Fees Articles and Resources

News and Important Information

January 2023 Update: Hospital Outpatient Prospective Payment System: changes to billing instructions for payment policies implemented in the January 2023 OPPS update.

Acute Inpatient Prospective Payment System- Understanding how DRGs work

VA-UCR Prof Services Modifier Charge Factor - How modifiers affect payment

Find-A-Code offers Outpatient Facility Pricing!

And Then There Were Fees - this article will address OPPS and MPFS some of the most common payment systems with CMS (2019-11-11)

UCR Fees on DRGs- Check it Out!

Resources

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Additional Links and Resources

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Jan 10th, 2024

Government Shutdown Looming as Congress Dithers

by Matthew Albright

Like most of the world, I procrastinate when paying my bills. I tend to put them off until the very last minute. And that pretty much explains Congress’s strategy last year – and they clearly plan on continuing this approach for 2024. The tough stuff, like funding a government,...

Nov 6th, 2023

CMS Issues Final Rules for PFS, OPPS/ASCs

by Mark Spivey

The regulatory changes will create a variety of changes for providers. Amid a flurry of regulatory activity, federal officials late last week issued twin final rules governing changes to the Medicare Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS), with the latter also featuring adjustments...

Jul 14th, 2023

CMS Unveils 2024 Medicare PFS, OPPS Proposed Rules

by Mark Spivey

The OPPS proposal did not feature reference to several high-profile issues industry leaders have been awaiting reform on. Federal officials yesterday unveiled a pair of proposed rules, featuring potential adjustments to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for the 2024 calendar year....

Feb 28th, 2023

Top 5 Takeaways from the CMS 2023 Final Rule, MIPS, telemedicine, telehealth, proposed rule, conversion factor, E/M, evaluation and management, refunds, discarded drugs, drugs

by Kem Tolliver, CMPE, CPC, CMOM

Each year the Centers for Medicare and Medicaid Services (CMS) rolls out the proverbial carpet and ushers in new rules on regulatory compliance, coding and reimbursement. Now the dust has settled, learn about the greatest impacts as a result of the CMS 2023 Final Rule. Gain insight into the top 5 regulatory and reimbursement changes that will impact the healthcare industry

Jan 26th, 2023

Relative Value Units (RVUs) the Easy Way, Really?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The Medicare Physician fee schedule was implemented in 1992 using a relative Value scale methodology called RVUs to base payment rates on the resources used to perform the service. This is currently how the Medicare Physician Fee Schedule (MPFS) is set. But beware, there may be an industry-wide change to a Value-Based Payment. We will save that for another time; this article will focus on how the RVUs are calculated and Medicare Fee schedules.

Oct 27th, 2022

Medicare Updates -- SNF, Neurostimulators, Ambulance Fee Schedule and more (2022-10-20)

by CMS - MLNConnects

Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...

Aug 9th, 2022

Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.

Aug 1st, 2022

CMS Started to Enforce Applicable Price Transparency Requirements

by Amanda Ballif

Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.

Jul 28th, 2022

Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule

by Amanda Ballif

The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.

Feb 15th, 2022

Interpreting the VA's UCR Pricing

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Representing the methodologies used in the VA's pricing determinations is better understood coming directly from the source or an attorney who is familiar with the laws. Our responsibility is to educate you with information directly from the source, where you can find your answers or contact them directly. We are happy to ...

Jun 23rd, 2021

UCR Anesthesia Fee Calculations and Base Units - Now Available!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

As per customer request, Find-A-Code now offers UCR Anesthesia Fee Calculations along with CMS and ASA. The anesthesia fee calculations can be found under the Fees section of the code and under the Anesthesia Fee Information. Time units are computed by dividing the reported anesthesia time by 15 minutes (17 minutes / 15 minutes = 1.13 units). NOTE: Always ...

Dec 8th, 2020

Final Rule on Communications Technology and 2021 Physicians Fee Schedule

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...

Sep 23rd, 2020

My Location and CBSA is Missing!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to ...

