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Medicare Fee Schedule

Amani Posted Tue 10th of September, 2013 20:33:54 PM

Do You know why Medicare will list a procedure on the fee schedule with zero amount. for example:

A6217 $0.00 Non-sterile gauze>16<=48 sq

Thank you,

SuperCoder Answered Tue 10th of September, 2013 21:41:13 PM

There may be different reasons why Medicare lists a code with $0 amount, but the answer can often be found in the code's status. For instance, for A6217, the status is P (definition is below). Basically, a supply like this is expected to be used for certain services/procedures, so Medicare doesn't pay for those codes separately under the MPFS. The payment is bundled into the service/procedure that required the supply.

The exact definition is:
P = Bundled/Excluded Codes. There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. --If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) --If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the Act.

Amani Posted Thu 12th of September, 2013 10:45:28 AM

Thank you

Where I can find the code's status and it is own deffintion?

Amani Posted Thu 12th of September, 2013 11:12:02 AM

This is for DME provider.

SuperCoder Answered Fri 13th of September, 2013 08:13:43 AM

The above answer used the Medicare Physician Fee Schedule status. The DMEPOS Fee Schedule also gives the code $0. It’s category is SD, which means surgical dressing. Fee schedule information is included on a code’s page for certain SuperCoder subscriptions. Or you can download the 2013 Excel sheet from CMS at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html

Amani Posted Sat 14th of September, 2013 12:51:03 PM

my question is why Medicare list a procedure on the Fee schedule with zero amount? The reason I am asking, we have a language of our contracts in the case of a procedure not listed on Medicare fee schedule, we should pay 70% of billed charges. Other procedure listed should be paid 65% of Medicare. My argument at work, since the procedure is listed with zero amount, 65% of zero is zero. instead we are paying 70% of billed. I am not sure how can I present my case that we should not pay any amount and we should not follow the language of 70% of billed since the procedure is listed with zero amount. Please help. Thanks

SuperCoder Answered Mon 16th of September, 2013 20:49:38 PM

Hi,

I have asked this from my senior editor. Please be patient. We will answer this soon.

Thanks

SuperCoder Answered Mon 16th of September, 2013 20:49:38 PM
I have asked the opinion from Leigh.
SuperCoder Answered Wed 18th of September, 2013 03:09:25 AM

Medicare does not pay for all procedure codes. A user needs to check the "code status". There could be various reasons why a code is not paid under Medicare. Sometimes a code is bundled, or a code's payment is decided by local payers etc.
The MPFS file published by CMS enlists the code status of every code which directs whether a code wouyld be paid by Medicare or not.

In this case, the code's status indicator is, as per CMS official guidelines:

P = Bundled/Excluded Codes. There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule. --If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.) --If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the Act.

This could be your point of argument. But again, please note that a contract between provider and payer holds the key of payment. In case your contract suggests to pay "in the case of a procedure not listed on Medicare fee schedule, we should pay 70% of billed charges. Other procedure listed should be paid 65% of Medicare" -- you need to follow the same.

Also, under DMEPOS fee schedule, this code's "Jurisdiction" is "J" that means "Local Carrier Jurisdiction". So it's clear that Medicare will not decide a price for this code and setting up payment for this code is individual payer's discretion.

For next financial year, the payer can review and change the contract with the provider as per requirement and bring in few more clauses.

SuperCoder Answered Wed 18th of September, 2013 03:09:25 AM

Answered in AAE live

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