Tuesday, December 14, 2010

Medicare Physician Fee Schedule Database - payment as per modifier

Modifier/MPFSDB Fact Sheet

The Medicare Physician Fee Schedule Database (MPFSDB) is a file that provides a basis of payment under Medicare Part B. It is provided to all carriers nationally to assure consitent claims processing for the Centers for Medicare & Medicaid Services (CMS).

The file contains information on more than 10,000 services physician services covered by the Medicare Physician Fee Schedule (MPFS). The file contains the associated relative value units, a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.) The information provided on the database is summarized as follows:

  • The database includes all Health Care Procedure Coding System (HCPCS) and Current Procedural Codes (CPT) codes that are included on the physicians' fee schedule. Codes that have multiple components, such as labs and x-rays, are broken down by these components with modifiers 26
- professional component and TC - technical component. ¾ The next field on the database is procedure code status.

  •  The MPFSDB also identifies for you what percentage of a surgical fee is designated as the pre-operative percentage, the intra-operative percentage, and the post-operative percentage.
  •  The MPFSDB identifies whether or not the concept of professional/technical components applies to a given code, and if so, how the code is defined. For example, 93017 (stress testing, tracing only) is considered a technical service. A "TC" modifier is not used to differentiate components for certain codes that are specifically technical or professional by definition.
  • The MPFSDB identifies for each code whether special pricing rules for multiple surgery, bilateral surgery, co-surgery, or team surgery apply. It also indicates for each surgical code whether an assistant at surgery may be separately paid.
  •  The MPFSDB identifies the applicable diagnostic imaging family. ¾ The MPFSDB verifies the applicability of the OPPS Imaging Cap mandated by Section 5102(b) of the Deficit Reduction Act of 2005. ¾ Finally, the MPFSDB indicates whether there are related codes.

The MPFSDB helps providers understand how claim payments are determined, and allows providers to estimate Medicare reimbursement with a much greater degree of accuracy. The MPFSDB will assist nonparticipating providers in understanding the Medicare reimbursement process which will enable providers to avoid exceeding the Limiting Charge exception. An advantage to both participating and non-participating providers is the link the MPFSDB indicators provide to current Medicare policy. As with all national Medicare regulations, MPFSDB is binding for all carriers.

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