Friday, June 4, 2010

Services Excluded from Medicare payment program

Services that are excluded from program payment, such as hearing aides, routine dental care, and
routine physical examinations are not subject to waiver of payment or advance beneficiary notice
requirements since they are excluded from program coverage under other provisions of the Law.
Examples:

1. Personal comfort items are denied under §1862(a)(6).
2. Routine physician checkups (including lab test furnished as part of the routine physical
examination), routine eye examinations and eyeglasses, and hearing aids are denied under
§1862(a)(7).
3. Orthopedic shoes, supportive devices for the feet, treatment of flat foot, subluxation of the foot,
and routine foot care are denied under §1862(a)(8).
4. Cosmetic surgery is denied under §1862(a)(10).
5. Dental services are denied under §1862(a)(12).
6. Ambulance denials for excessive mileage, or because the patient could have been transported
by another means, or to non-covered destinations are denied under §1861(s)(7).
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Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download