Question Provider Fee Calculations

DBoop87

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Can anyone assist me on the formula to calculate a physician's fee for a CPT (95004 & 95165)? Any help would greatly be appreciated.

Thank you
 

thomas7331

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There is no set formula for calculating a fee - that is a business decision that all practices have to make. Your practice manager or physician should look at their costs of providing services, their contracts with payers, and also take into consideration the patient population and their ability to pay, and come up with a strategy as to the best way to set fees. As a matter of simplicity, many practices set their fees at a percentage above Medicare rates, for example 150% or 200% of the current Medicare fee, which you can look up for your area on the CMS web site. For optimal reimbursement, you'll want to make sure your fee is set high enough that you are not undercharging your commercial payers - for example, if one of your payers gives you 160% of Medicare fees, you certainly would not want to set your fees below that level.
 
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