Tag: fee schedule

How to create a Medicare reference fee schedule (part 4)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 4: Drugs/vaccines fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html.
Select the most recent year from the left hand column.
Then select the most recent month's ASP Pricing File and download it.
In the zip file, choose the ASP Pricing File (eg Oct 18 ASP Pricing File) Excel file.
In the Excel file, the relevant columns are A, B, and D.
Unmerge the cells in this file. Type Ctrl-A to select all the cells, then choose Home > Alignment > Merge and Center > Unmerge Cells. Then move the columns so that the HCPCS Code is in column A, the HCPCS Description is in column C, and the Payment Limit column is in column F.
These cells can be selected, copied, and pasted to the bottom of the Physician Fee Schedule (PFS) file.

 

How to create a Medicare reference fee schedule (part 3)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 3: Durable Medical Equipment fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.
Select a time period. The latest data will have the most recent year and highest letter. In this particular case, since DME18-D (orange arrow) links to no updates, we will select DME18-C (green arrow) in this case.
Download the file (e.g. DME18-C.zip).
In the zip file, open the DMEPOS file (e.g. DMEPOS_JUL.xls)
The relevant columns in this file are the HCPCS code column (column A), the HCPCS code description column (column DJ), and the appropriate state column for your state.
Each state has two columns, nonrural (NR) and rural (R). To determine if you're in a rural or nonrural location, look in the DMERuralZip file (e.g. DMERuralZip_Q32018). If your zip code is listed, then use the rural (R) payments as a guide.
Delete all state columns that are irrelevant for your location.
If you are in a rural area, combine the nonrural and rural fee schedules into a single column. If the rural column shows 0.00 (green arrow), the rural payment for that HCPCS is the same as the nonrural payment. If the rural column shows a nonzero value (orange arrow), the higher rural column payment applies to rural areas.
To simply combine the rural/nonrural fees in this way, you can create a formula to take the maximum of the two columns into a third column.
To propagate the formula down to the bottom of the sheet, select the cell with the formula, Ctrl-C to copy it, click on an empty cell, drag down to the bottom, then type Ctrl-V.
To save the values so you can delete the two source columns, select the resulting column (here column J),
Now you can delete the two source columns.
Copy and paste the columns so that the HCPCS code is in column A, the HCPCS description is in column C, and the payment column is in column F.
Select the three resulting DME columns and copy them.
Paste the data to the bottom of the PFS data.

 

How to create a Medicare reference fee schedule (part 2)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 2: Clinical laboratory fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html.
Select a time period. The latest data will have the most recent year and most recent quarter. For example, Q3 (third quarter) is the most recent here of the 2018 files.
Click to download the file (e.g. 18CLABQ3.)
In the zip file, open the Excel file (e.g. CLFS 2018Q3.)
The file can be used as-is for lab reference pricing, or you can combine it with the Medicare Physician Fee Schedule file into a single reference file. Column B is the HCPCS/CPT code, column G is the description of the HCPCS/CPT code, and column F is the payment rate. Note that INDICATOR is usually either N for National (i.e. the same fee schedule is paid everywhere in the United States) or L for Local (i.e. there are some variations based on geographic location.) All L indicators will have a price of $0.00 in this spreadsheet. You will have to find the local fee for these codes through your geographic MAC, although by and large the L-indicator codes are not used in primary care.
To combine it with the PFS file, rearrange the columns so that the HCPCS column is in column A, the description is in column C, and the payment is in column F. To copy/paste an entire column at once, click on the letter column header, Ctrl-C, click on the target column header letter, then Ctrl-V.
Once the columns are reorganized, copy and paste the result at the bottom of the PFS file.

 

Finding fee schedules and real-time claims estimators for payers

Fee Schedules

Medicare fee schedule: how to create your own

State-run Medicaid fee schedules:  Alabama  – Alaska – Arizona – Arkansas – California – Colorado – Connecticut – Delaware – DC – Florida – Georgia – Hawaii – Idaho – Illinois – Indiana – Iowa – Kansas – Kentucky – Louisiana – Maine – Maryland – Massachusetts – Michigan – Minnesota – Mississippi – Missouri – Montana – Nebraska – Nevada – New Hampshire – New Jersey – New Mexico – New York – North Carolina – North Dakota – Ohio – Oklahoma – Oregon –Pennsylvania – Rhode Island – South Carolina – South Dakota – Texas – Utah – Vermont – Virginia – Washington – West Virginia – Wisconsin – Wyoming

Tennessee has no state-run Medicaid plan.

