Filling Gaps in A/B MAC (B) Reasonable Charge Screens

80.5 - Filling Gaps in A/B MAC (B) Reasonable Charge Screens (Rev. 1, 10-01-03) B3-5022, AB-02-136, B-02-089 Where there is insufficient actual charge data for determining the customary charge and/or the prevailing charge in the locality for a particular medical procedure or service, A/B MACs (B)/DME MACs must use one of the following gap-filling methods to establish the needed screen. A. Gaps in Customary Charge Screens A/B MACs (B)/DME MACs fill a gap in a customary charge screen: 1. By applying a conversion factor derived from the physician’s (or supplier’s) known customary charges for other services in the same category of service (medicine, surgery, etc.) to a relative value scale in the manner suggested in §§80.3, or 2. By using the 50th percentile in the array of customary charges (weighted by frequency) that was used to establish the prevailing charges for similar services for the physicians in the same specialty and locality. A/B MACs (B)/DME MACs must ensure that, where a 50th percentile charge is used as a customary charge for payment purposes, the reasonable charge does not exceed either that amount or the locality prevailing charge. Also, all A/B MACs (B)/DME MACs that use 50th percentile charges to fill gaps in their customary charge data must retain the capacity to calculate and use conversion factors with relative value scales when this is appropriate. B. Gaps in Prevailing Charge Screens Where the A/B MAC (B) has not been able to establish a prevailing charge for a service based on the prevailing charge screen procedures, then A/B MACs (B) must gap-fill the payment amounts using a prevailing charge conversion factor (§80.5.1) and a relative value scale, manually if necessary. (See §80.3 regarding charges for rare or unusual procedures. This is to be used as a last resort.