Wiki Medicare Allowable

[alexandasia]

I posted this in the local chapter but didn't get any help so I am hoping that a bigger forum might have some insight...

This might sound like a crazy question but I will explain why I have it. I have billed for two companies. One was a large corporation that loaded the fee schedules for everyone, so if a claim under or over paid it was really easy to tell. The other company I worked for didn't have a fee schedule and seldomly cared if something paid incorrectly... I now am billing for a couple of my own doctors and what I thought I knew about the Medicare allowable I may be misunderstanding.

On the PDF that Medicare has on their website for the 2010 allowables it has two allowables for many codes. One of those allowables is for facility. When do we go off that allowable? I thought I was once told that is for a doctor doing a procedure at like his office or something similar. But I have an out patient hospital procedure done and Medicare used the facility allowable, not the other one. There is a big difference in the reimbursement.

If it should have been the other allowable is there certain documentation that Medicare will be looking for to show it isn't the facility allowable?

Thanks for your input, hopefully I don't sound too crazy asking this

 

[mitchellde]

The facility allowable is for procedures performed in the facility setting as opposed to the office setting. The amount is different due to the cost to the physician is different in his office he is out the overhead for his services and at the facility the overhead is the facility's cost.

 

[alexandasia]

Thank you!!