The Medicare Physician Fee Schedule has values for some CPT® codes that include both a facility and a non-facility fee. The facility fee is typically lower.
When CMS develops the fee schedule, each code has three components: work Relative Value Unit (RVU), practice expense RVU and malpractice expense RVU. When a service is performed in a facility (that is, hospital, ASC, nursing home, etc) the practice expense RVU is lower. This is because the practice does not have the expense for the overhead, staff, equipment and supplies used to perform that service.
The non-facility rate is the payment rate for services performed in the office. This rate is higher because the physician practice does have the overhead expense for performing that service.
When you submit a claim submit your usual fee. The carrier or MAC processes your claim based on the place of service you select. Be careful to select the correct place of service.
Some codes may only be performed in one place or the other: for example, an initial hospital visit has only a facility fee, because it is never performed anywhere but a facility. Office visits, on the other hand, may be done in the office (non-facility) or in the outpatient department (facility.)
###
Questions, comments?
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.
The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI).
The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms.
ICD-10-CM Official Coding Guidelines - ...
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
Risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology based on the diagnoses of the individuals in that population. As payers move to value based models, they heavily rely on risk adjustment to ensure proper funding.
All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.
With all the new laboratory test codes that have been added due to the current public health emergency (PHE), there are a few additional guidelines CMS has released about collecting samples to perform the testing. Please keep in mind that these guidelines are by CMS and may or may not apply to other commercial payer policies.
