Wiki Setting Clinic Fee Schedule

[Melissa924]

Our clinic uses the CMS physician fee schedule to set billing rates.
We would like to know how other practices set rates for CPT codes that are not part of the CMS physician fee schedule look up tool.
For instance 99385 or 99395.
We are a student health center and the G-codes used by Medicare do not pertain to our services.
Thanks Everyone!

 

[julieordway]

Even though Medicare does not cover those codes, they should still have an RVU assigned to them. Here are current allowables for 2023:

99395- Medicare Fees​	National​	Portland Area​
Non-Facility Fee​	$116.91​	$121.00​
Facility Fee​	$86.07​	$87.61​
Participating Non-Facility Fee​	$116.91​	$121.00​
Participating Facility Fee​	$86.07​	$87.61​
Non-Participating Non-Facility Fee​	$111.07​	$114.95​
Non-Participating Facility Fee​	$81.77​	$83.23​
Limiting Charge Non-Facility Fee​	$127.73​	$132.20​
Limiting Charge Facility Fee​	$94.04​	$95.71​

99385- Medicare Fees​	National​	Portland Area​
Non-Facility Fee​	$129.79​	$134.42​
Facility Fee​	$94.21​	$95.88​
Participating Non-Facility Fee​	$129.79​	$134.42​
Participating Facility Fee​	$94.21​	$95.88​
Non-Participating Non-Facility Fee​	$123.30​	$127.70​
Non-Participating Facility Fee​	$89.50​	$91.09​
Limiting Charge Non-Facility Fee​	$141.79​	$146.85​
Limiting Charge Facility Fee​	$102.92​	$104.75​
you can also find fee values here: CPT® Code 99395 in section: Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient

 

[Akwaaba1450]

Those codes are in the CMS fee schedule lookup tool. They aren’t part of Medicare part A services so you don’t bill Medicare for them, but they are most certainly in the database. Our approach to establishing a fee schedule (we are a small Family Practice) was a hybrid process of searching the CMS fees, finding out what other local practices charge for services, and good old fashioned Googling. You didn’t specify what kind of practice you are working in so I don’t know if that helps

 

[Melissa924]

Even though Medicare does not cover those codes, they should still have an RVU assigned to them. Here are current allowables for 2023:

99395- Medicare Fees​	National​	Portland Area​
Non-Facility Fee​	$116.91​	$121.00​
Facility Fee​	$86.07​	$87.61​
Participating Non-Facility Fee​	$116.91​	$121.00​
Participating Facility Fee​	$86.07​	$87.61​
Non-Participating Non-Facility Fee​	$111.07​	$114.95​
Non-Participating Facility Fee​	$81.77​	$83.23​
Limiting Charge Non-Facility Fee​	$127.73​	$132.20​
Limiting Charge Facility Fee​	$94.04​	$95.71​

99385- Medicare Fees​	National​	Portland Area​
Non-Facility Fee​	$129.79​	$134.42​
Facility Fee​	$94.21​	$95.88​
Participating Non-Facility Fee​	$129.79​	$134.42​
Participating Facility Fee​	$94.21​	$95.88​
Non-Participating Non-Facility Fee​	$123.30​	$127.70​
Non-Participating Facility Fee​	$89.50​	$91.09​
Limiting Charge Non-Facility Fee​	$141.79​	$146.85​
Limiting Charge Facility Fee​	$102.92​	$104.75​
you can also find fee values here: CPT® Code 99395 in section: Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient

Thank you for this information.
Can you verify that some of these rates are only available through find-a-code with a paid subscription?
We use the limiting charge non-facility and this seems to be limited to a paid subscription? All I can see is ##.## when using this site.
I will need to present this to accounting in order to receive approved funds to pay for additional subscriptions.

 

[julieordway]

Thank you for this information.
Can you verify that some of these rates are only available through find-a-code with a paid subscription?
We use the limiting charge non-facility and this seems to be limited to a paid subscription? All I can see is ##.## when using this site.
I will need to present this to accounting in order to receive approved funds to pay for additional subscriptions.

Melissa, I do not have a paid subscription to Find A Code, but I believe the limiting charge is 15% of the non-participating fee.
As a side note, if you are looking for a good online encoder tool, we use AUA Coding Today. It lists all the fees, bundling edits, modifiers, etc. You can find it here if interested in a subscription: https://aua.codingtoday.com/restricted/ It lists the limiting charges and much more.