2019 National Fee Analyzer Charge data for evaluating fees nationally Power up your coding optum360coding.com
Contents Introduction...1 Key to Proper Reimbursement... 1 The Medical Coding System... 1 What This Book Has to Offer... 2 A Coding Overview...11 Coding Systems... 11 Using CPT... 14 Reimbursement Issues...33 Trends... 33 Other Reimbursement Trends... 33 Health Care Plans... 34 Contracts... 38 Auditing... 42 Rules... 45 Setting Medical Fees...51 Choose a Pricing Philosophy for Fees... 51 Developing a Pricing Strategy... 52 Conducting an Impact Analysis... 52 Summary Checklist... 53 Anesthesia...55 Anesthesia Section Arrangement... 55 Anesthesia Codes and Guidelines... 55 Coding and Billing for Anesthesia... 55 and Anesthesia Coding... 58 Other Billing Issues for Anesthesia... 59 Surgery...71 Surgery Section Arrangement... 71 Surgical Coding Methodology... 71 CPT Surgical Terminology and Coding Guidelines... 72 Negotiating with Payers... 79 Radiology...325 Radiology Section Arrangement... 325 Technical and Professional Components... 325 Documentation... 3 Coverage Issues... 3 Code Selection... 3 Interventional Radiology... 3 Modifiers... 327 Coding Insights... 327... 329 Pathology and Laboratory... 377 Pathology and Laboratory Section Arrangement... 377 Tracking Lab Work and Other Ancillary Services... 379 Reimbursement... 379 Clinical Laboratory Improvement Act (CLIA) Regulations... 379 Medicine... 441 Medicine Section Arrangement... 441 Guidelines... 441 Modifiers... 442 Coding Insights... 443 Dialysis... 448 and Multiple Procedures... 448 Evaluation and Management... 511 Evaluation and Management Section Arrangement... 511 E/M Guidelines... 511 E/M Documentation Guidelines... 513 Place of Service Distinctions... 515 Concurrent Care... 515 Consultation... 515 Hospital Observation... 516 Prolonged Services... 516 Case Management Services... 517 Preventive Medicine... 517 Care Management Services... 518 Transitional Care Management Services... 519 Advanced Care Planning... 520 2018 Optum360, LLC CPT 2018 American Medical Association. All Rights Reserved.
2018 National Fee Analyzer Introduction 3 charge by the code s relative value. Conversion factor percentiles are then created by range of service areas.the professional and technical components (PC/) in the Analyzer are calculated using custom PC/ split ratios. Please note that while insurance payers contribute billed charges to the data used in this product, no individual physician or clinic is identified in the data. Additionally, no allowed amounts or insurance company paid amounts are used in the product. FAIR Health licenses the data under the name FAIR Health FH Medical Benchmark Module (FH Medical). FH Medical has two releases per year May and November. The Analyzer and FH Medical use data that fall within a 12- month period. The 2018 Analyzer is based on the November 2017 release of FH Medical and contains data with a date of service range September 2016 August 2017. Prior to the 2018 edition, National Fee Analyzer used the FAIR Health RV Medical Module. November 2016 was the last release of the FAIR Health RV Medical Module. FAIR Health RV Medical Module is no longer maintained. National 50th, 75th, and 90th Amounts These amounts were developed using the methodologies described in the Charge Data section. National 50th This column is the 50th percentile of the database nationally. A fee at the 50th percentile does not mean 50 percent of providers charge that amount. If the fee for a given service is at the 50th percentile, then, based on FH Medical methodology and data, 50 percent of the charges for that service are equal to or higher than that fee. National 75th This column is the 75th percentile of the