UCR Fees
Usual, customary, and reasonable charges (UCR) typically refers to a base amount a third-party payer uses to determine how much they will pay for services provided. For more information about fees, please refer to the “Guide” found on the Fees Topic page.
Click on the following links for answers to some questions about UCR fees:
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There are 3 sections in the Guide.
Select the title to see a summary and a link to the full article. some articles require a subscription to view.
Oct 30th, 2024
What are the Different Medicaid Payment Systems?
The Medicaid payment system, which funds healthcare for low-income individuals and families, is complex and varies by state. It generally works through a combination of fee-for-service (FFS) and managed care models, with federal and state governments sharing costs. This article contains information to help explain some of the different ways that Medicaid pays for healthcare services.
The Medicaid Chronic Illness and Disability Payment System (CDPS) is a diagnostic-based risk adjustment model used to calculate payments for Medicaid health plans, particularly for those covering individuals with chronic illnesses and disabilities.
A conversion factor is a dollar amount that is applied to an adjusted Relative Value Unit (RVU) to arrive at a fee. Conversion factors can be based on a geographic location as well as a national level. The article contains information from the Veterans Administration about how they create their geographically-adjusted 80th percentile conversion factors.
Jul 31st, 2024
Where are UCR Fees Located in Find-A-Code?
by Wyn Staheli, Director of Content - innoviHealth
UCR fees can be found in several places within Find-A-Code. The most commonly used place is found in the Fees section of the individual code. When you are on the code information page for a specific code, scroll down to the fees section and click on the bar titled “Fees” (as shown below) to open this section:
Jul 25th, 2024
Does the Pro Fee Calculator Include UCR Fees?
by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code’s Pro Fee Calculator is an easy-to-use tool for calculating fees for CPT and HCPCS codes. Need to apply modifiers or additional units? The Pro Fee calculator can do this and much more. Check it out.
Jul 25th, 2024
Where does Find-A-Code get UCR Data?
by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code provides 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.
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...
by Adam Brenman
The Centers for Medicare & Medicaid Services (CMS) can’t seem to catch a break of late. 2023 has been a tough year for the agency, with the court system and Congress dealing it repeated blows, primarily over enactment of the No Surprises Act (NSA). Many are undoubtedly at least...
Sep 6th, 2023
When Is a Shared Visit Not a Shared Visit?
by David M. Glaser, Esq.
Can you do a “shared visit” in a physician clinic, site of service 11? The most common answer to this question seems to be “no,” and while that is technically correct, it is so misleading that it is effectively entirely wrong. To understand this confusion, we need to dig...
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....
Mar 15th, 2023
HCC Re-Structuring Coming Soon!
by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
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
by Jessica Hocker, CPC, CPB, CRC
Risk adjustment models are used by Medicare and Medicaid programs to classify patients based on the severity of their health conditions to determine the reimbursement for payers. Different types of models are used, such as HHS-HCCs, CMS-HCCs, RX-HCCs, and ESRD-HCCs, which are based on a hierarchical structure, meaning that patients are classified into categories based on the most severe condition they have. Medicaid risk adjustment models vary by state in the US, some states use their own models, while others use models developed by the CMS. These models take into account both diagnoses and procedures, and adjust the payment rates for healthcare providers based on the complexity of the care they provide.
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.
by Kem Tolliver, CMPE, CPC, CMOM
Diagnosis code usage is a major component of optimizing HCCs to improve overall healthcare. Readers will gain insight into how accurate diagnosis code usage and selection impacts reimbursement and overall healthcare.
Dec 13th, 2022
CPT Codes and Medicare's Relative Value Unit
by Find-A-Code™
A recently published study looking to explain income differences between male and female plastic surgeons suggests that billing and coding practices may be part of the equation. The study focused primarily on Medicare's relative value units (RVU) as applied to surgeon pay. But what exactly is an RVU?
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...
Oct 24th, 2022
End-Stage Renal Disease Risk Model Updates for 2023
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.
There are 40 related documentation, coding and billing tips.
Select the title to see a summary and a link to the full webinar information. some webinars require a subscription to view.
Jun 2nd, 2022
Coding 2022 Care Management Services
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
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
by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC
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…Dec 21st, 2017
What is RBRVS and How Can It Benefit Your Organization
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The Importance of Gathering Organizing and Using Fee SchedulesNov 16th, 2017
How Can Local Coverage Determinations Ensure Reimbursement
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The Future of Reimbursement - Medicare's Quality Payment ProgramLinks and resources by topic.
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