Usual, customary, and reasonable charges (UCR) typically refers to a base amount a third-party payer uses to determine how much they will pay for services provided. For more information about fees, please refer to the “Guide” found on the Fees Topic page.
Click on the following links for answers to some questions about UCR fees:
There are 3 sections in the Guide.
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Jul 31st, 2024by Wyn Staheli, Director of Content - innoviHealth
UCR fees can be found in several places within Find-A-Code. The most commonly used place is found in the Fees section of the individual code. When you are on the code information page for a specific code, scroll down to the fees section and click on the bar titled “Fees” (as shown below) to open this section:
Jul 25th, 2024by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code’s Pro Fee Calculator is an easy-to-use tool for calculating fees for CPT and HCPCS codes. Need to apply modifiers or additional units? The Pro Fee calculator can do this and much more. Check it out.
Jul 25th, 2024by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code provides UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is available for performing a fee comparison with our UCR Pricing add-on.
Jan 10th, 2024by Matthew Albright
Like most of the world, I procrastinate when paying my bills. I tend to put them off until the very last minute. And that pretty much explains Congress’s strategy last year – and they clearly plan on continuing this approach for 2024. The tough stuff, like funding a government.
Nov 6th, 2023by Mark Spivey
The regulatory changes will create a variety of changes for providers. Amid a flurry of regulatory activity, federal officials late last week issued twin final rules governing changes to the Medicare Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS), with the latter also featuring adjustments.
Oct 19th, 2023by Adam Brenman
The Centers for Medicare & Medicaid Services (CMS) can’t seem to catch a break of late. 2023 has been a tough year for the agency, with the court system and Congress dealing it repeated blows, primarily over enactment of the No Surprises Act (NSA). Many are undoubtedly at least.
Sep 6th, 2023by David M. Glaser, Esq.
Can you do a “shared visit” in a physician clinic, site of service 11? The most common answer to this question seems to be “no,” and while that is technically correct, it is so misleading that it is effectively entirely wrong. To understand this confusion, we need to dig.
Jul 14th, 2023by Mark Spivey
The OPPS proposal did not feature reference to several high-profile issues industry leaders have been awaiting reform on. Federal officials yesterday unveiled a pair of proposed rules, featuring potential adjustments to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for the 2024 calendar year.
Mar 15th, 2023by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Feb 28th, 2023by Kem Tolliver, CMPE, CPC, CMOM
Each year the Centers for Medicare and Medicaid Services (CMS) rolls out the proverbial carpet and ushers in new rules on regulatory compliance, coding and reimbursement. Now the dust has settled, learn about the greatest impacts as a result of the CMS 2023 Final Rule. Gain insight into the top 5 regulatory and reimbursement changes that will impact the healthcare industry
Feb 21st, 2023by Jessica Hocker, CPC, CPB, CRC
Risk adjustment models are used by Medicare and Medicaid programs to classify patients based on the severity of their health conditions to determine the reimbursement for payers. Different types of models are used, such as HHS-HCCs, CMS-HCCs, RX-HCCs, and ESRD-HCCs, which are based on a hierarchical structure, meaning that patients are classified into categories based on the most severe condition they have. Medicaid risk adjustment models vary by state in the US, some states use their own models, while others use models developed by the CMS. These models take into account both diagnoses and procedures, and adjust the payment rates for healthcare providers based on the complexity of the care they provide.
Jan 26th, 2023by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
The Medicare Physician fee schedule was implemented in 1992 using a relative Value scale methodology called RVUs to base payment rates on the resources used to perform the service. This is currently how the Medicare Physician Fee Schedule (MPFS) is set. But beware, there may be an industry-wide change to a Value-Based Payment. We will save that for another time; this article will focus on how the RVUs are calculated and Medicare Fee schedules.
Dec 27th, 2022by Kem Tolliver, CMPE, CPC, CMOM
Diagnosis code usage is a major component of optimizing HCCs to improve overall healthcare. Readers will gain insight into how accurate diagnosis code usage and selection impacts reimbursement and overall healthcare.
Dec 13th, 2022by Find-A-Code™
A recently published study looking to explain income differences between male and female plastic surgeons suggests that billing and coding practices may be part of the equation. The study focused primarily on Medicare's relative value units (RVU) as applied to surgeon pay. But what exactly is an RVU?
Oct 27th, 2022by CMS - MLNConnects
Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes.
Oct 24th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?
Oct 24th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.
