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Find Your Correct Medicare Fee

Are You Charging the Correct Fee?

 

Find Your Correct Medicare Fee

Each state, region, or Medicare Administrative Contractor (MAC) jurisdiction has its own fee schedule. The schedules are available for review on the website for each MAC, listed by state and/or region. Providers should be familiar with the Fee Schedule information available there to ensure they are charging correctly. Follow these easy steps to find your fee:

  1. Locate your MAC website for Part B providers. If one MAC covers several jurisdictions, make sure you select the jurisdiction that your state falls within. KMC University Library members click here to find your AB Map Jurisdiction Map.
  2. On the main menu, there should be an option to select Fee Schedules, sometimes referred to as Medicare Physician Fee Schedules (MPFS)
  3. Once there, locate the year for which you’re attempting to identify fees and be sure you locate your specific locality, if appropriate.
  4. Your MAC may allow you to search by code or to download the entire fee schedule in an excel or PDF format. If you can search by code, enter 98940, 98941 and 98942 individually to identify the allowable and limiting fees.
  5. If your MAC requires that you download the excel or PDF document, do so, and then scroll to locate the codes you’re looking for.

Fee Calculations

Understanding what and when to charge a Medicare patient is critical to complying with the rules. Whether participating or not, apply these instructions to ensure you stay within the lines:

Participating Providers

Non-participating Providers

  • May charge their actual fee when billing Medicare.
  • May charge no more than the Limiting Charge for the three spinal adjustment codes.
  • Medicare automatically reduces the fee to the par-fee and then, if allowed, pay 80% directly to the provider after the annual deductible is met.
  • As most claims are unassigned, you may collect this amount at the time of service.
  • Medicare advises you not to collect these amounts until you receive the Medicare Part B payment because it is difficult to predict when deductible/coinsurance amounts are applicable and over-collection is considered program abuse.
  • Medicare considers the non-par fee amount and pays 80% of that after applicable annual deductibles are met. Note: That amount is paid directly to the patient on unassigned claims.
  • If you can accurately predict the coinsurance amount and want to collect before Medicare Part B payment is made, note the amount collected on your claim form.
  • The difference between a Limiting Charge and a non-par fee is never recouped by the patient.
    • If the nonparticipating provider elects to accept assignment on a claim, Medicare considers 80% of the non-par fee and pays that amount directly to the provider. The patient pays 20% of this amount directly to the provider.
      • No additional money can be collected on unassigned claims.

      NOTE: Keep in mind fees may be impacted by Mandatory Fee Reductions as a result of MIPS reporting requirements. Negative adjustments must be written off and cannot be passed on to the patient as an additional charge. If you are a non-participating, NOT accepting assignment provider, according to CMS, " MIPS payment adjustment does not apply to non-assigned claims for non-participating clinicians." If you are wondering if your fees will be impacted because you were required to report MIPS, check your status at https://qpp.cms.gov/.

      KMC University has in-depth training on the on Medicare fee schedules within our Library compendium. We also offer analysis services that can evaluate your proper code usage which can lead to missed money and reimbursement challenges.

      Call (855) 832-6562 now or click to schedule a 15-minute Solution Consultation at your convenience.

       


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