The standard reimbursement methodology used by IHG for practitioners is based on the Resource-Based Relative Value Scale (RBRVS).

To calculate payment for a CPT® code, the conversion factor is multiplied by the sum of the relative value units (RVU) for physician work, practice costs, and malpractice insurance.

The formula is:

Work RVU x Work Geographic Practice Cost Index (GPCI)*
+ Practice Expense (PE) RVU x PE GPCI
+ Malpractice (PLI) RVU x PLI GPCI
________________________________________
= Total RVU
x $37.8975
________________________________________
= Payment

The IHG contracting philosophy is to contract at a percent of RBRVS. Not all providers may be contracted at the same percentage of RBRVS.

There are services or procedures performed by practitioners that are not found in RBRVS. These services or procedures may either be a new procedure which has not yet been assigned a value by RBRVS. IHG utilizes Ingenix® for some CPT codes that do not have values. Ingenix is a proprietary system. Codes were developed based on feedback from providers, not set based on federal policy. Values for CPT codes were established based on five criteria: Time, Skill, Severity of Illness, Risk to patient, and Risk to provider. For other CPT codes that do not have values, the IHG fee schedule reverts to a percentage of the provider’s usual billed charges.

For CPT coding instructions and guidelines, IHG applies CMS ground rules. The CPT coding system includes two-digit modifier codes which are used to report that a service or procedure has been “altered or modified by some specific circumstance” without altering or modifying the basic definition or CPT code.

Providers who utilize CPT modifiers appropriately can increase reimbursement and ensure claims are processing timely. Improper use of CPT modifiers may result in claims processing delays or trigger claims audit.

CPT Modifiers

Modifier Description Reimbursement Percentage
- 22 Unusual procedural services 120% of the allowable
- 26 Professional component Based on RBRVS values. In the event there is not an RBRVS established value, 40% of the allowable
- 50 Bilateral procedure 150% of the allowable
- 51 Multiple procedures 100% of the allowable for the first procedure and 50% of the allowable for all subsequent services
- 54 Surgical care only 70% of the allowable
- 55 Postoperative management only 30% of the allowable
- 56 Preoperative management only 10% of the allowable
- 78 Return to the operating room for a related procedure during the postoperative period 70% of the allowable
- 80 Assistant Surgeon 20% of the allowable
- 81 Minimum assistant surgeon 10% of the allowable
- 82 Assistant surgeon (when qualified resident surgeon not available) 10% of the allowable

In the event a provider reports a modifier not listed on the above table, reimbursement will be determined based on the payor’s guidelines for the modifier.

Providers who perform Immunizations and administer injectable medications will be reimbursed according to RBRVS guidelines (provider must report appropriate codes for proper administration of reimbursement).

RBRVS is updated annually, and is released in February. IHG updates each RBRVS fee schedule to reflect the changes in value by CPT code.

The reimbursement methodology as described above is utilized unless otherwise specified in your provider agreement with IHG. Not all practitioners are contracted by RBRVS. Some practitioners may have negotiated custom fee schedules, a derivative of RBRVS resulting in reimbursement adjustments by CPT code.

Anesthesia services are reimbursed based on the American Society of Anesthesiologists (ASA) methodology. IHG negotiates with the provider, a conversion factor to apply to the ASA guidelines.

If you are a participating provider with IHG and would like to receive a copy of your fee schedule, please submit a written request (please include an email address) to:

Interplan Health Group
Provider Networks
Attn: Reimbursement
2575 Grand Canal Blvd., Suite 100
Stockton, CA 95207