Gastroenterology Coding Alert

Question: When I'm looking at the Medicare Physician Fee Schedule (MPFS) to figure out the payment we'll get for our claims, I don't understand what columns to look at. Can you explain what the following column headings mean: non-facility price, facility price, nonfacility limiting charge, and facility limiting charge?

Maryland Subscriber

Answer: The difference between facility and nonfacility fees is based on where your physician performs services. Medicare will pay you the facility fee whenever your general surgeon does not pay fair market rent for the space, such as in a hospital, ambulatory surgery center, or nursing home. The non-facility fee applies when your surgeon assumes the cost of the space and the personnel at fair market pricing, as in the office.

The limiting charge is the maximum amount a physician or practice can charge for a physician's services when the physician does not accept the restrictions on fees established by Medicare laws.

How it works: The Medicare limiting charge is 115 percent of the payment amount for the service furnished by the non-Medicare-participating physician. However, the law sets the payment amount for nonparticipating physicians at 95 percent of the payment amount for participating physicians, which is reflected in the amount listed in the fee schedule.

Use this crib sheet:

• Non-facility price -- Fee for service done in your office by participating physician

• Facility price -- Fee for service done in a facility by participating physician

• Non-facility limiting charge -- Fee for service done in your office by non-participating physician

• Facility limiting charge -- Fee for service done in a facility by non-participating physician.