Medicare Physician Fee Schedule (MPFSDB) - Articles

Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
July 12th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?

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So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?
August 21st, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from?  It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems.  One of the ...
Medicare Conversion Factor
February 8th, 2017 - Wyn Staheli
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
Know how you can leverage your practice performance with 6 revenue cycle metrics
December 20th, 2016 - Ango Mark
Are you one of those busy physicians who pay just a cursory glance at monthly collections? Then you should be prepared to lose revenue every single day like this obgyn practice in southeast Georgia. It is essential for medical practices to track financial performance metrics, as every dollar that...
November 25th, 2016 - M. Ann Bachman, BSMT (ASCP), CLC (AMT), CMPM
The Clinical Laboratory Fee Schedule (CLFS) final rule, "Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System" (CMS-16F) implements PAMA, the Protecting Access to Medicare Act of 2014. The purpose of this rule is to more closely align CLFS payments under Medicare with payments made by private payers. CMS perceives ...
MACRA facts that every clinician should know [Infographic]
November 11th, 2016 - Adam Smith
MACRA is here and the new program is going to sunset several (un) popular programs such as Meaningful Use and the Value Based Payment Modifier model. Everybody who is anybody is busy discussing about MACRA and its ramifications. But as with any big updates the myths are jostling for space with the...
Modifiers in Postoperative Periods
December 29th, 2015 - Allison Singer, CPC
Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of...
Don’t expect beneficiaries to pick up the slack for PQRS, EHR cuts
December 4th, 2014 - Scott Kraft
2015 is a big year for payment adjustments for providers who’ve failed to take part in CMS incentive programs for electronic health records (EHR) meaningful use, e-prescribing and the Physician Quality Reporting System (PQRS). It’s the year that CMS goes from dangling the carrot...
Claims to be held by CMS for first 10 business days of April
March 28th, 2014 - Scott Kraft
While Congress hashes out whether and how to avert the more than 20 percent pay cut now set to start on April 1, CMS is making its own contingency plans to avoid paying out a lot of claims that will need to be re-processed later, if Congress ends up missing the April 1 deadline for action. CMS...
Dreams of permanent pay fix fade as House passes one-year SGR fix; ICD-10 also faces potential delay
March 27th, 2014 - Scott Kraft
Leaders on Capitol Hill spent so much time debating, discussing and even reaching a tentative deal on a permanent repeal to the Sustainable Growth Rate (SGR) formula that has caused so much payment uncertainty for physician practices that people started to think it would actually happen. It looks...
Medicare fee schedule’s big pay cut probably temporary – big PQRS change likely permanent
January 3rd, 2014 - Scott Kraft
CMS released Medicare’s 2014 Final Physician Fee Schedule rule on Thanksgiving Eve, delayed from its usual November 1 release by the government shutdown earlier this fall. Fee schedule followers won’t be surprised to see CMS finalize a 20.1% average cut to payments next year,...
Bevy of changes make figuring out 2014 Medicare payments more complicated
January 3rd, 2014 - Scott Kraft
Some years, it is relatively simple to project how your Medicare payments will change for the services rendered. When the only factor in Medicare’s complicated payment formula that changes is the conversion factor, the percentage change in your payment is identical to the percentage change in...
2014 Billing and Coding Primer for Therapy Services
December 10th, 2013 - Scott Kraft
The release of the 2014 Physician Fee Schedule Final Rule in late November, coupled with the scheduled expiration of certain provisions of the American Taxpayer Relief Act (ATRA) threatens to add a lot of confusion to how you bill for therapy services in 2014. We’re here to help. First, the...
How fees are calculated using RBRVS
March 22nd, 2010 - Codapedia Editor
CPT® codes have three components: Work RVU—this defines the physician work to perform the service. Work RVUs are often used to measure physician productivity. Practice expense RVU—this is a measure of the practice cost to perform the service, including rent, overhead,...
No More Consults? CMSs Proposal for 2010
January 30th, 2010 - Codapedia Editor
July, 2010 By now you've seen the headline! CMS proposes to eliminate payment for consults in 2010! Why? How will they pay for the services? First, the AMA develops and owns CPT® codes, and only they can add, delete, or change the definition of CPT® codes. However, Medicare and private...
Fee Schedule 2010 Impact by Specialty
January 30th, 2010 - Codapedia Editor
Elizabeth Woodcock prepared this Excel summary from the Physician Fee Schedule Final Rule, released Friday, October 30, 2009. She graciously shared the file with me, and invited me to post it here. It is in resources. You can access the Final Rule for yourself...
Medicare Physician Fee Schedule Data Base
December 23rd, 2009 - Betsy Nicoletti
The Medicare Physician Fee Schedule Data Base is published annually by Medicare, and posted on their web site. It is the source of Relative Value Units, but provides much more important billing information, aw well. It can be difficult to use in its Excel format. Many commercial vendors...
Assistant surgeon
July 19th, 2009 - Codapedia Editor
Some surgical procedures may be performed with both a primary surgeon and an assistant surgeon. Insurance companies typically pay 20% to 25% for the assistant. Medicare allows 16% of the full fee payment for the assistant surgeon.
Supervision Requirements for Diagnostic Tests
July 17th, 2009 - Codapedia Editor
Medicare has specific physician supervision requirements for diagnostic tests. Each CPT® code that represents a diagnostic test is given a supervision indicator in the Medicare Fee Schedule. From Chapter 15, of the Medicare Benefit Policy Manual describes these levels of supervision: General...
Facility versus non-facility in the Physician Fee Schedule
March 26th, 2009 - Codapedia Editor
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...
Two surgeons operating on the same patient, same session
March 18th, 2009 - Codapedia Editor
Most surgeries with two surgeons are reported and performed as the primary surgeon (no modifier on the CPT® code) and the assistant surgeon (modifiers 80, 81, 82, and AS). Some surgeries, however, require two surgeons (modifier 62) or a surgical team (modifier 66). How does a physician or...
Budget Neutrality Adjustment (BNA) in the Medicare Fee Schedule
March 3rd, 2009 - Codapedia Editor
In 2009, Medicare changed its payment calculation in the Physician Fee Schedule. It moved the Budget Neutrality Factor from the Work RVU to the Conversion Factor. In 2008, Medicare applied the budget neutrality factor to the Work RVU In 2009, Medicare applied a budget neutrality factor to the...

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