Jul 9th, 2020

Payment Adjustment Rules for Multiple Procedures and CCI Edits

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

Jul 1st, 2020

Understanding UCR Inpatient Fees Used on DRGs

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Jun 15th, 2020

Outpatient Facility Pricing

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information 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 ...

Mar 30th, 2020

Spotlight: UCR Fees are Available on DRGs- Check it Out!

by Brittney Murdock, QCC CMCS CPC

Check out the information page on any DRG! Look up DRGs by going to the list of DRG codes found under the Codes tab at the top of the page, or simply type in the desired DRG by using the search bar on the homepage. When using the search bar, be sure you have the ...

Dec 4th, 2019

Preview the PDGM Calculator (HIPPS calculator) for Home Health Today

by Wyn Staheli, Director of Content - innoviHealth

Find-A-Code's Patient-Driven Groupings Model (PDGM) home health payment calculator (HIPPS Calculator) simplifies payment calculations. See https://www.findacode.com/tools/home-health/ .

Nov 25th, 2019

New Medicare Home Health Care Payment Grouper — Are You Ready?

by Wyn Staheli, Director of Content - innoviHealth

In 2020, Medicare will begin using a new Patient-Driven Groupings Model (PDGM) for calculating Medicare payment for home health care services. This is probably the biggest change to affect home health care since 2000.

Nov 20th, 2019

VA: How UCR Charges are Determined

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

How does the VA determine charges billed to third party payers for Veterans with private health insurance? According to the VA. "38 C.F.R 17.101 stipulates the basic methodology by which VA bills third party insurance carriers. In order to generate a charge for medical services, VA establishes reasonable charges for five ...

Nov 11th, 2019

And Then There Were Fees...

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...

Oct 21st, 2019

VA- Reasonable Charges Rules, Notices, & Federal Register

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Aug 21st, 2019

So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from? It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems. One of the ...

Apr 1st, 2019

Spinal Cord Stimulator Used for Chronic Pain

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes. ICD-10-CM Diagnosis Codes ...

Nov 28th, 2018

No Good Deed Goes Unpunished

by Ray Foxworth, DC FICC MCS-P

You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.

Nov 26th, 2018

CMT Fees in 2019

by Wyn Staheli, Director of Content - innoviHealth

Now is the time to prepare. There were some minor reductions to the RVUs for CMT codes 90840-90843. Check here to see what those changes are.

Nov 7th, 2018

Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?

by Wyn Staheli, Director of Content - innoviHealth

The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...

Oct 17th, 2018

Wolters Kluwer Drug Pricing

by Find-A-Code™

Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...

Aug 27th, 2018

Pricing for ASC’s and APC’s

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...

Mar 1st, 2018

New Bipartisian Budget Act of 2018 Provisions

by Wyn Staheli, Director of Content - innoviHealth

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References. Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...

Jan 25th, 2018

UCR Pricing, What is it?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

UCR (Usual, Customary, and Reasonable) pricing is a method of generating healthcare pricing based on the average pricing in a particular geographic location. Gathering information on pricing based on what other providers in that area is charging is commonly used for a fee or payment reference, as it gives a basis ...

Jan 10th, 2018

MIPS - To Participate or Not Participate - That is the Question

by Wyn Staheli, Director of Content - innoviHealth

Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...

Dec 28th, 2017

Anesthesia

by Raquel Shumway

Anesthesia services fall into one of the following categories ranging from lowest to greatest: Local or topical anesthesia (not covered here) Moderate (conscious) sedation (See “Moderate Sedation” on page xx) Regional anesthesia General anesthesia Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. General anesthesia may only ...

Dec 13th, 2017

Specialty Exceptions — 2018 PE RVU Changes

by Raquel Shumway

Some specialties are not included in the new PPIS PE/HR RVU changes

Nov 7th, 2017

Four Final Rules Affecting CMS Payments for 2018

by Wyn Staheli, Director of Content - innoviHealth

It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018 HHAs: Payment Changes for 2018 Quality Payment Program Rule for Year 2 This ...

Nov 6th, 2017

Payment Rulings and Small Provider Practices

by Wyn Staheli, Director of Content - innoviHealth

Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...

