Coding and Billing

Medicare Physician Fee Schedule Lookup: Know the Codes to Make Revenues Flow

By Mark Wright, OD, FCOVD,
and Carole Burns, OD, FCOVD


Dec. 6, 2017

Medicare provides a great resource that helps you to examine your fees, as well as know exactly what Medicare is going to pay. This resource is called the Medicare Physician Fee Schedule Look-up. To use the Medicare physician fee schedule, start at the following web address: https://www.cms.gov/apps/physician-fee-schedule/license-agreement.aspx. Before you can get to the fee schedule look-up tool, you must first agree to the CPT License for use. When you click on ACCEPT at the bottom of the web page, you are taken to the Physician Fee Schedule Search.

To get the most out of this tool, go through the following steps:
1) Select the year.
2) Select the Type of Information (e.g.: Pricing Information).
3) Select whether you want to see a single code, a list, or a range of codes.
4) Select the MAC for your region.

Let’s do an example together to see how the process works. Here are the selections that were made for this example:

 

After clicking SUBMIT, this is what appears:

The arrow was added by us to show the column containing the fees for an out-patient visit for each of the established patient 99000 E/M codes in a practice represented by the selection criteria used in this example.

Choosing the codes you want is important, but equally important is choosing MAC LOCALITY. Different localities have different fees. Choosing the correct MAC LOCALITY to represent where your practice exists enables you to know what your fees are.

Once you do this exercise, there are questions you should ask about your own practice.
1) How close to these fees are your fees?
2) If your fees are different, why?
3) Realizing the Medicare fees are discounted fees, are your fees higher? Can you explain why?
4) With inflation in mind, what are your fees going to be for next year?

This example was for Medicare. You should repeat this exercise with every third party for which you are a provider.

The next thing to do with this information is to create an Excel spreadsheet for all the codes you use with patients in your practice. You know that once a patient meets their deductible, Medicare will pay you 80 percent of the non-facility fee, and you are expected to collect a 20 percent co-pay from the patient. Setting up this spreadsheet makes this process easy for staff to know exactly what to collect from the patient based on the codes you use.

Here is an example of that spreadsheet for the code 99214. Staff should collect today $20.91 from the patient, and you know that Medicare is going to pay $83.62.

The beauty of the Medicare Physician Fee Schedule Look-up tool is that it can be used to identify exactly what you will be paid, and what you need to collect, for every procedure code with every patient.

As for MACRA and MIPS, and how they impact fees, well, that’s a discussion for another day.

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