by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 21st, 2019 - Reviewed/Updated Jan 9th
Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and used by certain healthcare plans and third-party payers to generate fair healthcare pricing.
Where does Find-A-Code get their data for UCR?
Find-A-Code offers UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is offered as a fee comparison with our UCR Pricing add-on.
Where are UCR fees located in Find-A-Code?
While on the code information page scroll down to the fees section and open the tab titled “UCR Fees”, the fees will be displayed for UCR, Workers Comp, as well as Medicare Billed and Allowed.
What information comes from the VA?
The following information comes from the VA to give an understanding of accountability to the Federal Register, calculations, and links to data sources used on our UCR pricing.
Reasonable charges according to the VA are described as follows; Reasonable Charges are based on amounts that third parties pay for the same services furnished by private-sector health care providers in the same geographic area. In the past, the VA used average cost-based, per diem rates for billing insurers. Reasonable charges are calculated for inpatient and outpatient facility charges, and professional or clinician charges for inpatient and outpatient care.
Reasonable Charges Rules, Notices, & Federal Register
The VA determines the amount of the national average administrative cost annually for the prior fiscal year (October through September) and then applies the charge at the start of the next calendar year. Below are links to the Federal Register and data sources from the VA Website.
Outpatient and Professional
- V4.225 Reasonable Charges Federal Register Notice, 01/01/2022 (Outpatient and Professional) V4.225 FR PDF | V4.225 FR WEB
- V5.24 Reasonable Charges Data Sources (Outpatient and Professional) (2024 OP)
Inpatient
- V4.22 Reasonable Charges Federal Register Notice, 10/1/2021 (Inpatient)
V4.22 FR PDF | V4.22 FR WEB - V5.24 Reasonable Charges Data Sources (Inpatient) (2024 IP)
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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