Aug 15th, 2017

Transparency and Fees

by Christine Taxin, President - Links2Success

More than any other industry, healthcare is almost notorious for its lack of price transparency. While patients generally know how much their copay will be and certainly how much their final bill turns out to be, few hospitals and practices publish the actual costs of their services prior to those ...

May 12th, 2017

When Using Code 99050 (After Hours)

by Wyn Staheli, Director of Content - innoviHealth

Question: When using code 99050 (after hours), do I just add a amount, example $25.00, to our normal total charges for that patients visit?

Feb 8th, 2017

Medicare Conversion Factor

by Wyn Staheli, Director of Content - innoviHealth

In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...

Feb 6th, 2017

Quality Reporting is not Just for CMS

by Wyn Staheli, Director of Content - innoviHealth

If you thought that quality reporting is just for CMS, you are wrong. Other payers recognize the need to establish quality metrics.

Jan 16th, 2017

Alternative Payment Models (APMs) and Advanced APMs

by Wyn Staheli, Director of Content - innoviHealth

When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ? According to a fact sheet ...

Dec 7th, 2016

Discounts

by Wyn Staheli, Director of Content - innoviHealth

All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...

Jun 27th, 2016

CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)

by Brittney Murdock, QCC CMCS CPC

Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...

Aug 10th, 2015

Hardship Discounts

by Melissa Hall

What are they and how can I safely create one based on the patient's poverty level?

Jun 18th, 2015

Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)

by Jared Staheli, MPP

Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp The DMEPOS fee schedule applies to claims to FIs as follows. BILL TYPE/ DEFINITION ORTHOTICS/ PROSTHETICS DME/ OXYGEN 12X (Hospital inpatient Part B) Subject to fee schedule Not covered, therefore, ...

Jun 17th, 2015

General Payment Rules (Rev. 1, 10-01-03)

by Jared Staheli, MPP

DMEPOS are categorized into one of the following payment classes: • Inexpensive or other routinely purchased DME; • Items requiring frequent and substantial servicing; • Certain customized items; • Other prosthetic and orthotic devices; • Capped rental items; or • Oxygen and oxygen equipment. The CMS determines the category that applies to each HCPSC code and issues ...

Jan 8th, 2015

Discounts by ChiroCode

by ChiroCode™

All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing Section F-Fees of the ChiroCode DeskBook for important information on fee schedules and ...

Nov 21st, 2014

Understanding TOS Discounts and DMPOs

by Jared Staheli, MPP

Time-of-Service (TOS) discounts are a common occurrence in chiropractic. What is often assumed is that if insurance isn't involved, there are no rules that apply. Unfortunately, this is a myth that can become costly to practices and damage provider/patient relationships. So read on to learn the facts about TOS discounting and ...

Jul 24th, 2014

Are Medicare fees going up? Or down?

by Jared Staheli, MPP

PAMA (up 0.5%) On April 1, 2014, President Obama signed into law the Protecting Access to Medicare Act of 2014 (PAMA). Within this law, Congress instituted changes that went into effect on July 1, 2014. The law provided for a 0.5% update for claims with dates of service on or after ...

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Jun 2nd, 2022

Coding 2022 Care Management Services

by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Apr 12th, 2022

What do Chiropractors Need to do to Comply with the No Surprises Act?

by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Anyone who sees patients who have services that are not covered by insurance needs to know about the No Surprises Act. In this quick webinar, Dr. Gwilliam will show you how to properly notify patients of their options and create a Good Faith Estimate, as required by this law. Expect this…

Feb 15th, 2022

Pro Fee overview with UCR Fees.

by Alan Crop, VP Sales - innoviHealth

Dec 21st, 2017

What is RBRVS and How Can It Benefit Your Organization

by Find-A-Code™

What is RBRVS and How Can It Benefit Your Organization

Dec 14th, 2017

The Importance of Gathering Organizing and Using Fee Schedules

by Find-A-Code™

The Importance of Gathering Organizing and Using Fee Schedules

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