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Medicare Online Fee Schedules and Medicare Physician Fee Schedule Database

A fee schedule is a complete list of fees used by Medicare to pay doctors or other providers/suppliers. The comprehensive list of fee maximums is used to reimburse physicians and/or other providers on a fee-for-service basis. Medicare-covered services are normally allowed based on the lower of either the actual charge or the fee schedule amount for the procedure and reimbursed at 80 percent; however, there are exceptions. The Medicare Physician Fee Schedule (MPFS) can be accessed at: http://www.trailblazerhealth.com/Payment/Fee Schedules

Note: An option to utilize the Printable View feature within the left-hand browser is available.

Published May 2012 LH

© 2012 TrailBlazer Health Enterprises®/TrailBlazer®. All rights reserved.

After accessing the Medicare fee schedule, use the drop-down boxes to indicate the year, state and locality. A procedure code must be entered prior to using the search feature.

Downloading the Physician Fee Schedule The option to download the entire fee schedule, per locality, as an Adobe Acrobat file (PDF) or Microsoft Excel CSV file is available after successfully performing a search:

Is the Provider Participating or Non-Participating? Participating Amount Allowed amount for participating physicians Non-Participating Amount Allowed amount for nonparticipating physicians Limiting Charge Amount The maximum limiting charge amount that can be charged for the service on a non-assigned claim

What Is the Place of Service? Non-Facility These amounts apply when the service is performed in the: Physician's office. Patient's home. Facility or institution other than the places of service listed in the facility Facility These amounts apply when the service is performed in a facility setting: Inpatient hospital. Outpatient hospital. Emergency room. Military treatment facility.

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Non-Facility fee description.

Facility Hospice. Inpatient psychiatric facility. Ambulatory surgery center. Psychiatric facility. Partial hospitalization skilled nursing facility. Community mental health center. Psychiatric residential treatment facility. Comprehensive inpatient rehabilitation.

The place of service, type of service and the participation status of the provider are determining factors in the physician fee schedule allowed amount.

Note: A fee schedule amount has been given for each procedure code listed in the Medicare fee schedule. Based on Medicare policy, the specific procedure may not be payable by the Medicare program. Services with an Individual Consideration (IC) in the amount field are priced by individual consideration and may be payable subject to supporting documentation. Outpatient Prospective Payment System (OPPS) The Deficit Reduction Act (DRA) of 2005 limited the Technical Component (TC) payment for most imaging procedures paid under the MPFS to the amount paid under the OPPS. Effective January 1, 2012, the Multiple Procedure Payment Reduction (MPPR) will also be applied to the Professional Component (PC) of these services. The provision applies to PC-only services, TC-only services and to PC and TC portions of global services. The calculation and use of the global cap is being discontinued. The outpatient cap will be used on the TC for both TC-only and global services. For complete information about the PC/TC reduction of imaging procedures and the OPPS cap, refer to MLN Matters® article MM7703 at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads//MM7703.pdf

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How Are the Allowables Calculated? The MPFS reflects the variation in practice costs from area to area. This cost is calculated using the following three components: Relative Value Units (RVUs) In almost all cases, this is established nationally for each procedure code and will not vary between contractors. Geographic Practice Cost Indices (GPCIs) The locality where the service is furnished Conversion Factor (CF) This number is used by all contractors in calculating payments under the MPFS and includes two adjustment factors: Medicare Economic Index (MEI). Sustainable Growth Rate (SGR).

For claims with dates of service between June 1, 2010, and December 31, 2010, the conversion factor is 36.8729. For claims with dates of service between January 1, 2011, and December 31, 2010, the conversion factor is 33.9764. For claims with dates of service on or

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after January 1, 2012, the conversion factor is 34.0376. Detailed information, including the formula used to calculate the fee schedule allowables, can be accessed at: http://www.cms.gov/PhysicianFeeSched/ Reimbursement Overview Medicare-covered services are normally allowed based on the lower of either the actual charge or the fee schedule amount for the procedure and reimbursed at 80 percent. Exceptions Non-physician practitioners (physician assistants, nurse practitioners and clinical nurse specialists): o Allowed at 85 percent of the Medicare fee schedule. o Reimbursed at 80 percent of the Medicare fee schedule. Certified Nurse-Midwives (CNMs): o For services on or after January 1, 1992, through December 31, 2010: Medicare contractors will pay CNMs for their services and services furnished incident to their professional services at 80 percent of the lesser of the actual charge or 65 percent of the physician fee schedule amount that would be paid to a physician for the same service. Contractors will pay CNMs for their care in connection with a global service at 65 percent of what a physician would have been paid for the total global fee. o For services on or after January 1, 2011: Medicare will pay CNMs for their services and services furnished incident to their professional services at 80 percent of the lesser of the actual charge or 100 percent of the physician fee schedule amount that would be paid to a physician for the same service. Medicare will pay CNMs for their care in connection with global services at 80 percent of the lesser of the actual charge or 100 percent of what a physician would have been paid for the total global fee. Detailed information can be found in Change Request (CR) 7005 and MLN Matters® article MM7005 at: http://www.cms.gov/Transmittals/downloads/R2024CP.pdf http://www.cms.gov/MLNMattersArticles/downloads/MM7005.pdf

Licensed clinical social workers: o Allowed at 75 percent of the Medicare fee schedule. o Reimbursed at 80 percent of the Medicare fee schedule. Psychiatric services: o When the services are subject to the psychiatric limitation, Medicare reduces the allowed amount (or the billed amount, whichever is lower) as follows:

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January 1, 2010 ­ December 31, 2011, the limitation percentage is 68.75 percent (Medicare pays 55 percent and the patient pays 45 percent). January 1, 2012 ­ December 31, 2012, the limitation percentage is 75 percent (Medicare pays 60 percent and the patient pays 40 percent). January 1, 2013 ­ December 31, 2013, the limitation percentage is 81.25 percent (Medicare pays 65 percent and the patient pays 35 percent). January 1, 2014, and after, the limitation percentage is 100 percent (Medicare pays 80 percent and the patient pays 20 percent). Part B deductible is then applied, if applicable. Medicare then pays 80 percent of the remaining allowance.

