Description
The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Documentation will be reviewed to determine if professional services that affecting MPFS payment meet Medicare coverage criteria and applicable coding guidelines.
Affected Code(s)
CMS MPFS status code “A”
Applicable Policy References
1. 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
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §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
6. 42 CFR §405.986- – Establishing Good Cause for Reopening
7. 42 CFR §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
8. 42 CFR §414.40- Coding and Ancillary Policies
9. 42 CFR §415- Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings
10. 42 CFR §419.44- Payment Reductions for Procedures
11. Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners
12. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements
13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
14. American Medical Association (AMA), Current Procedural Terminology (CPT)
15. American Medical Association (AMA), Healthcare Common Procedure Coding System (HCPCS) Level II
16. American Medical Association (AMA) Current Procedural Terminology (CPT) Assistant
17. National Correct Coding Initiatives (NCCI) Policy Manual
18. CMS Physician Fee Schedule, Relative Value Files