Pulmonology Coding Alert

Look for differences in local and national rates to avoid rejection.

The Medicare Physician Fee Schedule establishes different values for codes depending on the setting/site (facility or non-facility) in which the provider performs the service or procedure. For some services, the total relative value units (RVUs) for a given procedure are the same in a facility or a non-facility setting. In some cases, however, the two totals may differ.

How it works: The facility and non-facility total RVUs are the sum of three component RVUs: physician work RVUs (to cover the cost of the provider’s “work”), practice expense RVUs (to cover the cost of supplies, equipment, etc.), and malpractice expense RVUs (to cover the cost of professional liability expenses).

Physician work RVUs and malpractice expense RVUs are the same, regardless of the setting (facility or non-facility). Practice expense RVUs may vary by site of service, however (which accounts for the difference in facility and non-facility RVU totals for a given code).

Medicare fees also vary geographically. Thus, each component RVU is multiplied by its own geographic practice cost index (GPCI) for the payment locality in which the service is rendered before the components are summed and multiplied by the dollar conversion factor that translates RVUs into fees. 

Non-facility calculations: Add together the physician work RVUs, the non-facility practice expense RVUs, and the malpractice RVUs for the total non-facility RVUs for a given code.

To then figure out the national, geographically unadjusted Medicare fee for a code, multiply the transitioned non-facility RVU total by the 2014 conversion factor ($35.8228). Note that private payers and other public payers may use different conversion factors for setting their fees, even if they use the same RVUs as Medicare. 

Facility calculations: Similarly, add together the physician work RVUs, the facility practice expense RVUs, and the malpractice RVUs for the total facility RVUs for a given code both nationally and otherwise. Many times, the RVUs, and hence, the payment for facility and non-facility procedures is the same, lessening your chances of mistakes.

For example: To calculate the geographically unadjusted Medicare fee for 94010 (Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement[s], with or without maximal voluntary ventilation), multiply the transitioned non-facility total RVU of 1.01 with the conversion factor of $35.8228. You can therefore figure out that the 2014 non-facility national fee for 94010 is $36.18 when performed in a private office setting. You will find that the same RVU (1.01) has been established for facility treatment when performed in a facility based setting such as an outpatient hospital or ED.

According to Carol Pohlig, BSN, RN, CPC, ACS, Senior Coding & Education Specialist at the Hospital of the University of Pennsylvania, “When providing services in a facility-based setting, a physician will not be able to recoup the total facility RVUs (1.01). The physician will only be able to report and recover the fee associated with the professional component of the service (94010-26), 0.24 RVUs and $8.60. The facility will bill and recover the technical component of the service (94010-TC), 0.77 RVUs and $27.58. Both components equate to 1.01 RVUs and $36.18.”

Alternative: You can simply look up national or local Medicare reimbursement rates for specific procedures on the Medicare Web site at www.cms.hhs.gov/PFSlookup, or on https://www.aapc.com/codes/. Many individual Medicare carriers have similar Web tools.

For example, Noridian’s fee schedule search tool (https://med.noridianmedicare.com/web/jeb/fees-news/fee-schedules/mpfs) makes available downloadable pdfs with details of the participating fee, the non-participating fee, and the limiting fee for both facility and non-facility visits, as well as the breakdown for modifiers 26 (Professional component) and TC (Technical component), for California.