Medicare Physician’s Fee Schedule Indicator Descriptions

The following post is to provide description to the indicators used on the Medicare Physician’s Fee Schedule.

Multiple Procedure Indicator

• 0 = Criteria does not apply
• 1 = Standard multiple surgery criteria applies. Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply. In the 1996 Medicare Physician’s Fee Schedule Indicator Descriptions, this indicator only applies to codes with procedure status of “D”.
• 2 = Standard multiple surgery criteria applies (January 1, 1996, and after).
• 3 = Endoscopic criteria applies
• 4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services on or after January 1, 2006 through June 30, 2010). Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after).
• 5 = Subject to 20% reduction of the practice expense component for certain therapy services (effective for services January 1, 2011 and after).
• 9 = Concept does not apply

Bilateral Surgery Indicator

• 0 = Bilateral does not apply
• 1 = Valid for bilateral – criteria does apply
• 2 = Money is already established for bilateral.
• 3 = Radiological procedures or diagnostic tests. Bilateral criteria does not apply
• 9 = Concept does not apply

Assistant Surgery Indicator

• 0 = Payment restriction – must have supporting documentation.
• 1 = Assistant at surgery cannot be paid.
• 2 = Assistant at surgery can be paid
• 9 = Concept does not apply.

Co-Surgery Indicator – Skills of two surgeons (Surgeons must be of different specialties)

• 0 = Co surgery not payable
• 1 = Can be paid with medical necessity established by documentation
• 2 = Co-surgeons permitted; no documentation required if two specialty requirements met
• 9 = Concept does not apply

Global Period

The field provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service.

• 000- Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.
• 010 – Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10 day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during this 10 day postoperative period generally not payable.
• 090 – Major surgery with a 1 day preoperative period and 90 day postoperative period included in the fee schedule payment amount.
• MMM – Maternity codes; usual global period does not apply
• XXX – Global concept does not apply
• YYY – Carrier determines whether global concept applies and establishes postoperative period, if appropriate, at time of pricing
• ZZZ – Code related to another service and is always included in the global period of the other service.

Facility setting A

A’#’ in this field indicates when facility pricing applies.

Conversion Factor

This is a single national number that is used by all carriers in calculating payments under the Medicare fee schedule. It transforms relative value units into payment amounts.

Work RVU – the physician work required for the service. The work component of the RVU is based on the time required to furnish the service, the intensity of the effort, and the technical skills required.

Practice RVU – the practice expenses involved such as office rent, salaries of office staff, and supplies.

Malpractice RVU – the professional malpractice liability premiums.

Facility RVU – the resource based practice expense relative units for facility settings.

Non Facility RVU – the resource based practice expense relative value units for non facility settings

Work GPCI – the geographic practice cost index that reflects the variation in work practice costs from area to area.

Practice GPCI – the geographic practice cost index that reflects the variation in practice costs from area to area

Malpractice GPCI – the geographic practice cost index that reflects the variation in malpractice costs from area to area

Status

Status of each code under the full fee schedule. The definition of each status code is at the end of the field descriptions.

Definitions of Status Codes Indicators:

• A = Active Code. These codes are separately paid under the physician fee schedule if covered. There will be RVUs and payment amounts for codes with this status. The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare Policy.
• B = Payment for covered services are always bundled into payment for other services not specified. There will be no RVUs or payment amounts for these codes and no separate payment is ever made. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident (an example is a telephone call from a hospital nurse regarding care of a patient).
• C = Carriers price the code. Carriers will establish RVUS and payment amounts for these services. Generally on an individual case basis following review of documentation such as an operative report.
• E = Excluded from physician fee schedule by regulation. These codes are for items and/or services that CMS chose to exclude from the fee schedule payment by regulation. NO RVUS or payment amounts are shown and no payment may be made under the fee schedule for these codes. Payment for these codes, when covered continues under reasonable charge procedures.
• I = Invalid code. No grace period for this status.
• N = Non-covered services. These codes are carried on the HCPCS tape as non-covered services.
• P = Bundled/excluded codes. There are no RVUS and no payment amounts for these services.
• No separate payment should be made for them under the fee schedule.
• If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident (an example is an elastic bandage furnished by a physician incident to a physician service).
• If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (for example, colostomy supplies) and would be paid under the other payment provisions of the act.
• R = Restricted coverage. Special coverage instructions apply.
• T = There are RVUS and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made.
• X = Statutory exclusion. These codes represent an item or service that is not in the statutory definition of “physician services” for fee schedule payment purposes. No RVUS or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule (examples are ambulance services and clinical diagnostic laboratory services).

PC/TC (Professional Component / Technical Component)

• 0 = Full Service only (Physician Service Codes) -26 and -TC modifiers are not valid.
• 1 = Diagnostic tests or radiology services -26 and -TC modifiers are valid.
• 2 = Professional component only codes -26 and -TC modifiers are not valid.
• 3 = Technical component only codes -26 and TC modifiers are not valid.
• 4 = Global test only codes. -26 and -TC modifiers are not valid.
• 5 = “Incident to” codes (payment may not be made for In-Hospital, or Out-patient.) -26 and -TC modifiers are not valid.
• 6 = Clinical laboratory codes (laboratory physician interpretation codes) -26 modifier is valid, -TC modifier is not valid.
• 7 = Physical therapy service. (payment may not be made for an inpatient or outpatient POS by an independently practicing physical or occupational therapist.
• 8 = Physician interpretation codes of clinical laboratory codes. (indicator identifies the professional component of clinical laboratory codes for which separate payment may only be made if the physician interprets an abnormal smear for a hospital inpatient. This applies to code 85060.) -TC modifier is not valid.
• 9 = Concept of a professional/technical component does not apply. -26 and -TC modifiers are not valid.

Limiting charge

The maximum amount that non-participating providers may bill their Medicare patients on non-assigned claims. The limiting charge is equal to 115 percent of the non-participating allowance.