Dear All,
You may want to pour a hot cup of coffee, tea or whatever else calms you before you read this; especially if you are in network with medical insurance carriers.
Every January 1st CMS publishes a new fee schedule that includes not only fees, but also which codes qualify for an assistant surgeon, which ones qualify for bilateral procedures and which ones follow the multiple procedure discount.
Sneaky, sneaky, sneaky…as of January 1, 2023 CMS changed the criteria for extractions and assigned what they call a payment indicator “2” for multiple procedures. Click here for a link to the CMS fee schedule that was updated.
“Standard payment rules apply, if the procedure is reported on the same day as another procedure with a numeric designation of 1, 2, or 3, rank each procedure by the fee schedule amount and the appropriate reduction: Highest valued procedure: 100%, second, third, fourth and fifth valued procedure 50%. Each procedure beyond the fifth: By report”
So, what does this mean? This means that for any carrier that follows the guidelines of CMS (yes, many BCBS plans, commercial plans, etc.) you will get paid 100% for the first extraction and 50% for each additional extraction. A set of third molars with a plan that follows these guidelines will pay you 100% for the first tooth and 50% for each additional tooth. There will be no appealing and if you are in network there will be nothing you can do about this.
For example, if the insurance allowable for a D7240 is $500, the carrier will process as follows if they follow CMS guidelines:
Tooth #1 D7240, payment $500
Tooth #16 D7240, payment $250
Tooth #17 D7240, payment $250
Tooth #32 D7240, payment $250
Total amount received: $1250
Under this formula prior to January 1st the same carrier with the same allowable would have paid:
Tooth #1 D7240, payment $500
Tooth #16 D7240, payment $500
Tooth #17 D7240, payment $500
Tooth #32 D7240, payment $500
Total amount received: $2000
How can this happen and why didn’t we know? When it comes to CMS, if it was published, then you were notified! Deep within all of your medical contracts it does have language about payment guidelines, whether or not they follow CMS, etc. If they do, your eobs should be starting to look a bit strange.
So now what? Pay attention to your eobs and watch to see if the carriers are enforcing these new guidelines. AAOMS is aware and is working with CMS to see if they can get this overturned. In the meantime, although there is no recourse, be vigilant and perhaps it’s a good time to review your contracts!
