Services Paid Under the Medicare Physician’s Fee Schedule

30 - Services Paid Under the Medicare Physician’s Fee Schedule (Rev. 1717, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09) Following is a general description of services paid under the Medicare Physicians’ Fee Schedule (MPFS). A. Physician’s Services Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians’ services based on the MPFS. The Medicare allowed charge for such physicians’ services is the lower of the actual charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after the deductible is met for most services paid based on the fee schedule. Exceptions to the rule, e.g., services for which deductible is not applicable, are specifically identified for the service where the exception applies. The Physicians Fee Schedule is used when paying for the following physicians’ services. • Professional services (including attending physicians’ services furnished in teaching settings) of doctors of medicine and osteopathy (including osteopathic practitioners), doctors of optometry, doctors of podiatry, doctors of dental surgery and dental medicine, and chiropractors; • Services covered incident to physicians’ services other than certain drugs covered as incident to services; • Physical and occupational therapy, and speech-language pathology services furnished by physical therapists, occupational therapists, and speech-language pathologists in private practices; • Diagnostic tests other than clinical laboratory tests. See chapter 16 for payment for clinical diagnostic laboratory tests; • Radiology services; and • Monthly capitation payment (MCP) for physicians’ services associated with the continuing medical management of end stage renal disease (ESRD) services. The fee schedule is not used to pay for direct medical and surgical services of teaching physicians in hospitals that have elected cost payment under §1861(b)(7) of the Act. When processing a claim, A/B MACs (B) continue to determine if a service is reasonable and necessary to treat illness or injury. If a service is not reasonable and necessary to treat illness or injury for any reason (including lack of safety and efficacy because it is an experimental procedure, etc.), A/B MACs (B) consider the service noncovered notwithstanding the presence of a payment amount for the service in the Medicare fee schedule. The presence of a payment amount in the MPFS and the Medicare physician fee schedule database (MPFSDB) does not imply that CMS has determined that the service may be covered by Medicare. The nature of the status indicator in the database does not control coverage except where the status is N for noncovered. A/B MACs (B) pay the above-mentioned physician services according to the physician fee schedule when billed by the following entities: • A physician or physician group including optometrists, dentists, oral and maxillofacial surgeons, podiatrists, and chiropractors; • A privately practicing physical therapist, (for outpatient physical therapy services); • A privately practicing speech-language pathologist (for outpatient speech-language services); • A privately practicing occupational therapist (for outpatient occupational therapy services); • A nonphysician practitioner including a nurse practitioner, a physician assistant, and a clinical nurse specialist beginning January 1, 1998, with respect to services these practitioners are authorized to furnish under state law: payment is equal to 85 percent of the participating physician fee schedule amount for the same service; • A nurse midwife: payment is equal to 65 percent of the participating physician fee schedule amount for the same service; • A registered dietitian or nutrition professional, for medical nutrition therapy services provided as of January 1, 2002: payment is equal to 85 percent of the participating physician fee schedule amount for the same service; • An audiologist, for services rendered to beneficiaries not in a skilled nursing facility (SNF) Part A covered stay; • A clinical psychologist who renders services in community mental health centers (CMHCs) on or after July 1, 1988, and in all settings on or after July 1, 1990; • A clinical social worker: The fee schedule for CSW services is set at 75 percent of the fee schedule for comparable services furnished by clinical psychologists; • Another entity that furnishes outpatient physical therapy, occupational therapy, and speech- language pathology services. This could be a rehabilitation agency, a public health agency, a clinic, a skilled nursing facility, a home health agency (for beneficiaries who are not eligible for home health benefits because they are not home bound beneficiaries entitled to home health benefits), hospitals (when such services are provided to an outpatient or to a hospital inpatient who is entitled to benefits under Part A but who has exhausted benefits during a spell of illness, or who is not entitled to Part A benefits) and comprehensive outpatient rehabilitation facilities (CORFs). The fee schedule also applies to outpatient rehabilitation services furnished under an arrangement with any of the enumerated entities that are to be paid on the basis of the physician fee schedule; • The supplier of the technical component of any radiology or diagnostic service; • An independent laboratory doing anatomic pathology services; and • Services billed by entities authorized to bill for physicians, suppliers, etc. under the reassignment rules. B. Hospice Services The Physicians Fee Schedule is used when paying for hospice physician’s services by the A/B MAC (HHH). Regular hospice services are paid under the hospice rate schedule (see chapter 11.) C. Outpatient Rehabilitation Services Effective with services furnished on or after January 1, 1999, A/B MACs (A) pay for outpatient rehabilitation services based on the MPFS. Services included are physical therapy, speech-language pathology, occupational therapy, and certain audiology and CORF services. Effective with services furnished on or after July 1, 2000, A/B MACs (A) pay for all CORF services under the MPFS. Effective with claims with dates of service on or after July 1, 2003, OPTs/Outpatient Rehabilitation Facilities (ORFs), (74X bill type) are required to report all their services utilizing HCPCS. A/B MACs (A) are required to make payment for these services under the MPFS unless the item or service is currently being paid under the orthotic fee schedule or the item is a drug, biological, supply or vaccine. The MPFS applies when these services are furnished by rehabilitation agencies, (outpatient physical therapy providers and CORFs), hospitals (to outpatients and inpatients who are not in a covered Part A stay), SNFs (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF), and HHAs (to individuals who are not homebound or otherwise are not receiving services under a home health plan of treatment). The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers. The MPFS allowed charge for these services is the lower of the actual charge or the fee schedule amount. The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met. This is a final payment. The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs). CAHs are paid on a reasonable cost basis. Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A)) In accordance with §1833 of the Act, payment is made at 62½ percent of the approved amount for outpatient mental health treatment services. This provision will continue to be implemented in accordance with the Act when these services are furnished to beneficiaries by CORFs. Therefore, make payment at 62½ percent of 80 percent of the approved amount (or in effect 50 percent) for outpatient mental health treatment services. D. SNF Services Effective with services furnished on or after April 1, 2001, A/B MACs (A) pay for Part B services furnished to SNF Part B inpatients and outpatients (22X and 23X types of bill) under the MPFS and other applicable fee schedules. Thus, where a fee schedule exists for the type of service, the fee amount (or charge if less than the applicable fee amount) is paid. Fee schedules made effective for SNF on this date include: Therapy, Lab, and DMEPOS. Effective for services furnished by a SNF on and after January 1, 2002, A/B MACs (A) pay SNFs for radiology, other diagnostic, and other services under the MPFS. Payment is the lower of billed charges or the fee schedule amount. In either case, any applicable deductible and coinsurance amounts are subtracted from the payment amount prior to payment. Coinsurance is calculated on the Medicare payment amount after the subtraction of any applicable deductible amount. If there is no fee schedule for the service or item being billed, A/B MACs (A) and (HHH) are to make payment based on cost. Consequently, all services billed under Part B are to be billed using HCPCS codes, whether the beneficiary resides in a certified bed or a noncertified bed.