Select the title to see a summary and a link to the full article.
March 30th, 2020
Spotlight: UCR Fees are Available on DRGs- Check it Out!
By Brittney Murdock, QCC, CMCS, CPC | Published March 30th, 2020
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 ...
Preview the PDGM Calculator (HIPPS calculator) for Home Health Today
By Wyn Staheli, Director of Research | Published December 4th, 2019
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/ .
New Medicare Home Health Care Payment Grouper — Are You Ready?
By Wyn Staheli, Director of Research | Published November 25th, 2019
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.
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 20th, 2019
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 ...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 11th, 2019
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...
So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 21st, 2019
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 ...
By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA | Published November 28th, 2018 - Last Review/Update January 21st, 2019
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.
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
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 ...
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...
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 27th, 2018
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...
By Linda Walker | Published May 30th, 2018 - Last Review/Update June 4th, 2018
Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient's co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations....
By Wyn Staheli, Director of Research | Published March 1st, 2018
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 ...
Payment Rates Increase for Behavioral Health Office Services
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...
By Ashley Choate | Published January 31st, 2018 - Last Review/Update March 29th, 2018
High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 25th, 2018
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 ...
MIPS - To Participate or Not Participate - That is the Question
By Wyn Staheli, Director of Research | Published January 10th, 2018
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 ...
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 ...
Clinical Drug Information, LLC Average Wholesale Price (AWP) is intended only to be used by Clinical Drug Information, LLC customers. While many use this information as a price index, the Clinical Drug Information, LLC AWP does not represent an average of wholesale prices from any group of transactions in the ...
By Wyn Staheli, Director of Research | Published November 7th, 2017
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 ...
By Wyn Staheli, Director of Research | Published November 6th, 2017
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 ...
By Wyn Staheli, Director of Research | Published November 6th, 2017
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 ...
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 ...
By ChiroCode | Published February 16th, 2017 - Last Review/Update March 5th, 2019
Many providers are unsure of where their fee schedule actually came from or when it was last reviewed. As a component of compliance and for other preventive purposes, fee schedules should be evaluated once per year. Read more to help evaluate your fee schedules.
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
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 ...
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published May 26th, 2016 - Last Review/Update March 5th, 2019
Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful.
So what will that mean to you and your practice? It isn’t pretty.
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
Summary of Adjustments to Fee Schedule Computations (Rev.1931, Issued:03-12-10)
By | Published August 19th, 2015
For services prior to January 1, 1994, B/MACs computed the fee schedule amount for every service. Through 1995, the fee schedule amount is the transition fee schedule amount. For services after 1995, CMS computes and provides the fee schedule amount for every service discussed below. Certain adjustments are made in ...
First Physician Fee Schedule Proposed Rule Since SGR Repeal
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
Carrier Claims Processing - Reporting of Pricing Localities for Clinical Laboratory Services (Rev. 85, 02-06-04)
By Jared Staheli | Published July 10th, 2015
Carriers shall report to the common working file (CWF) new State pricing localities (positions 58 and 59 on the carrier record) indicated on the Clinical Diagnostic Laboratory fee schedule for any reference laboratory service billed with a HCPCS 90 modifier. If the laboratory test billed is not a reference laboratory ...
Calculation of Payment Rates - Clinical Laboratory Test Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Under Part B, for services rendered on or after July 1, 1984, clinical laboratory tests performed in a physician’s office, by an independent laboratory, or by a hospital laboratory for its outpatients are reimbursed on the basis of fee schedules. Current exceptions to this rule are CAH laboratory services as ...
Initial Development of Laboratory Fee Schedules (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Initially, each carrier established the fee schedules on a carrier-wide basis (not to exceed a statewide basis). If a carrier’s area includes more than one State, the carrier established a separate fee schedule for each State. The carrier determined the fee schedule amount based on prevailing charges for laboratory billings ...
The CMS adjusts the fee schedule amounts annually to reflect changes in the Consumer Price Index for all urban consumers (CPI-U) (U.S. city average) and the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity, unless alternative updates are specified by legislation. The CMS communicates this ...
The Medicare Modernization Act section 303(e)(1) added section 1842(o)(5)(C) of the Social Security Act which requires that, beginning January 1, 2005, a furnishing fee will be paid for items and services associated with clotting factor.
Beginning January 1, 2005, a clotting factor furnishing fee is separately payable to entities that furnish ...
Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)
By Jared Staheli | Published July 9th, 2015
Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State ...
Carrier - Medicare Part B Physician and Practitioner Services Paid Under the Medicare Physician Fee Schedule (MPFS) - Payment Policy for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Prior to the enactment of BIPA, reimbursement for Medicare services provided in IHS facilities was limited to services provided in hospitals and SNFs. Effective July 1, 2001, §432 BIPA extended payment to services of IHS physicians and practitioners furnished in hospitals and ambulatory care clinics.
The services that may be paid ...
FI - Medicare Part B Services Paid Under Various Fee Schedules for Indian Health Services (Rev. 2075, 01-28-11)
By Jared Staheli | Published June 25th, 2015
The legislative change in MMA §630 of 2003, which was effective January 1, 2005, and indefinitely extended by §2902 of the ACA, allows IHS providers to bill for other Medicare Part B services, not covered under §1848 of the Act. In an effort to clarify that these charges are not ...
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
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, ...
Contractor Application of Fee Schedule and Determination of Payments and Patient Liability for DME Claims (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all contractors processing DMEPOS claims:
First the 'allowable amount' is determined. This is the lower of the fee schedule amount or the billed charge.
The application of deductible and coinsurance are calculated as follows.
A. Claims to Carriers and DMERC
Any unmet deductible is subtracted from the allowed ...
