Medicare Physician Fee Schedule Payment

Note Due to AMA copyright on CPT, you must be a registered user: either on free trial or subscription based - to use this part of the ICD10Doc application

Watch a short YouTube movie and see how easy it is to calculate the Medicare Physician Fee Schedule Payment with ICD10Doc.

1. Find a CPT code, with the search or reverse search functions on the Home page. The result will show in its own box as CPT / HCPCS. Click on the link that you'd like to continue with.





2. The next screen asks for the region - in order to match the correct Medicare carrier for reimbursement. From the drop down menu pick the region for your caculation purposes and then click on the big blue button to calculate the fees.



3a. The page after picking the region will show the Medicare Physician Fee Schedule Payment - for Facility and Non-Facility.





3b. If you find yourself browsing a page which at the bottom has a big blue button - Calculate Anesthesia Fees, then the CPT code is Anesthesia related and is calculated in a different manner. Anesthesia Fees explained

Background

RVU Relative Value Units
PE Practice Expenses
MP Malpractice Component
GPCI Geographic Practice Cost Indices

Non-Facility Fee =
[(Work RVU * Work GPCI) + (Non-Facility PE RVU * PE GPCI) +(MP RVU * MP GPCI)] * Conversion Factor

Facility Fee =
[(Work RVU * Work GPCI) + (Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

NOTES:
Medicare may or may NOT reimburse you for a code. The fees provided by ICD10Doc are based on information published by CMS/Medicare. Please check with your local Medicare carrier the reimbursement details.

The Medicare limiting charge is set by law at 115 percent of the payment amount for the service furnished by the nonparticipating physician.
However, the law sets the payment amount for nonparticipating physicians at 95 percent of the payment amount for participating physicians (i.e., the fee schedule amount).
Calculating 95 percent of 115 percent of an amount is equivalent to multiplying the amount by a factor of 1.0925 (109.25 percent). Therefore, to calculate the Medicare limiting charge for a physician service for a locality, multiply the fee schedule amount by a factor of 1.0925. The result is the Medicare limiting charge for that service for that locality to which the fee schedule amount applies.

Certain therapy codes will receive a 20 percent reduction to the PE (note: a 25 percent reduction to the PE will be applied for services rendered in an institutional setting). Please see CR7050.
Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on the technical component (TC) of certain diagnostic imaging procedures and the TC portions of the global diagnostic imaging services.
This cap is based on the Outpatient Prospective Payment System (OPPS) payment. To implement this provision, the physician fee schedule amount is compared to the OPPS payment amount and the lower amount is used in the formula below to calculate payment.

For more information on Physician Fee Schedule visit CMS web site
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