Question Florida Fee Schedule

SA91

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Hi all!

I just want some clarification on this as I am still learning how these carriers calculate their reimbursement and how they reimburse the providers:

I have checked on CPT add-on 20930 and 20936 whether Florida Medicare Fee Schedule reimburses and found that no data comes up for these specific codes. Just to add this is specifically for an ASC facility which I checked on. I want to understand if this means that Florida does not reimburse these add-on codes? If so, why does Florida not reimburse them?

To add: We have received an EOR from a Worker's Comp Carrier in which they stated they use the Florida Fee Schedule. The allowed and paid add-on CPT 20936 but not 20930.

Any info would be appreciated to help me understand!

Thank you,
LR.
 
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sls314

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Hi all!

I just want some clarification on this as I am still learning how these carriers calculate their reimbursement and how they reimburse the providers:

I have checked on CPT add-on 20930 and 20936 whether Florida Fee Schedule reimburses and found that no data comes up for these specific codes. Just to add this is specifically for an ASC facility which I checked on. I want to understand if this means that Florida does not reimburse these add-on codes? If so, why does Florida not reimburse them?

Any info would be appreciated to help me understand!

Thank you,
LR.


Are you talking about Florida Medicaid, or a Florida commercial insurance company?

The commercial insurance reimbursement will be dictated by the terms of your contractual agreement. For a facility, contracts will often have a flat rate reimbursement for surgery regardless of how many procedures were performed. So, it's possible that the facility wouldn't receive any additional reimbursement for an add-on code, because the reimbursement would be bundled into the main procedure. You'd have to double-check the contractual agreement to confirm whether that's the case.
 

sls314

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For Flordia Medicaid, a quick search tells me that they reimburse ASC by EAPG methodology. The screenshot below should help direct you to the links you can use to estimate expected reimbursement for an ASC service. Hope this helps!


florida eapg.JPG
 

thomas7331

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I'm not familiar with this EAPG methodology, but reimbursement methodologies for outpatient facility services typically do not allow an additional payment for add-on codes because they are reimbursing the procedures at the grouper or case rate for the base procedure code. I would expect that this would be the case for the FL Medicaid reimbursement as well.

I always stress though that this does not mean you should not bill the add-on codes - you need to report the codes accurately on the claim based on what was performed and not based on whether there is a separate line-item payment for that code.
 

SA91

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For Flordia Medicaid, a quick search tells me that they reimburse ASC by EAPG methodology. The screenshot below should help direct you to the links you can use to estimate expected reimbursement for an ASC service. Hope this helps!


View attachment 5148
Thank you for that info. I have looked up on the Florida Medicare Fee Schedule just to clear that up. This was regarding an EOR we received back from a Worker's Comp carrier.
 

SA91

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I'm not familiar with this EAPG methodology, but reimbursement methodologies for outpatient facility services typically do not allow an additional payment for add-on codes because they are reimbursing the procedures at the grouper or case rate for the base procedure code. I would expect that this would be the case for the FL Medicaid reimbursement as well.

I always stress though that this does not mean you should not bill the add-on codes - you need to report the codes accurately on the claim based on what was performed and not based on whether there is a separate line-item payment for that code.
Thank you Thomas for advising! I forgot to add to my original thread that I used the Florida Medicare Fee Schedule as I was stuck on this EOR we received from a Worker's Comp carrier. It was a little odd because as far as the review went with the carrier the 20936 was allowed and paid but not the 20930 (not allowed or paid). I have asked the carrier what fee schedule they use as the EOR states only "...according to STATE fee schedule …" obviously I would assume Florida but I never want to just assume. But besides what fee schedule is used I understand now that the add-on codes for ASC is processed differently like you explained. Thank you for that :) I don't know then why one add-on was paid then? Maybe they realized they made a mistake?
 

sls314

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Thank you Thomas for advising! I forgot to add to my original thread that I used the Florida Medicare Fee Schedule as I was stuck on this EOR we received from a Worker's Comp carrier. It was a little odd because as far as the review went with the carrier the 20936 was allowed and paid but not the 20930 (not allowed or paid). I have asked the carrier what fee schedule they use as the EOR states only "...according to STATE fee schedule …" obviously I would assume Florida but I never want to just assume. But besides what fee schedule is used I understand now that the add-on codes for ASC is processed differently like you explained. Thank you for that :) I don't know then why one add-on was paid then? Maybe they realized they made a mistake?

If it is a workers comp carrier, the state fee schedule they are referring to was likely the state Work Comp fee schedule.

States set their own workers compensation reimbursement and methodologies - if you go to the Florida state work comp website, there should be a provider manual or reimbursement manual spelling out how different provider types will be reimbursed.
 

SA91

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If it is a workers comp carrier, the state fee schedule they are referring to was likely the state Work Comp fee schedule.

States set their own workers compensation reimbursement and methodologies - if you go to the Florida state work comp website, there should be a provider manual or reimbursement manual spelling out how different provider types will be reimbursed.
Thank you Susan! Yes, I actually was looking for that manual as someone else has mentioned that to me some time ago but I cannot find it? Would you please be able to share the link so I can download it or advise which tab it falls under maybe I am just overlooking it?
 

SA91

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If it is a workers comp carrier, the state fee schedule they are referring to was likely the state Work Comp fee schedule.

States set their own workers compensation reimbursement and methodologies - if you go to the Florida state work comp website, there should be a provider manual or reimbursement manual spelling out how different provider types will be reimbursed.
Is this the website?: https://www.myfloridacfo.com/Division/WC/PublicationsFormsManualsReports/Manuals/Default.htm#
 

SA91

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If it is a workers comp carrier, the state fee schedule they are referring to was likely the state Work Comp fee schedule.

States set their own workers compensation reimbursement and methodologies - if you go to the Florida state work comp website, there should be a provider manual or reimbursement manual spelling out how different provider types will be reimbursed.
I think this carrier made a mistake in reimbursing us because even in the latest 2015 manual the add-on codes are not there (obviously). And as I understand from Thomas's previous reply "outpatient facility services typically do not allow an additional payment for add-on codes because they are reimbursing the procedures at the grouper or case rate for the base procedure code". It is just interesting to always learn something new well for me it is.:)
 
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