ED Coding and Reimbursement Alert

fee schedule that determines how and what to pay for services provided to Medicare patients.” You’ll find payment amounts in the database that will help you calculate the beneficiary’s coinsurance amount (when applicable) as well, she said. In most cases, the patient’s responsibility will be 20 percent of the fee. You can also find payment amounts for situations such as when you use certain modifiers or if a provider other than a physician is providing the service, she said.

The second reason to use the database is to determine whether any specific payment policies impact the payment for a particular code, such as whether multiple procedures performed at one session would prompt a payment reduction in the subsequent services.

Fact 4: Geography Changes Payment Amounts

To pinpoint the exact amount you’ll receive from your MAC, you’ll have to input your region into the database, since the geographic practice expense is based on your location, said NGS’ Carleen Parker during the call. Therefore, select your locality and area in your MAC’s database to get a handle on your specific payment amounts.

Fact 5: You’ll Differentiate Facility from Non-Facility Amounts

Once you look up a code or code range in the database and you choose either your specific MAC or national payment amount, those codes will come up along with such information as the descriptor, the facility and non-facility payment amounts, and the pay adjustments for any modifiers that might apply. Higher payments make sense for non-facility payments because, in facilities, the hospital pays for much of the overhead costs, Obergfell said. In the office setting, the practice owners incur those costs, which results in higher Medicare payments to them.

Fact 6: Non-Participating Providers Can Benefit from the Database

You’ll find information on limiting charges in the database, which apply to healthcare professionals not participating in the Medicare program, Obergfell said. “A nonpar provider usually does not accept assignment on claims and their payment amounts are subject to a limiting charge, which equals 115 percent of the nonpar fee schedule amount, which is the maximum amount a nonpar provider can charge a beneficiary on a nonassigned claim.”

Fact 7: You Can Break Down Global Fees, Or Modifier- Appended Amounts

If you bill both the technical and professional components of a particular code (when applicable), you’ll see the global fee in the database, but it will also reveal what you’d collect if you only reported the code with modifier 26 (Professional component) appended or if you’re only reporting the technical component using modifier TC (Technical component), she said.

Fact 8: Bilateral, Supervision Data Will be Clear

The database goes beyond showing you payment amounts — you can also use it to search for payment policy indicators, which can show you the professional and technical modifiers, the postoperative days, whether Medicare pays for a particular code, level of physician supervision required, and whether services can be billed bilaterally, Obergfell said.