Wiki Facility pricing part a ??


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Hello All,

Typically I bill for Part B fee-for-service. That pricing is pretty cut-and-dry and you can easily pull up the fee schedule and know what you are getting paid.

What I am trying to find out is what the facility gets paid. For example, lets say my physician goes into a surgery center, performes an outpatient procedure. I can see what my doc will be paid but how do I see what the facility will be paid for the bed stay and what ever else is involved in such a procedure. Pick a procedure, it doesn't matter, lets say CPT 50590 ESWL. I used the CMS part A search but don't understand the facility vs no facility....

Can anyone explain how facility pricing works and how I look that up?

thanks in advance
It actually depends on the facility type. ASCs are paid based on the Medicare ASC fee schedule, which has these things called "groups", and each group is assigned a fee, and there are several procedures assigned to each group, so you look up the procedure, find out what group it falls under, then find out what that group fee is for the particular ASC.

Hospitals, it depends on inpatient or out. Inpatient is based off of prospective payment, which means DRGs. Outpatient I believe is based on the Ambulatory Payment Classification. Not sure how the part A search works or if it differentiates between the type of facility. Maybe look to see if there is a separate ASC look up?