Wiki Fee Schedules

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Hello, if this is the wrong thread to post this in I'll move it.

I've been working in a small medical office for about a month and we just got our CLIA certificate.

The doctor wants me to find fee schedules for 80305 and I'm not sure where to start.

Training has been lacking as the last trainer left abruptly and the coder who has seniority was still undergoing training herself and finding answers has been difficult at best.

Is there a database we can access with all this information? Do I need to contact the insurance companies individually?

I'm in Illinois and we primarily work with Medicaid and BCBS Commercial, if that helps.

Thank you in advance.
 
I was trying to check this out for you, I stumbled upon the CMS website. However, it only allows me to look up HCPCS codes. Which CPT is actually considered HCPCS Level 1, but I apologize. I am of no help. I'm going to continue researching this, and if I find out I promise to let you know. The billing part of this career can be very tricky!

This is the website I used though:

Maybe you have to find the proper HCPCS LEVEL 2 Code for it. For example, colonoscopy has codes in both HCPCS AND CPT.


That's the Medicare Physician Fee Schedule look-up tool, which is definitely very useful for reimbursement research.

However, most lab codes are found on the Clinical Lab Fee Schedule:

 
I was trying to check this out for you, I stumbled upon the CMS website. However, it only allows me to look up HCPCS codes. Which CPT is actually considered HCPCS Level 1, but I apologize. I am of no help. I'm going to continue researching this, and if I find out I promise to let you know. The billing part of this career can be very tricky!

This is the website I used though:

Maybe you have to find the proper HCPCS LEVEL 2 Code for it. For example, colonoscopy has codes in both HCPCS AND CPT.
 
AHH! Thank you so much for your response and your help!

So I looked in HCPCS for an equivalent but it looks like the only drug test codes they have are for definitive tests. The specific test my facility will be performing is a 12 panel presumptive and will only require direct visualization for interpretation (which is how I found 80305).

I'll keep searching as well and will post any answers I find (because nobody likes being left in suspense).
 
For any non-government payors, your contract will determine your fee schedule. Another office telling you their fee schedule for the code does not mean you will be paid the same. Most commercial carriers have a "standard" fee schedule, but many providers have alternate fee schedules. Large healthcare systems definitely negotiate their contracts. If you are a small medical office, you may not have anything other than the standard fee schedule unless you belong to an IPA or similar organization.
I suggest first checking your contract. If you don't have it, then reach out the carrier for a copy and KEEP IT ON FILE. I know many small practices where the physicians will just blindly sign contracts without anyone reading them, and then not even keep a copy.
I don't deal with Illinois Medicaid, but found this: https://www2.illinois.gov/hfs/MedicalProviders/MedicaidReimbursement/Pages/Practitioner.aspx
 
For any non-government payors, your contract will determine your fee schedule. Another office telling you their fee schedule for the code does not mean you will be paid the same. Most commercial carriers have a "standard" fee schedule, but many providers have alternate fee schedules. Large healthcare systems definitely negotiate their contracts. If you are a small medical office, you may not have anything other than the standard fee schedule unless you belong to an IPA or similar organization.
I suggest first checking your contract. If you don't have it, then reach out the carrier for a copy and KEEP IT ON FILE. I know many small practices where the physicians will just blindly sign contracts without anyone reading them, and then not even keep a copy.
I don't deal with Illinois Medicaid, but found this: https://www2.illinois.gov/hfs/MedicalProviders/MedicaidReimbursement/Pages/Practitioner.aspx


I agree with Christine - you're going to need a copy of your commercial contracts. Reimbursement is based on your contracted rate for those types of payors.

Government payer rates are public information and easier to locate if you know where to look. (I worked as a contract analyst for many years before becoming a coder. I've spent a large chunk of my career researching and reviewing reimbursement rates.)

After finding those rates for traditional Medicare and Medicaid, you'll also need the contracts for your Managed Medicare and Managed Medicaid payors. Most of them will pay based on a percentage of the traditional rate. (Hopefully 100% or more, and your provider didn't sign contracts for less than 100%.)

Unfortunately, you're not going to be able to compile any really useful information without getting a copy of your insurance contracts.

Some people try to back into rates by looking at remits and seeing what a payor paid for a code. The problem with that is...what if the insurance company is paying you the wrong amount? It's important to know what your contract says you should actually be paid, and not assume the rate on the EOB is correct.

Get those contracts, and keep them on file in the office. Good luck!
 
Thank you so much for your help everybody! The link sls led me right to it (my mouse is pointing at the link in the picture).

Now I have to convince my boss that the fee listed is, in fact, correct (he INSISTS it's too low).

Thank you again!
 

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Thank you so much for your help everybody! The link sls led me right to it (my mouse is pointing at the link in the picture).

Now I have to convince my boss that the fee listed is, in fact, correct (he INSISTS it's too low).

Thank you again!

I'm glad I could help!

$12.60 is the correct rate. Once you get your commercial contracts, he'll probably find that some commercial insurances may not reimburse substantially more.

Did he not do any type of financial analysis before adding the service to the practice? I'm guessing not, if he's surprised that CMS reimburses $12.60 for 80305.
 
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I'm glad I could help!

$12.60 is the correct rate. Once you get your commercial contracts, he'll probably find that some commercial insurances may not reimburse substantially more.

Did he not do any type of financial analysis before adding the service to the practice? I'm guessing not, if he's surprised that CMS reimburses $12.60 for 80305.
Sorry, there have been lots of big chaotic changes in my personal life so I'm a bit slow to respond.

He hasn't done any financial analysis whatsoever and when I asked him about the contracts with insurance companies he's a provider under, he had no idea what I was talking about.

I am currently (desperately) searching for a new job.
 
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