database nationally. If the fee is at the 75th percentile, then, based on FH Medical methodology and data, 25 percent of the charges are equal to or higher than that fee. National 90th This column is the 90th percentile of the database nationally. If the fee is at the 90th percentile, then, based on FH Medical methodology and data, 10 percent of the charges are equal to or higher than that fee. s that are the same in the Analyzer indicate that there is a large pocket of data that has enough frequency to span numerous percentiles. The following is a simplified version of how data are arrayed when a frequent charge spans multiple percentiles. A scenario for a set of data with 20 frequencies of $5, 5, 6, 6, 6, 6, 7, 8, 9, 9, 9, 9, 9, 9, 11, 11, 11, 11, 11, 11 would have the following percentiles displayed: The 50th percentile is the (20*.5) or 10th occurrence = $9 The 75th percentile is the (20*.75) or 15th occurrence = $11 The 90th percentile is the (20*.9) or 18th occurrence = $11 Amounts The majority of values for CPT codes are from the Physician Fee Schedule (MPFS). The codes contained in the MPFS are primarily professional services, but some technical services are also listed. While the amounts from the MPFS reflect the nonfacility reimbursement amounts, it should be noted that for procedures that must be performed on an inpatient basis, CMS does not provide a separate nonfacility rate. For procedures that must be performed on an inpatient basis, the facility reimbursement rate is provided. MPFS amounts published in the Analyzer do not include the 2 percent sequestration adjustment in effect until 2021. For 2018, the MPFS fees are based on a conversion factor of 35.9996. For codes that are not valued on the MPFS, the RVU column will display. For these codes, a fee in the Average column comes from one of the following fee schedules. Average Sales Price (ASP) Drug Pricing Files The ASP drug pricing files provide a national fee schedule. does not adjust reimbursement rates based on geographic area; however, different rates exist for some drugs based on supplier. The majority of codes on the ASP pricing files are for HCPCS J codes. The Analyzer contains the subset of fees from the ASP drug pricing files that are assigned to CPT codes. Clinical Lab Fee Schedule (CLAB) The clinical laboratory fee schedule contains fees for outpatient laboratory services, primarily for the 80000 section of CPT codes. Effective January 1, 2018, fees in the CLAB schedule are national. Actual reimbursement rates vary by locality, but the national average reimbursement provides a good benchmark to compare to provider charges and private payer allowables. amounts are subject to change throughout the year. The averages published in this Analyzer are the most current available at the time of printing. Please check with CMS or your local contractor to obtain rates for a specific locality and date. Introduction 2017 Optum360, LLC CPT 2017 American Medical Association. All Rights Reserved. Data only 2017 FAIR Health, Inc.
102 Surgery 2019 National Fee Analyzer CPT Code Description RVU 50th 75th 90th Average 20982 Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency 48.38 4568.40 6022. 7872.72 1736.30 20983 cryoablation 178.44 8111.98 10693.54 13979.35 6403.98 Surgery + 20985 20999 21010 21011 21012 21013 21014 21015 21016 21025 210 21029 21030 21031 21032 21034 Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less (List separately in addition to code for primary procedure) Unlisted procedure, musculoskeletal system, general Arthrotomy, temporomandibular joint Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 2 cm Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm Excision of bone (eg, for osteomyelitis or bone abscess); mandible facial bone(s) Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage Excision of torus mandibularis 4. 