Charge Adjustment Factors for Professional Services Charge Modifiers
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 UCR Data?
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 available for performing a fee comparison with our UCR Pricing add-on. Reasonable charges are updated by the VA annually on or around January 1st each year.We include 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 (listed below).
Understanding the 80th Percentile
"80th percentile" charges are not the same as a fee multiplier.
When the VA performs its survey of fee amounts, the fee amount they chose as the UCR amount is in 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.
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 some links to the Federal Register and data sources from the VA Website.
VA Data Sources
The VA uses multiple sources to arrive at their "Reasonable Charges" amounts. These sources can be found in the Federal Register as well as their website. On their website, open the "Payer Rates and Charges" section. From there, select the type of data, such as "Reasonable Charges Data Sources," and select the most current version of the Inpatient or Outpatient and Professional files.
Rules and Notices such as the Federal Register are available and helpful in understanding where the Information used by the VA is coming from. Visit the "Payer Rates and Charges" page for information under Reasonable Charges Rules, Notices, & Federal Register.
Data Sources used by the VA when assigning UCR fees can be found on the "Payer Rates and Charges" page under "Reasonable Charges Data Sources."
After reviewing this information, if you have further questions, please contact the VA, 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) or 800-698-2411.
Information From the VA
The following statement from the VA provides information about how reasonable charges are created:
"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, the VA used average cost-based, per diem rates for billing insurers. Reasonable charges are calculated for inpatient and outpatient facility charges, and professional or clinician charges for inpatient and outpatient care".
Where are UCR Fees Located in Find-A-Code?
Once you are on the code information page on a specific code, 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 amounts.
The percentage calculations can be used for adjusting your fees to obtain a range of Low, Medium, or High pricing; it can also be used to adjust for modifier usage.
Example 1: UCR for CPT/HCPCS Code using zip code 84660 for comparison
Example2: UCR for DRG Codes:
Example 3: UCR Fees for Outpatient Facility
Pro Fee Calculator
The Pro Fee Calculator is an easy-to-use tool for calculating fees for CPT and HCPCS codes. Need to apply modifiers? Additional units? The Pro Fee calculator can do this and more. For example, when using modifier 50, "bilateral procedure," the charge factor will be adjusted by 1.50; modifier 22, Unusual procedure, uses a charge factor of 1.25. This means your fee will change from 100% to 150 for the bilateral Modifier 50 and from 100% to 125% when reporting the 22 modifiers. See Find-A-Code for a list of all CPT Modifiers and descriptions.
Subscribers will see a Guide designed to provide structured information on this topic. The guide contains information about documentation, coding, billing and more.
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Select the title to see a summary and a link to the full article. some articles require a subscription to view.
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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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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 ...
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I submitted a claim to the VA and it’s being denied. Why?
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ICD-10-CM Diagnosis Codes ...
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For ...
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Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
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 ...
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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
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It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
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HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ...
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Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
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by Wyn Staheli, Director of Content - innoviHealth
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According to a fact sheet ...
Whiplash Damages in Rear-end Collisions - The Patient’s Dilemma:
The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it.
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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 ...
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Consumer Directed Healthcare Plans (CDHP) were developed as a way to shift the control of healthcare dollars from the insurance companies to the patient (consumer). The goal of these types of plans is to allow the patient to take a more active role in their own health and healthcare decisions ...
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 Kate Goodrich, MD MHS Director - Center for Clinical Standards & Quality - CMS
On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...
by Wyn Staheli, Director of Content - innoviHealth
High-deductible plans are changing the way patients utilize medical services, therefore, providers must also adapt by adjusting both their communication and billing practices to keep pace with these changes.
by Wyn Staheli, Director of Content - innoviHealth
Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an effective tool for healthcare providers to identify, reduce, and prevent problematic substance use disorders. Healthcare practices can help their patients and improve their integrated care standards with the proper use of the SBIRT.
Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures...
A. Payment to Government Agency
Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician.
B. Payment ...
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, ...
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 ...
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 ...
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 ...
Least Expensive Alternative Treatment Clause
What your patients do not know!
When alternate benefit or LEAT provisions are applied, they are not meant to dictate treatment, question professional judgment or interfere with doctor-patient relationships. The ultimate decision on treatment is up to the dentist and patient. The LEAT provision actually funds a ...
In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous ...
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 ...
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
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…
August 18, 2020 Join this webinar for a birds-eye review of crucial components of your practice revenue cycle system. Inefficient or unattended revenue cycle systems result in a tremendous loss of time and money for practices. So often, that additional cash flow that practices are seeking, are…