UCR Fees

News and Important Information:

Understanding UCR Inpatient Fees used on DRG's

VA-UCR Prof Services Modifier Charge Factor

Outpatient Facility Pricing

Interpreting the VA's UCR 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 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 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 (listed below).

Understanding the 80th Percentile
"80th percentile" charges, are 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 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 links to the Federal Register and data sources from the VA Website.

VA Data Sources
The VA uses multiple Reasonable Charges Data Sources and has them sorted by charge type on their website as well as where to obtain the data. Using the links below, the page will open up under "Payer Rates and Charges", from there select the type of data such as "Reasonable Charges Data Sources", select the most current version, or 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 on Reasonable Charges Rules, Notices, & Federal Register.

Data Tables offer additional information on how the VA uses its UCR Data please see the Reasonable Charges Data tables on the "Payer Rates and Charges" page.

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.

Charge adjustment factors are taken from the VA, See TABLE M. for Charge Adjustment Factors for Profesional services charge modifiers. 

RVU Conversion Factors V4.235 Table L: Professional Services RVU Conversion Factor Geographic Area Adjustment Factors (GAAFs) by Zip Code  See data sources for information on where the VA gets RVU Data from see (Table 1. sample page).

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 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 are 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".

Inpatient

• Reasonable Charges Federal Register Notice
• Data sources for VA Reasonable charges, See: V4.23 Reasonable Charges Data Sources (Inpatient)

Outpatient and Professional

• Reasonable Charges Federal Register Notice, (Outpatient and Professional)
• Data sources for VA Reasonable charges, See: V4.235 Reasonable Charges Data Sources (Outpatient and Professional), 01/01/2023. 

Anesthesia

• Professional Anesthesia Base codes by CPT code- VA, See Table H

Third-Party Pharmacy Prescription Administrative Charge

• Average Administrative Cost for Prescriptions

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.

UCR for CPT/HCPCS Code:

UCR for DRG Codes:

UCR Fees for Outpatient Facility:

Pro Fee Calculator

The Pro Fee Calculator is an easy-to-use tool when calculating UCR 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. Meaning 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. 

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