Increase Reimbursement and Coding Accuracy Using This MPFS Primer

Are you making the most of the Medicare Physician Fee Schedule? It offers so much more than lists of dollars and cents. The information the MPFS provides is indispensable to ensure accuracy and to bring in every dollar you’ve earned. Here’s a look at what the MPFS is and some of the top fields that deserve your focus.

Increase Reimbursement and Coding Accuracy Using This MPFS Primer

Meet the MPFS

You may hear the Medicare Physician Fee Schedule referred to as the MPFS, PFS, or even Medicare Part B Fee Schedule. You’ll find payment information for thousands of services in the MPFS. It is a fee schedule for CPT® codes and a fee schedule for HCPCS codes, but not all codes from those code sets are included or priced. CMS updates the MPFS quarterly, so it’s important to have the version that applies to your date of service.

 Medicare uses the fee schedule to determine payment for professional services (such as those provided by a physician in private practice), incident to services, diagnostic tests (except clinical lab), and radiology services. Mammography centers and even a small number of institutional services are paid under MPFS, too.

The fees reflected in the MPFS are based off a calculation. You start with the relative value units (RVUs) assigned to the code for work, practice expense, and malpractice insurance, and then adjust the RVUs based on Geographic Price Cost Indices (GPCIs). In other words, Medicare sets national levels for the code and then provides the GPCI to adjust the fee based on geographic location. You then multiply your adjusted RVUs by the conversion factor, which typically changes at the start of the year. For example, the Medicare Physician Fee Schedule 2017 conversion factor is 35.8887.

What other information can you get from the MPFS? Here’s a selection of just some of the important areas covered in this valuable resource.

Stop and Confirm Status

The MPFS shows a status indicator for each code, offering a quick idea about where your code and the related service stand. For instance, status A means the code is an active code that Medicare will pay under the MPFS if the service is covered.

Some of the other possibilities you may see include status B (bundled code), C (carrier/MAC priced), E (excluded from MPFS by regulation), I (not valid for Medicare purposes), and N (non-covered service). There are others, so be sure to check the definition of your code’s status before you report. That way you’ll know what to expect for your code.

Watch PC/TC for Modifier Rules (But Beware Mod PC)

The PC/TC concept is an important one to master and relates to certain codes having a professional component (PC) and/or a technical component (TC) on the MPFS. For a simplified explanation, think of an X-ray. A tech sees the patient in a facility and takes the X-ray using the facility’s equipment. This is the technical component. Then a radiologist interprets the X-ray and provides a report. This is the professional component.

If you’re reporting only the technical component, appending modifier TC (Technical component) indicates that. If you’re reporting only the professional component, append modifier 26 (Professional component).

Warning: Do not append modifier PC (Wrong surgery or other invasive procedure on patient) when you want to show the professional component!

Use of modifier 26 or TC affects payment because the payer will reimburse you for only the component you provided. Which codes have a professional/technical component split isn’t always obvious, so be sure to check each code before you report it. If you report a code with a PC/TC split without 26 or TC appended, also called the global code, you’ll receive payment for both components.

Don’t Take Global Days at Face Value

Medicare currently applies a global period concept to surgical procedures, bundling in payment for E/M visits that are typical for the procedure over a certain number of days. The global surgery indicator tells you the timeframe that applies, but you need to read the indicator definitions to understand the days included. For instance, assuming 000 means there are zero days included in the global period is understandable. But it’s wrong. Period 000 means E/M services on the day of the procedure generally aren’t payable because they’re included in the RVUs for the surgery 

Bring In Bilateral Payment

The MPFS prices some codes based on the resources and work required to complete the work on one side of the body. The bilateral surgery indicator tells you whether reporting the service for both sides, such as by appending modifier 50 (Bilateral procedure), is appropriate and will bring in additional reimbursement.

For example, indicator 1 means Medicare applies a 150 percent payment adjustment when you append modifier 50 to the code, while indicator 2 means RVUs are already based on the procedure being bilateral, so appending modifier 50 won’t increase your payment.

Take Advantage of Fee Schedule Lookup Options

Before online coding tools became commonplace, finding up-to-date fee schedule data could be a major chore. Now we have the convenience of online fee schedule lookup. The national CMS website has one, and you can find ones for specific MACs, as well. Commercial online medical coding solutions also offer fee schedule lookup options integrated with their packages, so you can have information about fees and all the other accuracy-enhancing data the fee schedule provides right at your fingertips.

Categories: Health & Fitness