Wiki G2025 Medicare Telehealth

[JeanWest]

The question is: For Telehealth reimbursement, (G2025) we were told Medicare would have an allowed amount of $92.03.
We send the claim out for $100 and expect a payment to be 80% of the $92.03 allowed amount which would be a payment of $73.63, (20% of $92.03 is $18.40) .
However, Medicare is processing the $100 and doing 80-20% and reimbursing us $72.03 which is $20.00 (or 20% of 100) off the allowed $92.03 amount.
know it's not alot of money we are talking about, but are we understanding this correctly? Or is the MAXIMUM reimbursement $92.03 and we are submitting our billing too low? We have called Medicare and they state they are paying the G2025 correctly.
Can someone please clarify this, while we continue our investigation? Thank you.

 

[csperoni]

G2025 rate is $92.03, but then can be price adjusted based on geographic location. In my area in NY for example, the full rate would be $107.26. In Nebraska, $86.10.
If the allowed rate was over $100, then Medicare would be paying $80 with $20 co-insurance.
On the EOMB, what is the allowed amount and patient co-insurance? Perhaps in your area, with geographic adjustment, the rate is $90.04, for which 80% is $72.03.
This is not unique to this procedure code, and is how all claims are processed by Medicare. If you are not familiar with Medicare's GPCI, here's a good place to start. https://www.cms.gov/apps/physician-fee-schedule/overview.aspx

And just to add my two cents - if the allowable is $92.03, I would be setting my fee higher than $100 for this exact reason. The lowest I see anyone setting their fee schedule is 150% of Medicare. In my current practice, we use about 300% of Medicare (which is determined by the corporate office).