Refer to: http://www.trailblazerhealth.com/Publications/Training Manual/PsychiatricServices.pdf.

Multiple Procedure Payment Reduction (MPPR) of the technical component of certain diagnostic imaging procedures: o The reduction applies to professional-only codes, technical-only codes and to the professional and technical portion of global services for the procedures that contain a diagnostic imaging indicator of 88. o For the TC with dates of service on or after January 1, 2011, full payment will typically be allowed for the highest-priced procedure and approved at 50 percent of the allowable for each additional procedure, when performed during the same session on the same day. o For dates of service on or after January 1, 2012, full payment will be made for each PC and TC service with the highest payment under the MPFS and approved at 75 percent of the allowable for each additional PC procedure and 50 percent of the allowable for each additional TC procedure when performed during the same session on the same day. Refer to: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads//MM7442.pdf

MPPR for therapy codes: o For dates of service on or after January 1, 2011, Medicare is applying a new MPPR to the Practice Expense (PE) component of payment of select therapy services paid under the MPFS. o The reduction is similar to that applied to multiple surgical procedures and to diagnostic imaging procedures. o The MPPR PE reduction applies when more than one unit or procedure is provided to the same patient on the same day (i.e., the MPPR applies to multiple units as well as multiple procedures). o Full payment is made for the unit or procedure with the highest PE payment.

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For subsequent units or procedures furnished to the same patient on the same day, full payment is made for work and malpractice, 80 percent payment for the PE for services furnished in office settings, and 75 percent payment for the PE services furnished in institutional settings. For therapy services furnished by a group practice or incident to a physician's service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physician therapy, occupational therapy or speech-language pathology. Regardless of the type of provider that furnishes the service, the reduction applies to the HCPCS codes contained on the list of "always therapy" services that are paid under the MPFS.

Refer to: http://www.cms.gov/Transmittals/downloads/R826OTN.pdf http://www.cms.gov/MLNMattersArticles/downloads/MM7050.pdf http://www.trailblazerhealth.com/Publications/Training Manual/Physical Therapy.pdf http://www.trailblazerhealth.com/Education/CBTs/Default.aspx

The following services have separate fee schedules: o Ambulance. http://www.trailblazerhealth.com/Payment/Fee Schedules/Ambulance.aspx o Anesthesia Conversion Factors. http://www.trailblazerhealth.com/Payment/Fee Schedules/Anesthesia.aspx o Ambulatory Surgery Center (ASC). http://www.trailblazerhealth.com/Payment/Fee Schedules/ASCFeeSchedules.aspx o Clinical Lab. http://www.trailblazerhealth.com/Tools/Fee Schedule/ClinicalLabFeeSchedule.aspx o Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS). http://www.trailblazerhealth.com/Payment/Fee Schedules/DMEPOS.aspx o Drugs (ASP/NOC). http://www.trailblazerhealth.com/Tools/Fee Schedule/DrugFeeSchedule.aspx o End Stage Renal Disease (ESRD) Separately Billable Drugs. http://www.trailblazerhealth.com/Tools/Fee Schedule/ESRDFeeSchedule.aspx o Image-Guided Robotic Linear Accelerator-Based Stereotactic Radiosurgery. http://www.trailblazerhealth.com/Payment/Fee%20Schedules/Robotic.aspx o Proton Therapy. http://www.trailblazerhealth.com/Fee Schedules/ProtonTherapy.aspx o Radiopharmaceuticals. http://www.trailblazerhealth.com/Payment/Fee Schedules/Radiopharmaceutical.aspx

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To request a printed copy or an electronic version of the MPFS: Fax your request to Medicare at (469) 372-3554. Please include the physician's provider number and either a mailing address or an email address and a telephone number. The Medicare Physician Fee Schedule Database (MPFSDB) The Medicare Physician Fee Schedule Database (MPFSDB) is a document used to determine correct billing information on all CPT codes for successful claims processing. Data Found in the MPFSDB The data contained in the document addresses aspects of billing such as: Global surgery periods. Percentages allotted for preoperative, intraoperative and postoperative services. Procedure code status. Bilateral services. Multiple surgery. Cosurgery. Team surgery. Assistant surgery. Base endoscopy codes. Physician supervision of diagnostic tests. Procedures subject to multiple procedure reduction on the Technical Component (TC) of certain diagnostic imaging procedures Procedures subject to the Outpatient Prospective Payment System (OPPS) cap. Obtaining an MPFSDB The MPFSDB is available on both the CMS and TrailBlazer Web sites: CMS: https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Relative-Value-Files.html Note: The MPFSDB is also referred to as the National Relative Value File on the CMS Web site. TrailBlazer: http://www.trailblazerhealth.com/Payment/Fee Schedules. To use the search function, enter the year, state, locality and procedure code and/or any modifier that would apply. This will give the fee allowables for the procedure code in question and the same information that can be found on the MPFSDB. There will also be a "?" prompt box beside the different columns of information. To get the definition of a particular indicator, click "?" and a detailed description of that indicator will appear.

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