EBM and GOÄ billing - this applies to gynecologists
The different regulations of the physician fee schedule and the uniform assessment basis increase the bureaucratic billing burden for many gynecologists and their practice staff. Read now what you should consider in the complex cost calculation of gynecological services and how you can succeed in billing more efficiently.
All important answers on billing in gynecology at a glance:
Die GOÄ-Ziffern für Gynäkologie finden Sie auf der Seite des Bundesministeriums für Gesundheit sowie mit aktuellen Änderungen und Ergänzungen im Buch "GOÄ 2022 Kommentar, IGeL‑Abrechnung: Gebührenordnung” von Peter M. Hermanns (Hrsg.)
Die Online-Version des EBM unter Berücksichtigung der aktuellen Beschlüsse finden Sie kostenlos auf der Webseite der Kassenärztlichen Bundesvereinigung. Dort können Sie die Abrechnungsziffern für Gynäkologie nachschlagen oder die Suchfunktion nutzen.
Bei der Honorarberechnung nach EBM bzw. GOÄ wird zwischen vertrags- und privatärztlichen gynäkologischen Leistungen unterschieden. Leistungen, die Sie im Rahmen der vertragsärztlichen Versorgung erbringen, müssen nach EBM bei der Kassenärztlichen Vereinigung abgerechnet werden. Für die Abrechnung von privat Versicherten, Selbstzahler, aber auch von IGeL-Leistungen gilt die GOÄ.
For many gynecologists, billing for services is more than a nuisance. Instead of concentrating on their patients, they spend about seven hours a week on administrative tasks, many of them on billing. There are a number of things to keep in mind - first and foremost, the differences between private and SHI fee-based billing.
Note: Here you can learn how orthodontic billing works.
This is how billing according to EBM works
Services provided by contract physicians are billed to the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung) according to the nationally applicable uniform valuation scale (EBM). There are complex specifications: Doctors are only allowed to provide a certain number of EBM services per quarter. The number of services is defined in the standard service volume, which is determined by the health insurance funds on a quarterly basis. In total, gynecological treatment cases amounted to over 11 million in the fourth quarter of 2020 alone! The average fee revenue per case was 55.94 euros.
These services are listed in the EBM
The EBM includes GP, specialist and jointly billable services and also takes into account material costs. Gynecological services can be found in the eighth section of Part III b:
- 8.2 Basic gynecological flat rates
- 8.3 Diagnostic and therapeutic fee schedule items
- 8.4 Obstetrics
- 8.5 Reproductive medicine
- 8.6 Cryopreservation of egg or sperm cells or germ cell tissue and corresponding medical measures due to germ cell damaging therapy.
You can access the current version of the EBM on the website of the National Association of Statutory Health Insurance Physicians.
How to calculate your fee according to the EBM
The EBM contains both flat rates and fees for individual services. Each service has its own fee schedule item (GOP) and many also have a number of points.
Example: The "Apparatus examination of a patient with urinary incontinence" in Part 8.3 has GOP 08310 and 605 points.
To determine the costs, the points are multiplied by the orientation value. Currently, it is 11.2662 cents per point.
Example 1: The costs for the "Apparative examination of a patient with urinary incontinence" amount to: 605 x 0.112662 euros = 68.16 euros.
Example 2: A "proof of pregnancy" with GOP 32132 is reimbursed at a flat rate of 1.30 euros.
For services that go beyond the scope of care provided by an SHI-accredited physician (IGeL services), there is a different billing basis, namely the GOÄ.
This is how billing according to GOÄ works
If you treat private patients and self-pay patients, or if your patients with statutory health insurance require additional or IGeL services, you will bill them according to the German Medical Fee Schedule (GOÄ).
You can find the GOÄ online here.
More leeway in fee accounting
Due to fixed minimum and maximum rates, you are not completely free in your pricing, but you can adjust the costs to the respective expenditure. The bottom line is that you can usually achieve higher fees than with treatment by an SHI-accredited physician.
Important: Conclude a treatment contract with your patients before the start of treatment. This creates transparency and security for both sides.
How to calculate the costs according to GOÄ
As in the EBM, the services in the GOÄ are assigned numbers and point values. The nationally uniform point value is currently 0.0582873 euros.
