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Jurisdiction 1 Part B
2012 Medicare Part B Revised Fee Schedule Update: Northern California

The Northern California 2012 revised Medicare Part B Fee Schedule is now available and is effective for services performed on or after January 1, 2012. 

2012 Medicare Part B Fee Schedule
Effective Date File Type
California: Area 03
(Marin, Napa and Solano Counties)
1/1/2012

Excel File (XLS, 1 MB)
California: Area 05
(San Francisco County)
1/1/2012

Excel File (XLS, 1 MB)
California: Area 06
(San Mateo County
1/1/2012
 Excel File (XLS, 1 MB)
California: Area 07
(Alameda and Contra Costa Counties)
1/1/2012

Excel File (XLS, 1 MB)
California: Area 09
(Santa Clara County)
1/1/2012
 Excel File (XLS, 1 MB)
California: Area 99
(All other Northern California Counties)
1/1/2012
 Excel File (XLS, 1 MB)

The 2012 fee schedule will contain the following: 

Heading Definition
   Codes with the 'F' symbol. If these procedures are performed in the hospital in/outpatient, emergency department, skilled nursing, inpatient psychiatric, comprehensive in/outpatient rehabilitation facility or ambulatory surgical center, they are subject to ‘Facility Setting’ amounts. 
PROCEDURE CODE/MOD
 Procedure code and modifier: CPT codes and modifiers begin with a numeric character and HCPCS codes and modifiers begin with an alpha character.
PAR FEE  
 Participating fee schedule amount. 
NONPAR FEE
 Non-participating fee schedule amount.
LIMITING CHARGE
 Limiting charge for non-participating physicians. The limiting charge equals 115 percent of the nonparticipating fee schedule amount. The limiting charge applies to non-assigned claims. Under public law NO. 99-509, The Omnibus Budget Reconciliation Act, there continue to be limits on the charges to Medicare beneficiaries which may be made by non-participating physicians. If a physician violates these limits, he or she may be subject to sanctions such as exclusion from the Medicare Program and/or the payment of civil monetary penalties ($2,000 each service frequency). 

If you have elected to be a participant during 2012, the limiting charges indicated on the report will not pertain to your practice. The non-participating fee schedule amounts and limiting charges do not apply to services or supplies unless they are paid under the physician fee schedule. Limiting charge applies to unassigned claims by non-participating providers. All services provided to Medicare beneficiaries are subject to audit and documentation requirements.

Clinical Social Workers
Reimbursements for all clinical social worker (CSW - specialty 80) services reimbursement amounts remain, as set by law, at 75 percent of the clinical psychologist reimbursement level.

Facility Setting Payment Differential
As part of the resource-based practice expense initiative, the Centers for Medicare & Medicaid Services (CMS) has replaced the previous policy that systematically reduced the practice expense relative value units (RVUs) by 50 percent for certain procedures performed in facilities with a policy that would generally identify two different levels (facility and nonfacility) of practice expense RVUs for each procedure code depending on the location of the service.

Some services, by the nature of their codes, are performed only in certain settings and will have only one level of practice expense RVU per code. Many of these are evaluation and management codes with code descriptions specific as to the location of the service. Other services, such as most major surgical services with a 90-day global period, are performed entirely or almost entirely in the hospital, and those services generally are provided with a practice expense RVU only for the out-of-office or facility setting.

The higher nonfacility practice expense RVUs are generally used to calculate payments for services performed in a physician’s office and for services furnished to a patient in the patient’s home; facility; or institution other than a hospital, skilled nursing facility (SNF), or ambulatory surgical center (ASC). For these services, the physician typically bears the cost of resources, such as labor, medical supplies and medical equipment associated with the physician’s service.

The lower facility practice expense RVUs generally are used to calculate payments for physicians’ services furnished to hospital, SNF and ASC patients. The cost for non-physicians’ services and other items, including medical equipment and supplies, are typically borne by the hospital, SNF or ASC.

The facility-based fees are linked to their own separate RVUs independent of the nonfacility fee RVUs. This differs from the former site-of-service fee reductions, which were based simply on a percentage reduction of the full fee rather than a separate RVU.

2012 Non-physician Practitioner Fee Schedule
Sections 4511 and 4512 of the Balanced Budget Act of 1997 (BBA) provide that payment for the professional services of these non-physician practitioners will be linked to the physician fee schedule.

Payment may be made for services furnished by nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNs) in all settings permitted by state law, but only if no facility or other provider charges are paid in connection with the service. Payment would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule. Payment for a PA’s services may only be made to the PA’s employer. Under certain circumstances, a PA as an independent contractor qualifies as an employment relationship where payment is made to the employer.

Practitioners Subject to Mandatory Assignment
Some practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed charge amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus the 20 percent coinsurance. The following practitioners must accept assignment for all Medicare covered services they furnish, and carriers do not send a participation enrollment package to these practitioners. The non-participating fee schedule amounts and limiting charges do not apply to services rendered by:

  • Specialty 32 - Anesthesiologist assistants (AAs)
  • Specialty 42 - Certified nurse midwives
  • Specialty 43 - Certified registered nurse anesthetists (CRNAs)
  • Specialty 50 - NPs
  • Specialty 68 - Clinical psychologists
  • Specialty 71 - Registered dietitians/nutritionists
  • Specialty 73 - Mass immunization roster billers
  • Specialty 80 - Clinical social workers
  • Specialty 89 - CNs
  • Specialty 97 - Physician assistants
Note: The provider type 'mass immunization biller' (specialty 73) can bill only for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.

 

last updated on 01/06/2012
ver 1.0.37