by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
June 15th, 2020
Our pricing for outpatient facilities is based on databases of insurance claims from private-sector health care providers.
Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate fair healthcare pricing.
Outpatient Facility pricing is the pricing charged by the facility in an outpatient setting. We also offer professional fees for UCR which are available with your UCR package. Outpatient Facility pricing is found under our fees section on any CPT code information page, then select the UCR Fees (green bar).
Notice the fees reflect the National Unadjusted fees in one column and the Geographic location using the zip code from your account settings in the other column (the location settings may be previously set up under your account).
UCR Pricing Adjustments
Another feature requested by our customers is the ability to adjust the fees according to the desired percentage. This can be changed according to the customers' needs at any time. The 100% pricing still reflects the Geographically-adjusted or national un-adjusted charges and the 80th percentile conversion factors, however, we are offering the ability to adjust the UCR fees if needed, If the differences are not required simply put a zero -0- in the box. Examples of reasons for adjusting your fees may be High, Medium, or Low pricing or for Modifier adjustments, for example, if a code has a bilateral indicator #1 such as 27447 or multiple procedure adjustment, different payment rules will apply.
NOTE: The fee data we offer comes from the Veterans Administration (VA). For more information on where the VA gets the information please visit the TOPIC page on UCR FEES.
If you are not seeing a price for Outpatient Facility Pricing, verify how the code should be used. One way to verify this is to look under the Additional Code Information bar, for example;
27134 Revision of total hip arthroplasty, is an inpatient-only code. This information is identified with a "Status C" code indicating this should be billed as inpatient.
If you currently have our Facility Base product and our UCR add-on, you can start using the Outpatient Facility Pricing today.
Please contact one of our Customer Success Managers at 801-770-4203 (9-5 Mountain), if you have any questions.