Allowed Amount Reductions - JE Part B
Allowed Amount Reductions
Medicare allowed and paid amount reductions may occur for a variety of reasons. Below are various conditions that may reduce allowed and paid amounts under the Medicare program. The CMS Internet Only Manual (IOM) location of each reduction is provided with the explanation for each reduction. In the absence of an IOM reference, another published reference is used.
| Reduction Reason | Description |
|---|---|
| Ambulance Transports (Multiple Patients) | If two patients are transported to same destination simultaneously, for each Medicare beneficiary, Medicare will allow 75 percent of payment allowance for base rate applicable to level of care furnished to that beneficiary plus 50 percent of total mileage payment allowance for entire trip If three or more patients are transported to same destination simultaneously, payment allowance for Medicare beneficiary (or each of them) is equal to 60 percent of base rate applicable to level of care furnished to beneficiary; however, a single payment allowance for mileage will be prorated by number of patients onboard This applies to both ground and air transports |
| Assistant-at-surgery Services | Allowed at 16% of Medicare Physician Fee Schedule (MPFS) |
| Automated Multi-channel Test Panels | Go to CMS Clinical Lab Fee Schedule webpage and choose file that corresponds with date of service year and open
|
| Certified Nurse-Midwife (CNM) Services | Reimbursement is made at 80% of lesser of actual charge or 100% of MPFS for same service performed by a physician |
| Diagnostic Cardiovascular Services |
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| Diagnostic Imaging Professional/ Technical Component Procedures |
|
| Diagnostic Ophthalmology Services |
|
| Endoscopies (Multiple) | Medicare has special payment rules for multiple endoscopies performed on same day Modifier 51 will be added, by Noridian, to reduced services, if necessary. Providers should not append this modifier on any services
|
| Facility-based Reduction | Allowed amounts for services performed in facility based settings are reduced and are represented within MPFS by # symbol |
| Five Year Pricing Limitation | Medicare's claims processing system only holds the pricing/fee schedules for five calendar years. Services processed for dates of service outside of the five-year range will be priced using the oldest year still available.
|
| Global Period/Surgery | Procedures having a global period (0, 10 or 90 days) may be reduced if another service (no global modifier appended) was performed, within global period, and was paid prior to payment of claim containing global procedure itself
|
| Licensed Clinical Social Worker (LCSW) Services | Allowed at 75% of MPFS |
| Marriage and Family Therapists (MFT) Services |
Allowed at 75% of MPFS |
| Mental Health Counselor (MHC) Services |
Allowed at 75% of MPFS |
| Modifier 26 | Indicates Professional Component (PC) only (separate from Technical Component (TC)) |
| Modifier 52 | Partially Reduced/Eliminated Services. To determine charge amount, reduce normal fee by percentage of service not provided
|
| Modifier 53 | Discontinued Procedure (professional services only). To determine appropriate amount to charge, reduce normal fee by percentage of service not provided
|
| Modifier 54 | Surgical Care Only. MPFS allowed amount multiplied by sum of pre-operative and intra-operative percentages |
| Modifier 55 | Postoperative Management Only. MPFS allowed amount multiplied by post-operative percent divided by 90 days equals amount per day Medicare allows for procedure. Amount per day multiplied by number of days a provider is providing post-operative care equals MPFS allowed amount |
| Modifier 62 | Co-Surgeons. Reimbursement is 62.5% of MPFS allowed amount |
| Modifier 66 | Team Surgeons – Surgical Team. Priced "by report" |
| Modifier 78 | Return to Operating Room for related surgery during post-operative period |
| Modifier FX | Effective for DOS 1/1/2017 and after.
|
| Modifier TC | Reimbursed for technical component of service only |
| Modifier QX | Qualified nonphysician anesthetist service: With medical direction by a physician. 50% reimbursement reduction |
| Modifier QY | Medical direction of one CRNA by an anesthesiologist |
| Multiple Procedure Payment Reduction (MPPR) | HCPCS codes identified as "always therapy" services payable under MPFS have a reduction to Practice Expense (PE) component of payment |
| Multiple Surgery Rules | Apply to certain procedure codes.100% of MPFS amount is allowed for highest valued surgical procedure and 50% for additional surgical procedures (with a multiple surgery indicator of "2") performed same day. Modifier 51 will be appended, by Noridian, to identify reduced services, if necessary |
| Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services | Allowed at 85% of MPFS
|
| Nutrition Professional/ Registered Dietitian Services | Allowed at 85% of MPFS |
| Physician Assistant (PA) Services | Reimbursement may occur in all POS settings permitted by state law as long as no other facility or provider charges are paid in connection with service. Reimbursement equals 80% of actual charge or 85% of MPFS, whichever is less. |
| Physician Assistant-at-surgery Services | Allowed at 85% of MPFS and then 16% of that amount is allowed for Assistant-at-surgery |
| Physician Quality Reporting System (PQRS) |
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| Procedure to Procedure Code Edits (Column 1 / Column 2) | Per National Correct Coding Initiative (NCCI) rules, Column 2 codes will bundle their payment to specific Column 1 codes.
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| Sequestration |
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When reviewing a claim, keep in mind that more than one type of reduction may apply for the performed service.
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