How Will Changes to the Physician Fee Schedule Affect Your Practice?

Medicare Physician Fee Schedule, Physician Fee Schedule, Reimbursement

Did you remember to check the Medicare Physician Fee Schedule Database (MPFSDB) for July? CMS implements the changes on July 5, 2016, but some of the changes will be effective back to Jan. 1, 2016.

Check Out Key Changes in July Update

CMS requires Medicare Administrative Contractors (MACs) to amend payment files to conform with the July changes. Note that MACs will not search their files to retract payment for claims already paid, nor will they retroactively pay claims. However, they will adjust claims that are brought to their attention.

We talked yesterday about some of the new CPT® Category III codes added to the MPFS. Next week we’ll go over changes to HCPCS codes and to National Correct Coding Initiatives (CCI) edits. But today, let’s focus on the CPT® Category I codes affected by the 2016 MPFS changes.

Review Ways the Fee Schedule Changes Payment for These Codes

The MPFS adjusts the following CPT® codes by adding one of several indicators that affect reimbursement for these services. The codes’ official descriptors are unchanged.

  • +10036, Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; each additional lesion…

Multiple Surgery Indicator = 0

Note that Medicare’s multiple procedure rule allows payment of a reduced amount for subsequent procedures performed during the same session. The indicator digit listed in the Physician Fee Schedule’s “Multiple Procedure” column tells the amount that the reimbursement is reduced. Here’s what Chapter 1 of the National Correct Coding Initiative (NCCI) Policy Manual tells us about indicator 0: “0=No payment adjustment rules for multiple procedures apply.”


  • 37188, Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy

Multiple Surgery Indicator = 0

This means that for 37188, no payment adjustment for multiple procedures applies to this code.


  • 45346, Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)

Endo Base Code = 45330

The endo base code rule is similar to the multiple procedure rule, in that it affects the reporting of two or more endoscopic procedures. CPT® and CMS classify endoscopic procedure codes by “family.” Each family is made up of related services with a “parent” code consisting of an endoscopic base code, representing the most basic version of that endoscopic service. The base code for 45346 is 45330, a flexible sigmoidoscopy with or without collection of specimens. This means that if a gastroenterologist performs diagnostic sigmoidoscopy (45330), and finds lesions that require ablation, you can only report 45346. This is because the ablation procedure includes the work of the diagnostic sigmoidoscopy procedure.


  • +61651, Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; each additional vascular territory (List separately in addition to code for primary procedure)

Multiple Surgery Indicator = 0

As noted above, a Multiple Surgery Indicator of 0 tells us that no payment adjustment for multiple procedures applies to this code.


  • 65855, Trabeculoplasty by laser surgery

Bilateral Indicator = 1

Bilateral indicators identify which procedures can be billed as bilateral. A bilateral indicator of 0 means the criteria doesn’t apply. An indicator of 1 means the procedure is Conditional Bilateral. This means that if you report 65855 with modifier 50 to indicate a bilateral procedure, Medicare will reimburse at 150 percent of the allowed amount.


  • 69209, Removal impacted cerumen using irrigation/lavage, unilateral

PC/TC indicator = 3

This indicator 3 designates 69209 as a technical component only code, which is a standalone code describing the technical component (that is, staff and equipment costs) of this diagnostic test.


What About You?

Do you think these changes will have a big effect on your practice? Please let us know in the comment box below.

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Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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