Example: The "Suture of a perfect perineal tear (III degree)" with GOÄ number 1045 has a point value of 924. For the simple fee rate, this means the following calculation: 924 x 0.0582873 euros = 53.86 euros.
For GOÄ billing, you can apply an increase rate of 1.0 to 3.5 depending on the effort and degree of difficulty. A factor of 2.3 is usually selected.
Example: The service "Suture of a perfect perineal tear (III degree)" is to be charged at 2.3 times the rate. This means the following calculation: 924 x 0.0582873 Euro x 2.3 = 123.88 Euro.
Increase more than 2.3 times? These requirements must be met
You can use your discretion to decide which factor is appropriate in the individual case. However, caution is advised when selecting a 3.5-fold increase rate. According to Section 5 (2) GOÄ, you must fulfill special requirements for this. For example, the increase requires a written justification in the invoice with regard to:
- Difficulty,
- Time required,
- Circumstances
In addition to the specifics of choosing the increment rate, there are also rules to consider for combinations of digits.
Beware of GOÄ exclusions
The GOÄ stipulates that certain numbers may not be billed together. You can find out what these are specifically in the respective service legends, notes or in the General Provisions of the GOÄ.
Example: The "Suture of a complete perineal tear (III degree)" with the code 1045 cannot be billed with the service 1044 ("Suture of the soft birth canal also after previous artificial dilation and/or suture of a perineal tear of the I. or II. degree and/or suture of a vaginal tear").
Due to the regulatory hurdles, billing according to GOÄ proves to be a demanding task that costs gynecologists and their practice staff a lot of time. Many therefore ask themselves how they can make the process more efficient.
Internal or external billing? These are your options
You can reduce your GOÄ billing effort in two ways. Either by hiring external service providers or by using digital technologies.
Engage external billing services
If you choose to outsource your billing to a service provider, there are two different options: true and non-genuine factoring. With both options, you receive the amount billed from your service provider rather than from the patient. The difference lies in the risk of non-payment.
- True factoring: In this case, the billing service assumes the full risk. The invoice amount cannot be reclaimed from you because of this.
- Non-genuine factoring: If an invoice remains unpaid, the billing service can reclaim the advanced invoice amount from you.
You don't want to leave the accounting "out of your hands"? Then simplify your internal processes with digital solutions!
Use digital billing assistants
An external factoring company is not a must for gynecologists who want to spend less time on fee billing. Digital billing software like Nelly not only saves you and your staff a lot of time, but also money - for example, 30 percent billing fees! Your added benefit: No training is required to use Nelly. You can get started right away!
Gynecological GOÄ billing made easy with Nelly
Thanks to Nelly's innovative technology, the billing of gynecological services for private patients and self-pay patients takes place automatically. All necessary data, such as the payment method, can be entered directly on your patient's smartphone with just a few clicks. We will advise you on your individual case without obligation and free of charge!
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we have refrained from using double or opposite names.
For many gynecologists, billing for services is more than a nuisance. Instead of concentrating on their patients, they spend about seven hours a week on administrative tasks, many of them on billing. There are a number of things to keep in mind - first and foremost, the differences between private and SHI fee-based billing.
Note: Here you can learn how orthodontic billing works.
This is how billing according to EBM works
Services provided by contract physicians are billed to the Association of Statutory Health Insurance Physicians (Kassenärztliche Vereinigung) according to the nationally applicable uniform valuation scale (EBM). There are complex specifications: Doctors are only allowed to provide a certain number of EBM services per quarter. The number of services is defined in the standard service volume, which is determined by the health insurance funds on a quarterly basis. In total, gynecological treatment cases amounted to over 11 million in the fourth quarter of 2020 alone! The average fee revenue per case was 55.94 euros.
These services are listed in the EBM
The EBM includes GP, specialist and jointly billable services and also takes into account material costs. Gynecological services can be found in the eighth section of Part III b:
- 8.2 Basic gynecological flat rates
- 8.3 Diagnostic and therapeutic fee schedule items
- 8.4 Obstetrics
- 8.5 Reproductive medicine
- 8.6 Cryopreservation of egg or sperm cells or germ cell tissue and corresponding medical measures due to germ cell damaging therapy.
You can access the current version of the EBM on the website of the National Association of Statutory Health Insurance Physicians.
How to calculate your fee according to the EBM
The EBM contains both flat rates and fees for individual services. Each service has its own fee schedule item (GOP) and many also have a number of points.
