And Then There Were Fees...

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Nov 11th, 2019

Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS.

• (OPPS) -Outpatient Prospective Payment System.
• (MPFS)- Medicare Physician Fee Schedule

Others include Home health, hospice, and Inpatient Psychiatric Facility as well as the below payment systems.

• (IPPS) - Inpatient Prospective Payment System
• (LTCH-PPS) - long-term care hospital prospective payment system
• (SNF) - Skilled Nursing Facility (SNF) prospective payment system

The Fees section on each code page is determined on the type of services you are viewing. For example, Lab fee pricing and DME pricing will be displayed in addition to physicians’ fees. Keeping that in mind, physician services will be displayed under Facility and Non-facility.  It is up to you to understand if you are viewing a Lab, DME or service code, as we have several types of fees on each code information page. This article does not include inpatient hospital fees - we will address that at another time. 

Facility: Paid under (MPFS) - Medicare Physician Fee Schedule, billed on CMS-1500. Medicare has separate payment rates for the professional services of the physician when provided in facility and non-facility settings (physicians are paid under the applicable site of service and payment is adjusted accordingly).

Non-Facility (Office, etc): Paid under (MPFS) - Medicare Physician Fee Schedule, billed on CMS-1500  (physicians are paid under the applicable site of service and payment is adjusted accordingly).

APC: Paid under (OPPS) - Outpatient Prospective Payment System, paid to a distinct certified entity enrolled in Medicare, reported on a UB-04. Payment is made to the hospital for outpatient services and has no impact on physician payments. Status indicators are used to identify how the services are priced.   

ASC Fee: Paid under (OPPS) - Outpatient Prospective Payment System. ASC payments do not include physician services. The POS for physicians/practitioners who perform services in Medicare-participating ASCs is 24. Paid to a distinct certified entity enrolled in Medicare, independent of provider services. Billed on CMS-1500 under part B for CMS; other payers may require a UB-04. Must be an approved procedure. ASCs are “packaged” - bundled and paid in one lump sum using a combination of physician and hospital billing with CPT and Level II codes.

NOTE: If a physician is employed by a hospital, the hospital will bill for the physician services on a CMS-1500. The Medicare Administrative Contractor pays the facility fee from the MPFS to the physician. The facility fee is for services performed in a facility other than the physician’s office and is typically less than the non-facility fee for services performed in the physician’s office.

For more detailed information on Medicare Payment Systems, see the Medicare Claims Processing Manual Chapter 1- General Billing Requirements.