Calculation and Update of Payment Rates (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Section1834 of the Act requires the use of fee schedules under Medicare Part B for reimbursement of durable medical equipment (DME) and for prosthetic and orthotic devices, beginning January 1 1989. Payment is limited to the lower of the actual charge for the equipment or the fee established.
Beginning with fee ...
The DMEPOS fee schedule is updated annually to apply update factors and quarterly to include new codes and correct errors.
The July 2003 update of the DMEPOS fee schedule is located at http://cms.hhs.gov/manuals/pm_trans/AB03071.pdf
The October 2003 quarterly update is located at: http://cms.hhs.gov/manuals/pm_trans/AB03100.pdf
...
The fee schedule file provided by CMS contains HCPCS codes and related prices subject to the DMEPOS fee schedules, including application of any update factors and any changes to the national limited payment amounts. The file does not contain fees for drugs that are necessary for the effective use of ...
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 ...
For payment purposes, used equipment is considered routinely purchased equipment and is any equipment that has been purchased or rented by someone before the current purchase transaction. Used equipment also includes equipment that has been used under circumstances where there has been no commercial transaction (e.g., equipment used for trial ...
Capped Rental Fee Variation by Month of Rental (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For the first three rental months, the capped rental fee schedule is calculated so as to limit the monthly rental to 10 percent of the average of allowed purchase prices on assigned claims for new equipment during a base period, updated to account for inflation. For each of the remaining ...
Payment for Power-Operated Vehicles that May Be Appropriately Used as Wheelchair (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The allowed payment amount for a power-operated vehicle that may be appropriately used as wheelchair, including all medically necessary accessories, is the lowest of the:
• Actual charge for the power-operated vehicle, or
• Fee schedule amount for the power-operated vehicle.
(Rev. 1, 10-01-03)
...
For oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.
When an inpatient is not entitled to Part A, payment may not be made under ...
Adjustments to Monthly Oxygen Fee (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
If the prescribed amount of oxygen is less than 1 liter per minute, the fee schedule amount for stationary oxygen rental is reduced by 50 percent.
The fee schedule amount for stationary oxygen equipment is increased under the following conditions. If both conditions apply, contractors use the higher of either of ...
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
By Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
By | Published January 9th, 2015 - Last Review/Update June 13th, 2016
Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:
• Prompt an audit or some level of claims review
• Cause claims delays
• Increase provider liability in case of an audit or investigation
• Potentially lead to being paid less than the actual value of ...
By | Published November 21st, 2014 - Last Review/Update January 30th, 2017
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 ...
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, I have listed some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees:Â Fee ...
By | Published October 29th, 2014 - Last Review/Update January 30th, 2017
Each new year brings a bundle of surprises in terms of changes and updates that practices must learn and implement. In effort to aid in the preparation of this year, here are some common helpful tips that you might follow in order to best manage your workload ahead.
-Evaluate fees: Fee schedules ...
By | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Are PPOs are affecting the value of your practice?
Did you know that taking a 20% PPO write-off on a $200 procedure with a 60% overhead cuts practice profits in half?
By participating in PPO plans, you agree to take a certain discount on fees; however, your fixed overhead costs remain the same ...
Virtual Credit Cards -A new trend in trying to keep up with E-Health
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Beware of the changes sneaking in as “money streams” in the name of EFT standards. Virtual Credit Cards are being used in provider’s offices as payments from payers; clearinghouses are starting to offer this service as well.
Effective January 1, 2014, health plans were required to offer electronic funds transfer (EFT). ...
By | Published July 24th, 2014 - Last Review/Update January 25th, 2017
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 ...
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017
Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders.
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Medicare Fee Alert-June 21, 2010, by Dr. Ron Short
By | Published June 21st, 2010 - Last Review/Update January 27th, 2017
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update.
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October 30th, 2018
Skyrocket Cash Collections, Even When Patients Have High Deductibles and Copays
Are you seeing $5,000, $7,500, and even $10,000 deductibles? We're hearing doctors from every state tell us they can't believe how high patients' insurance deductibles are getting. Some are even reporting patient copays of $50 - $60. (That's more than most docs charge for their adjustment!) When accepting insurance, do you know that you CAN'T discount services that apply to these large deductibles? And you can't treat them as "cash" patients. There is a way to overcome this problem of rising deductibles & copays and collect more cash - all while still accepting insurance. This one strategy alone will help you increase your case acceptance, even when patients have $10,000 deductibles. Join Dr. Miles Bodzin for this information-packed presentation. If you're going to be able to serve your communities and sleep well at night, you need this information.
How to Convert Your Medicare Patients to Cash to Avoid the Penalties of MACRA
The #1 concern reported by CMS about chiropractors is that, as a profession, we do a poor job of understanding maintenance care. Of course, that is THEIR definition of maintenance care. When you better understand the rules of medical necessity in Medicare, you begin to see what they are talking about. The truth is that there is a “gray” area between the distinct “white” of active treatment and the “black” of maintenance treatment, and that gray area is confusing when defining “covered” vs. “not covered” chiropractic care in Medicare. Join us to find out the following critical information in time for the MACRA Section 514 implementation January 1, 2017:
Find out exactly what Medicare deems as maintenance care and how to recognize it with our patients
Learn what your options are for treating your Medicare patient’s maintenance care for cash
Hear scripting that is vital to your patient understanding what’s going on with their coverage, or lack thereof
Properly document the difference between active and maintenance care
Better manage those little incidents that come up for chronic, Medicare patients
Find-A-Code's 2020 specialty specific Reimbursement Guides give you the coding, billing, and documentation support you need to get paid properly and keep it.
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