Example: The "Apparatus examination of a patient with urinary incontinence" in Part 8.3 has GOP 08310 and 605 points.
To determine the costs, the points are multiplied by the orientation value. Currently, it is 11.2662 cents per point.
Example 1: The costs for the "Apparative examination of a patient with urinary incontinence" amount to: 605 x 0.112662 euros = 68.16 euros.
Example 2: A "proof of pregnancy" with GOP 32132 is reimbursed at a flat rate of 1.30 euros.
For services that go beyond the scope of care provided by an SHI-accredited physician (IGeL services), there is a different billing basis, namely the GOÄ.
This is how billing according to GOÄ works
If you treat private patients and self-pay patients, or if your patients with statutory health insurance require additional or IGeL services, you will bill them according to the German Medical Fee Schedule (GOÄ).
You can find the GOÄ online here.
More leeway in fee accounting
Due to fixed minimum and maximum rates, you are not completely free in your pricing, but you can adjust the costs to the respective expenditure. The bottom line is that you can usually achieve higher fees than with treatment by an SHI-accredited physician.
Important: Conclude a treatment contract with your patients before the start of treatment. This creates transparency and security for both sides.
How to calculate the costs according to GOÄ
As in the EBM, the services in the GOÄ are assigned numbers and point values. The nationally uniform point value is currently 0.0582873 euros.
Example: The "Suture of a perfect perineal tear (III degree)" with GOÄ number 1045 has a point value of 924. For the simple fee rate, this means the following calculation: 924 x 0.0582873 euros = 53.86 euros.
For GOÄ billing, you can apply an increase rate of 1.0 to 3.5 depending on the effort and degree of difficulty. A factor of 2.3 is usually selected.
Example: The service "Suture of a perfect perineal tear (III degree)" is to be charged at 2.3 times the rate. This means the following calculation: 924 x 0.0582873 Euro x 2.3 = 123.88 Euro.
Increase more than 2.3 times? These requirements must be met
You can use your discretion to decide which factor is appropriate in the individual case. However, caution is advised when selecting a 3.5-fold increase rate. According to Section 5 (2) GOÄ, you must fulfill special requirements for this. For example, the increase requires a written justification in the invoice with regard to:
- Difficulty,
- Time required,
- Circumstances
In addition to the specifics of choosing the increment rate, there are also rules to consider for combinations of digits.
Beware of GOÄ exclusions
The GOÄ stipulates that certain numbers may not be billed together. You can find out what these are specifically in the respective service legends, notes or in the General Provisions of the GOÄ.
Example: The "Suture of a complete perineal tear (III degree)" with the code 1045 cannot be billed with the service 1044 ("Suture of the soft birth canal also after previous artificial dilation and/or suture of a perineal tear of the I. or II. degree and/or suture of a vaginal tear").
Due to the regulatory hurdles, billing according to GOÄ proves to be a demanding task that costs gynecologists and their practice staff a lot of time. Many therefore ask themselves how they can make the process more efficient.
Internal or external billing? These are your options
You can reduce your GOÄ billing effort in two ways. Either by hiring external service providers or by using digital technologies.
Engage external billing services
If you choose to outsource your billing to a service provider, there are two different options: true and non-genuine factoring. With both options, you receive the amount billed from your service provider rather than from the patient. The difference lies in the risk of non-payment.
- True factoring: In this case, the billing service assumes the full risk. The invoice amount cannot be reclaimed from you because of this.
- Non-genuine factoring: If an invoice remains unpaid, the billing service can reclaim the advanced invoice amount from you.
You don't want to leave the accounting "out of your hands"? Then simplify your internal processes with digital solutions!
Use digital billing assistants
An external factoring company is not a must for gynecologists who want to spend less time on fee billing. Digital billing software like Nelly not only saves you and your staff a lot of time, but also money - for example, 30 percent billing fees! Your added benefit: No training is required to use Nelly. You can get started right away!
Gynecological GOÄ billing made easy with Nelly
Thanks to Nelly's innovative technology, the billing of gynecological services for private patients and self-pay patients takes place automatically. All necessary data, such as the payment method, can be entered directly on your patient's smartphone with just a few clicks. We will advise you on your individual case without obligation and free of charge!
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we have refrained from using double or opposite names.
Laura Sophia Hauck
Author
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