Friday, August 08, 2014

So, how do we find out what will we be paid for that service from Medicare?

Often times a healthcare administrator will be questioned, or be the one questioning:

 What will we get paid from Medicare if we start doing a certain procedure/ provide a particular service?

Sometimes we know what our business model is focused on, but do we really know how to build a solid proforma to direct the efforts of our staff and financial resources to be successful in targeting what will truly benefit our facility?

There are so many acronyms such as RBRVS, PPS, IPPS, CPT, IRF PPS, GPCI, HOPPS, IPF PPS, ASC, MS-DRG, SNF PPS, HCPCS, and DRG just to name a few. But there is one acronym that can be very helpful from CMS. Oh, another acronym! The Centers for Medicare and Medicaid Services (CMS) is a repository of information that can help just about any practice, group practice, Ambulatory Surgical Center (ASC), or other healthcare organization to breakdown the reimbursement for any service or procedure to help identify the appropriate reimbursement from CMS.

This tool is called the Searchable Medicare Physician Fee Schedule (MPFS)

It has over 10,000 services listed and each is broken down by all elements of reimbursement including pricing, payment policies, and Resource Based Relative Value Scale. This tool allows healthcare professionals to find out the Medicare payment for any code that is part of the MPFS database. It will identify the payment for those providers that are a “Participating Provider” under CMS. Moreover, it will identify for those providers that are “Nonparticipating” what the limiting charge is for a particular code. This will put a ceiling on the charge for a code that the provider cannot exceed when billing Medicare and this will also limit the out-of-pocket expense for a beneficiary. 

Overall, the MPFS is an excellent tool to see if Healthcare Common Procedure Coding System (HCPCS) codes are affected by the place in which the services are performed and if there are any modifiers that are available.

The payment procedure is that there are many codes available for reimbursement. CMS will reimburse 80% of the allowed charges for an approved code and the patient will be responsible for the remaining 20% (plus any annual deductible that may be due). There are reductions that are identified in the MPFS that include a 16% reduction of the MPFS rate for an assistant surgeon. There are other reductions such as nurse practitioners (NP), physician assistants (PA), and clinical nurse specialists are paid 85% of the allowed rate and clinical social workers are paid 75% of the allowed rate from Medicare.

The MPFS will take the user through several steps to identify the appropriate codes, locality, and reimbursement. To start the search you click on the “Physician Fee Schedule Search” or the “Start Search” button. You will need to accept the terms and conditions of using the Current Procedural Terminology, Fourth Edition (CPT©).
Then you will need to select:
  • ·             The year
  • ·             The type of Information that you are looking to search
  • ·             The pricing information
  • ·             Payment policy indicators
  • ·             RVU
  • ·             Geographic Practice Cost Index (GPCI)
  • ·             Specific Locality (each area has a unique locality code, like Metropolitan Philadelphia Pennsylvania is 12502)
  • ·        All Carriers or specific MACs

·    Then you can enter the HCPCS code that you are looking for and if you want specific modifiers or “All”  
·        Click Submit

The MPFS tool will help the healthcare administrator and their staff to better forecast revenues based on actual reimbursement. Moreover, having the ability to find out all payment rules and requirements will allow for a successful and compliant billing process for the new or existing service that your facility provides.
To locate the searchable Medicare Physician Fee Schedule you can go to

-Kevin Harrington, MSHA, RHIA, CHP

Monday, August 04, 2014

$100 Prize

Saint Joseph's College gave a $100 gift card as a prize to an attendee at the ASRT conference in Orlando this year.  Meredith Gammons was the winner!