21.78 9.93 9.75 14.82 15.00 20.35 29.38 25.67 17.80 22.10 14.96 11.40 288.89 1596.35 563.42 594.72 1001.63 1064.23 1345.94 2253.67 1940.66 1252.04 1658.95 876.43 6.02 380.82 2374.56 838.08 884.64 1489.92 1583.04 2002.08 3352.32 2886.72 1862.40 2467.68 1303.68 Sample data Excision of maxillary torus palatinus Excision of malignant tumor of maxilla or zygoma 11.53 37.88 657.32 60.59 931.20 977.76 3957.60 497.84 3514.36 1240.36 1309.27 2205.09 2342.91 2963.09 4961.45 4272.36 2756.36 3652.18 1929.45 1378.18 1447.09 5857.27 152.89 781.66 356.37 349.91 531.87 538.33 730.34 1054.41 921. 638.82 793.14 536.89 409.13 413.80 1359.46 21040 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage 15.06 939.03 1396.80 2067.27 540.48 21044 Excision of malignant tumor of mandible; 25.24 2065.87 3072.96 4547.99 905.83 21045 radical resection 35.34 2817.09 4190.40 6201.81 18.31 21046 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]) 32.36 2504.08 3724.80 5512.72 1161.36 21047 requiring extra-oral osteotomy and partial mandibulectomy (eg, locally aggressive or destructive lesion[s]) 38.04 3098.80 4609.44 6821.99 1365.21 21048 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive or destructive lesion[s]) 33.20 2566.68 3817.92 5650.54 1191.50 # Resequenced Code CPT 2018 American Medical Association. All Rights Reserved. s Revised Code l New Code 2018 Optum360, LLC
2019 National Fee Analyzer Radiology 339 CPT Code Description RVU 50th 75th 90th Average 72052 6 or more views 1.58 0.52 1.06 194.00 58.20 135.80 249.40 74.80 174.60 320.40 96.10 224.30 56.70 18.66 38.04 72070 72072 72074 72080 72081 72082 72083 72084 72100 72110 Radiologic examination, spine; thoracic, 2 views thoracic, 3 views thoracic, minimum of 4 views thoracolumbar junction, minimum of 2 views Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view 2 or 3 views 4 or 5 views minimum of 6 views Radiologic examination, spine, lumbosacral; 2 or 3 views 0.96 0.64 0.97 0.66 1.10 0.79 0.86 0.55 1.10 0.38 0.72 1.76 0.46 1.30 1.91 0.50 1.41 2.27 0.58 1.69 0.99 0.67 118.34 35.50 82.84 135.80 38.01 97.79 155.20 37.28 117.92 128.04 38.41 89.63 141.99 49.70 92.29 227.97 59.23 168.74 247.51 64.30 183.21 294.40 76.48 217.92 120.28 36.08 84.20 Sample data minimum of 4 views 1.38 0.45 0.93 174.60 52.38 122.22 152.13 45.63 106.50 174.58 48.86 125.72 199.52 47.92 151.60 164.60 49.37 115.23 182.54 63.89 118.65 293.07 76.15 216.92 318.18 82.67 235.51 378.46 98.33 280.13 154.63 46.38 108.25 224.46 67.32 157.14 195.44 58.62 136.82 224.28 62.79 161.49 256.32 61.52 194.80 211.46 63.43 148.03 234.50 82.05 152.45 376.50 97.89 278.61 408.77 106.27 302.50 486.21 1.41 359.80 198.65 59.58 139.07 288.36 86.49 201.87 34.45 22.97 34.81 23.69 39.48 28.35 30.86 19.74 39.48 13.64 25.84 63.16 16.51 46.66 68.55 17.94 50.60 81.47 20.82 60.65 35.53 24.05 49.53 16.15 33.38 72114 72120 72125 complete, including bending views, minimum of 6 views bending views only, 2 or 3 views Computed tomography, cervical spine; without contrast material 1.75 0.47 1.28 1.14 0.82 5.22 1.53 3.69 213.40 61.93 151.47 155.20 37.28 117.92 1057.06 211.60 845.46 274.34 79.53 194.81 199.52 47.92 151.60 1390.95 278.01 1112.94 352.44 102.19 250.25 256.32 61.52 194.80 1837.50 367.32 1470.18 62.81 16.87 45.94 40.91 29.43 187.34 54.91 132.43 Radiology 721 with contrast material 6.45 1.74 4.71 1246.32 224.10 1022.22 1639.98 295.38 1344.60 2166.48 389.88 1776.60 231.48 62.45 169.04 + Add-on Code 2018 Optum360, LLC, AMA Mod 51 Exempt B Optum360 Mod 51 Exempt a Mod 63 Exempt H Telemedicine CPT 2018 American Medical Association. All Rights Reserved.