Medicare Payment Information for Common Urology CPT® Codes
Physician Fee Schedule
The Centers for Medicare and Medicaid Services (CMS) uses the Physician Fee Schedule (MFS) to reimburse physician services. This system became effective in 1992 and is composed of resource costs associated with physician work, practice expense and professional liability insurance.
Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Centers (ASC) Payment System
CMS implements a prospective payment system (PPS) under Medicare for hospital outpatient services. All services paid under the new PPS are classified into groups called Ambulatory Payment Classifications or APCs.
Medicare physician pymt. non-facility
Medicare professional fee to a physician when a procedure is performed in the office or in an ASC if the procedure is not on the Medicare-approved ASC list (see explanation below). These fees are based on the assumption that the space, equipment and overhead costs are absorbed by the physician. N/A in this column means the procedure is rarely or never performed in the non-facility setting. There are other sites of service that are considered non-facility as well.
Medicare physician pymt. facility
Medicare professional fee to a physician when a procedure is performed in a hospital or in an ASC if the procedure is on the Medicare-approved ASC list (see explanation below). These fees are based on the assumption that the space, equipment and overhead costs are absorbed by the hospital or ASC. There are other sites of service that are considered facility as well.
Medicare ASC facility payment
Medicare facility payment to an ASC for CPT® codes that are on the ASC list. Physician also receives separate payment, non-facility or facility, depending on whether the CPT® code is on the ASC list. CPT® Codes with a payment identified in this column are on the ASC list.
CPT® codes that are payable by Medicare only when performed in an inpatient setting.
CPT® codes for which Medicare will pay for modifier -50 (bilateral surgery). When this modifier is reported, Medicare payment for surgical procedures is reimbursed at 150 percent of the fee schedule, taking into consideration any multiple surgery adjustments.
Yes indicates that Medicare will pay for an assistant surgeon. The -80 modifier is used to describe the use of an assistant surgeon. Medicare will pay the lower of the actual charge or 16% of the fee schedule amount.
Maybe indicates that Medicare will not usually pay for an assistant surgeon unless you submit supporting documentation to establish medical necessity for using an assistant.
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