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Issue Number - Name
0151-Physician/Non-physician Practitioner Coding Validation
Review Type
Complex
Claim Type
Professional Services
Region and State
RAC 1-4
All Regions
Date Approved
03/05/2019

Description

The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Specifically, Medicare uses this fee schedule when paying the following services:
• Professional services of physicians and other enrolled health care professionals in private practice;
• Services covered incident to physicians’ services (other than certain drugs covered as incident to services);
• Diagnostic tests (other than clinical laboratory tests); and
• Radiology services

Affected Codes

CMS MPFS status code “A”

Applicable Policy References

Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)-Exclusions from Coverage and Medicare as a Secondary Payer
Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1833(e)-Payment of Benefits
42 CFR, Section 405.980-Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)-Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
42 CFR, Section 405.986-Good Cause for Reopening
42 CFR, Section 414, Payment for Part B Medical and other Health Services, Subpart A–General Provisions, Subpart B – Physicians and other Practitioners, Subpart E–Determination of Reasonable Charges under ESRD Program
42 CFR, Section 414.40, Coding and Ancillary Policies
42 CFR, Section 415, Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings
42 CFR, Section 419.44, Payment Reductions for Procedures
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners
CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations
American Medical Association (AMA), Current Procedural Terminology (CPT)
AMA, HCPCS Level II
AMA CPT Assistant 
National Correct Coding Initiatives (NCCI) Policy Manual
1995 and 1997 Documentation Guidelines for Evaluation and Management Services