Sep 20th, 2022by Kem Tolliver, CMPE, CPC, CMOM
If you’ve been in any healthcare role for more than two years, you’ve seen quite a bit of change. And guess what, it’s not over. We are living and working in uncertain times. This climate requires each of us to step outside of our comfort zones to lead exactly where we stand. It’s not required of one to have a “title” to lead. What is required, however, is a willingness to trust your instincts, look for answers and rely on your team.
Aug 9th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
Aug 1st, 2022by Amanda Ballif
Beginning July 1, 2022, CMS started to enforce applicable price transparency requirements because of the Trump Administration's historic price transparency requirement in 2019 to increase competition and lower healthcare costs for all Americans.
older articles ↓ Jul 28th, 2022by Amanda Ballif
The Centers for Medicare and Medicaid Services (CMS) is soliciting public comments on proposed changes for Medicare payments under the Physician Fee Schedule (PFS) and other Medicare Part B issues effective on January 1, 2023 and thereafter. The Calendar Year (CY) 2023 PFS proposed rule is one of several proposed rules aimed at increasing equity in health care.
Jul 5th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.
May 26th, 2022by Terry Fletcher, CPC CCC CEMC CCS CCS-P CMC CMSCS CMCS ACS-CA SCP-CA QMGC QMCRC
Choosing a proper office visit code can become confusing unless one understands the rules separating preventive medicine and evaluation and management (E&M) coding. Problem-oriented E&M services, office, and other outpatient visit codes 99202-99215 (along with hospital, observation, and consultative encounters) are for patients who present with signs, symptoms.
May 13th, 2022by Mary Beth Pace, RN BSN MBA ACM CMAC
Do you keep them under inpatient status? Or do you bring them in as outpatients and just keep them overnight? For our Medicare populations, in all of our organizations, the ability to follow the CPT code of the applicable surgical procedure is the determining factor to bill inpatient.
May 11th, 2022by SAMSHA Newsroom
New Resources to Help People Seeking Care to Understand and Access Protections Offered Under the Parity Law for Mental Health and Substance Use Disorder Benefits
May 4th, 2022by Knicole C. Emanuel, Esq.
Medicare providers are your claims clean? Federal regulations mandate that 90 percent of “clean claims” must be paid to healthcare providers within 30 days. But what if the payor doesn’t pay within 30 days? What if your claims are unclean? The problem is – who determines what a.
Apr 21st, 2022by CMS - MLNConnects
News - Ambulance Prior Authorization Model Expands April 1 - Nutrition-related Health Conditions: Recommend Medicare Preventive Services - Claims, Pricers, & Codes - HCPCS Application Summaries & Coding Decisions: Drugs and Biologicals - Events - ICD-10 Coordination & Maintenance Committee Meeting — March.
Apr 19th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Does your documentation meet the standards for reporting therapeutic, prophylactic, and diagnostic infusions and injections? Take a minute to infuse yourself with the information needed to accurately code and sequence these services for maximum reimbursement.
Mar 31st, 2022by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step .
Mar 2nd, 2022by Wyn Staheli, Director of Content - innoviHealth
Excludes1 edits can cause problems with claim denials. It is important to watch for annual changes to the Excludes1 and Excludes2 edits. Know the rules to properly submit and appeal claims.
Feb 15th, 2022by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Representing the methodologies used in the VA's pricing determinations is better understood coming directly from the source or an attorney who is familiar with the laws. Our responsibility is to educate you with information directly from the source, where you can find your answers or contact them directly. We are happy to .
Feb 10th, 2022by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
The new guidelines for evaluation and management (E/M) services 99202-99215 refer to social determinants of health (SDoH) on the new or revised Table of Risk. Healthcare professionals have long hoped for the ability to score these problematic patient conditions in a meaningful way, not only for reimbursement, but also for quality of care and treatment options. SDoH codes recently added to the ICD-10-CM codeset continue to impress upon us the importance of identifying and reporting these patient issues and when combined with the new table of risk for scoring the E/M service, can impact reimbursement and care.
Sep 2nd, 2021by Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Jun 23rd, 2021by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
As per customer request, Find-A-Code now offers UCR Anesthesia Fee Calculations along with CMS and ASA. The anesthesia fee calculations can be found under the Fees section of the code and under the Anesthesia Fee Information. Time units are computed by dividing the reported anesthesia time by 15 minutes (17 minutes / 15 minutes = 1.13 units). NOTE: Always .
Dec 8th, 2020by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. .
Dec 8th, 2020by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs .
Nov 18th, 2020by Raquel Shumway
Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.
Sep 23rd, 2020by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to .
Jul 9th, 2020by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS .