charges/Unit 1 99204 Outpatient visit of new patient 2 72072 X-ray of lumbar, min 4 views 2 72146 MRI of lumbar spine; w/o contrast 3 72072 X-ray of lumbar, min 4 views 3 72146 MRI of lumbar spine; w/o contrast 4 85025 Complete blood and platelet count 4 80053 Comprehensive metabolic panel 15 2,706 15 196 15 133 80 190 15 100 15 89,121 15 114,707 $ xx $ xx 5 00670 Anesthesia for extensive spine and spinal cord procedures 15 117 6 95861 Needle electromyography 15 940 6 95938 Short-latency somatosensory evoked study of upper and lower limbs (1 unit technical, 1 unit professional) 15 1,078 6 G0453 Continuous intraoperative neurophysiology monitoring from outside the OR (15 mins per unit) 15 795 $ xx 7 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique 35 54 7 63047 Laminectomy, facetectomy and foraminotomy 15 36 7 22840 Posterior non-segmental instrumentation 80 11 PAGE 12 OF 14
Bill # Code Description Data Source Radius (miles) Total Patients U&C Charges/Unit 7 22851 Application of intervertebral biomechanical device(s) 15 20 7 38220 Bone marrow; aspiration only 7 20937 Bone autograft for spine surgery 405 35 35 33 8 22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique 23 32 8 63047 Laminectomy, facetectomy and foraminotomy 15 150 8 22840 Posterior non-segmental instrumentation 23 55 8 22851 Application of intervertebral biomechanical device(s) 15 39 8 38220 Bone marrow; aspiration only 8 20937 Bone autograft for spine surgery 23 34 23 47 9 459, 460 PR 8162 Spinal fusion except cervical (weighted average of codes) The National (Nationwide) Inpatient Sample (NIS) 2013 15 2,388,xxx 10 72100 X-ray exam of lower spine 11 72100 X-ray exam of lower spine 12 85025 Complete blood and platelet count 12 80048 Comprehensive metabolic panel 15 1,753 15 58 15 89,198 15 25,760 $ xx $ xx 13 99213 Examination for existing patient, of moderate complexity. 15 8,925 14 97001 Physical therapy evaluation 15 9,002 14 97110 Therapeutic procedure to develop strength, ROM, and flexibility 15 12,453 $ xx PAGE 13 OF 14
Bill # Code Description Data Source Radius (miles) Total Patients U&C Charges/Unit 15 97110 Therapeutic procedure to develop strength, ROM, and flexibility 15 12,453 $ xx PAGE 14 OF 14