Neurology & Pain Management Coding Alert

Question: Is it true that a nonparticipating Medicare provider may round the limiting charge up or down to the nearest dollar when billing? My understanding is that so long as you round all of your charges the same way, it is acceptable.

Illinois Subscriber

Answer: The section of the Medicare Carriers Manual containing language about rounding charges has been deleted and it is no longer acceptable to round the limiting charge.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, says that Medicares policy, from the Medicare Part B billing manual for Alabama, Arizona, Colorado, Hawaii, Nevada, North Dakota, Oregon, South Dakota, Washington, and Wyoming, is as follows:

The Social Security Act Amendments of 1994 (SSAA 94) extended the limiting charge provision. The statute prohibits nonparticipating providers/suppliers, who do not accept assignment, from billing or collecting amounts above the applicable limiting charge, regardless of whether Medicare is primary or secondary. Effective for services on/after Jan. 1, 1994, all individuals/entities who bill for services paid under the physician fee schedule are now subject to the limiting charge. Charge limits are enforced to protect a patients out-of-pocket expense on services where assignment is not taken. These limiting charge amounts are updated annually.

A nonparticipating provider is a provider that has opted not to participate with Medicare. A nonparticipating physician can choose to accept assignment on some, none, or all of their Medicare claims, whereas participating physicians must accept assignment on all Medicare claims. All nonparticipating physicians are given the opportunity to change their participation status each year during the open enrollment period, which usually starts in the middle of November and runs through Dec. 31. During this period all physicians/suppliers are sent information on the reimbursement, charge limits and regulation changes for the upcoming year.

Nonparticipating physicians and suppliers submitting non-assignment claims for services payable on the physician fee schedule are limited to the amount they can charge the Medicare program and the patient. This limit is called the charge limit or limiting charge. The limiting charge serves to protect Medicare beneficiaries from undue balance billing expenses.

Physicians/suppliers who continually, knowingly and willfully exceed the limiting charge can be assessed $10,000 for each limiting charge violation and face possible exclusion from the Medicare program.