Pulmonology Coding Alert

Question: Is it true that a non-participating Medicare provider can round the limiting charge up or down to the nearest dollar when billing? My understanding is that as long as we round all of our charges the same way, it is acceptable.

Chicago 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.

The Social Security Act Amendments of 1994 (SSAA 94) extended the limiting charge provision. The statute prohibits non-participating providers/supplies 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 or after Jan. 1, 1994, all individuals or 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 non-participating provider is one that has opted not to participate with Medicare. A non-participating 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 non-participating physicians are given the opportunity to change their participation status each year during the open enrollment period, which usually starts in mid-November and runs through Dec. 31. During this period all physicians and suppliers are sent information on the reimbursement, charge limits and regulation changes for the upcoming year.

Non-participating 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.