Also compare KFF’s Medicaid-to-Medicare fee index by state

Real Time Claims Estimators

Real-time claims estimators: Cigna

  • CignaForHCP > Patients
  • Enter patient information.
  • Click Estimate Costs.

Real-time claims estimators: Aetna, Cigna, Humana, local BCBS  plans (BCBS AR, FL, IL, KS, MS, NM, OK, SC, TN, TX and Highmark):

  • Availity > Patient Registration > Eligibility & Benefits Inquiry
  • Select payer from the dropdown.
  • Enter patient information.
  • Click Patient Care Estimator.

Real-time claims estimators: United plans:

  • UHCProvider > Link > United Healthcare Claim Estimator
  • Click Pre-Determination of Benefits > Agree
  • Confirm provider information > Continue
  • Enter patient information.

 

 

 

How to create a Medicare reference fee schedule (part 1)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 1: Physician fee schedule (outpatient and inpatient professional services)

1. Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html.
2. Select a time period.  The latest data will have the most recent year and highest letter: for example, the first fee schedule for any calendar year is "A," with subsequent fee schedules for the same year being marked "B," "C," and so on.
3. Click to download the file (e.g. RVU18D.zip)
4. In the zip file, there are several Excel files. First open the LOCCO Excel file (e.g. 18LOCCO.xls.)
5. Find the carrier code and location code that correspond to your state and city/county region. In this example, let's look for Knoxville, Tennessee. Tennessee has a single carrier/location code pair: 10312 and 35.
6. Next, open the GPCI Excel file (e.g. GPCI2018.xls) in the zip file.
7. In the GPCI file, find your carrier and location code. Then make a note of the three Geographic Practice Cost Indicators for your location: physician work (PW GPCI), practice expense (PE GPCI), and malpractice (MP GPCI). In our example, the indicators for Tennessee’s sole locality are 1.000, 0.901, and 0.526, respectively.
You may close the GPCI file.
8. Now, open the RVU file (e.g. PPRRVU18_OCT.xls.) I recommend that you make a Save As copy, e.g. “My Medicare Fee Schedule 2018 – D.xlsx.”
9. Add two new columns to the file. Hover over the Column F column header, right-click, and choose Insert. A new column will appear. Repeat for a second new column.
10. Label your two new columns Payment (nonfacility) and Payment (facility).
11. Optional: Hide rows that will not be valued on by this fee schedule.   There are over 16,000 rows on this spreadsheet, many of which are zero-valued on this particular spreadsheet (indicating they are priced elsewhere.)   The more useful data may get lost, so you can temporarily filter out the rows you don't think you need. For example, you can hide everything that has a practice expense factor of zero.   To do this, first type Ctrl-A to select all rows.  Then in the Data tab, under Sort & Filter, click Filter.  Click the filtering arrow under the Column I header.  In the dropdown, remove the check box next to 0.00, then click OK.  You can always remove this filter later if you want to see everything again.
12. Now, create the non-facility formula.  First find the row index for the first row of data.  In this example, the first medical service listed is G0101, located in row 1366.
13. In that row, find the Excel coordinates of four cells: the first row's Work RVU, the first row's Non-Facility PE RVU, the first row's Malpractice (MP) RVU, and the first row's Conversion (Conv) Factor.    In this example, these are found in cells H1366, I1366, M1366, and AA1366, respectively.


14. In the first Payment (nonfacility) cell (here, F1366), enter a formula based on the following construction:

=ROUND(((row's Work RVU cell * PW GPCI)+(row's Non Facility PE RVU cell * PE GPCI)+( row's Malpractice RVU cell * MP GPCI)) * row's Conversion Factor),2)

Or in this example:

=ROUND(((H1366*1)+(I1366*0.901)+(M1366*0.526))*AA1366,2)
15. Press Enter, and a value should appear in F1366.
16. Now you can copy/paste this formula down all of column F.   Click in cell F1366.  Then type Ctrl-C to copy the formula in F1366.   Then click and drag to the bottom of the column, and type Ctrl-V.  You should now see the formula's result in every row.
17. Create the Payment (facility) formula in a similar manner. In the first Payment (facility) cell (here, G1366), enter a formula based on the following construction:

=ROUND(((row's Work RVU cell * PW GPCI)+(row's Facility PE RVU cell * PE GPCI)+( row's Malpractice RVU cell * MP GPCI)) * row's Conversion Factor),2)

Or in this example:

=ROUND(((H1366*1)+(K1366*0.901)+(M1366*0.526))*AA1366,2)
18. Copy/paste the formula down through column G.
19. Be sure to save your work!