UCR Fees

News and Important Information:

Understanding UCR Inpatient Fees used on DRG's

VA-UCR Prof Services Modifier Charge Factor

Outpatient Facility Pricing

Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and used by certain healthcare plans and third-party payers to generate fair healthcare pricing. 

Where does Find-A-Code get their data for UCR?

Find-A-Code offers UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is offered as a fee comparison with our UCR Pricing add-on. We display the VA's data for our customers and have listed the VA's detailed information below from the VA, however, for additional questions on the VA's data and processes please contact the Veterans Administration, the information is listed below.

 "80th percentile" charges, is not the same thing as a fee multiplier.

When the VA did their survey of fee amounts, the fee amount they chose as the UCR amount is the middle of at least 80% of the fee amounts reported. Like in a bell curve that covers X%, the middle or peak of the bell curve is the amount they chose.  

For additional information on how the VA uses their UCR Data please see the Reasonable Charges Data tables below. 

Reasonable Charges Data Tables– Outpatient and Professional V3.27 Dated January 01, 2020

After reviewing this information, if you have further questions please contact the VA, "Romona Greene, Office of Community Care, Revenue Operations, Payer Relations and Services, Rates and Charges (10D1C1), Veterans Health Administration (VHA), Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC 20420, (202) 382– 2521. (This is not a toll-free number). 

Where are UCR fees located in Find-A-Code?

While on the code information page scroll down to the fees section and open the tab titled “UCR Fees”, the fees will be displayed for UCR, Workers Comp, as well as Medicare Billed and Allowed.

The percentage calculations can be used for adjusting your fees to obtain Range of Low Medium or High pricing, it can also be used to adjust for modifier usage. The Pro Fee Calculator can be used as well. For example; if using Modifier 50 "bilateral Procedure" the charge factor can be adjusted by 1.50, modifier 22 Unusual procedure uses a charge factor of 1.25.

Charge adjustment factors are taken from the VA, TABLE M. — CHARGE ADJUSTMENT FACTORS FOR PROFESSIONAL SERVICES CHARGE MODIFIERS 

Charge adjustment factors for professional services charge modifiers for the VA is on Table M

UCR for CPT/HCPCS Code:

UCR for DRG Codes:

UCR Fees for Outpatient Facility:

What information comes from the VA? 

The following information comes from the VA to give an understanding of accountability to the Federal Register, calculations and links to data sources used on our UCR pricing.  

Reasonable charges according to the VA is described as follows; Reasonable Charges are based on amounts that third parties pay for the same services furnished by private-sector health care providers in the same geographic area. In the past, VA used average cost-based, per diem rates for billing insurers. Reasonable charges are calculated for inpatient and outpatient facility charges, and for professional or clinician charges for inpatient and outpatient care.

Reasonable Charges Rules, Notices, & Federal Register

The VA determines the amount of the national average administrative cost annually for the prior fiscal year (October through September) and then applies the charge at the start of the next calendar year. Below are links to the Federal Register and data sources from the VA Website.

Inpatient:

Outpatient and Professional

Federal Register / Vol. 84, No. 189 / Monday, September 30, 2019 / Notices 

Anesthesia

Find-A-Code's Tools & Resources

Pro-Fee Calculator

Verify Medicare Reimbursement and UCR Fees for Professional Services

Unlimited Fee Reports

Compare your fees with Medicare, OWCP, VA's UCR

UCR Pricing, What is it?

Read this short article on what UCR is and where it comes from

Additional Links and Resources

Inpatient/SNF

REASONABLE CHARGES DATA SOURCES — v3.26

OPT/Phys/Anes/Lab/DME

REASONABLE CHARGES DATA SOURCES — v3.25 (January - December 2019) - Sorted By Charge Type

Outpatient Facility Fees

UCR Section VA Table F Nationwide charges v3.27 (January-December 2020)

UCR - VA, Payer Rates and Charges

Inpatient MS-DRG FY 2020 v3.26

Select the title to see a summary and a link to the full article.

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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 ...

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Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule

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When the proposed Medicare Physician Fee Schedule came out last year, it really got everyone worried. In a time where we are all facing issues related to COVID, this seemed like a really big problem. Professional organizations lobbied and everyone tried to stop the proposed changes, and the 10.2% decrease didn’t happen, but other changes will still be taking place. So how bad is it really and how will it affect your organization?

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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. ...

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My Location and CBSA is Missing!

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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 ...

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On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.

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Payment Adjustment Rules for Multiple Procedures and CCI Edits

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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 ...

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Understanding UCR Inpatient Fees used on DRGs

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Outpatient Facility Pricing

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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 ...

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

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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 ...

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