Imaging Procedure Pricing calculation

Imaging Procedure Pricing for Multiple Procedure Reduction and OPPS Cap Worksheet Example

1. Look up the TC of the procedure on the Medicare Fee Schedule on TrailBlazer’s Web site at: http://www.trailblazerhealth.com/Payment/Fee Schedules/.

2. Check the Diagnostic Imaging Indicator. The multiple procedure reduction applies to codes within the same family (same indicator).

3. List the Medicare Fee Schedule amount (listed under Non-Facility Fee), either Par or Non-Par, whichever is appropriate. Repeat this step for all procedures.

4. Determine the ranking of all imaging procedures within the same family.

5. The procedure with the highest allowed amount is not reduced. All other procedures within the same family are reduced by 50 percent. In this step, list the full Medicare Fee Schedule amount for the primary procedure and the product of the Medicare Fee Schedule multiplied by 50 percent for the subsequent procedures.

6. List the OPPS Cap Non-Facility Fee, either Par or Non-Par, whichever is appropriate.

7. Compare the adjusted fee amounts from step 5 to the OPPS amount from step 6. The correct Medicare-allowed amount is the lower of the two amounts from steps 5 and 6.