Examples of calculating fee schedule maximums using the administrative rules:
Effective July 1, 2008
Simple office visits:
Dr. Smith sees Mr. Jones for a follow-up visit lasting 15 minutes and an expanded problem focused history and examination are completed. Dr. Smith bills $120.00 using CPT® code 99213 and includes a chart note documenting the services provided. The RVU for CPT® code 99213 is 1.67 and the applicable conversion factor is $64.79. The maximum allowable under the fee schedule is $108.20 (1.67 x $64.79). Dr. Smith is paid the fee schedule amount of $108.20 for the services provided.
Ms. Smith, PA, sees Mr. Jones for a follow-up visit lasting 15 minutes and an expanded problem-focused history and examination are completed. Ms. Smith bills $82.00 using CPT® code 99213-81 and includes a chart note documenting the services provided and that the services were provided by a physician assistant. The RVU for CPT® code 99213 is 1.67 and the applicable conversion factor is $64.79. The maximum allowable under the fee schedule for a physician is $108.20 (1.67 x $64.79). The maximum allowable under the fee schedule for a physician assistant is $91.97 ($108.20 x 85%). Ms. Smith is paid $82.00 for the services provided.
Services at an ASC:
Mr. Jones is in need of arthroscopic knee surgery and Dr. Cotter provides it at an ASC. Dr. Cotter and the ASC will each bill. Dr. Cotter bills and is paid for performing the surgery. The ASC bills and is paid for providing the facility for the surgery.
Dr. Cotter bills $2500.00 using CPT® code 29880. The RVU for CPT® code 29880 is 17.66 and the applicable conversion factor is $86.44. Dr. Cotter is paid $1526.53 (17.66 x $86.44) for performing the surgery.
The ASC bills $3100 using CPT® code 29880-SG and provides a copy of the operative report. The ASC group number assigned by the Division 009 rules for CPT® code 29880 is 6, and the maximum allowable fee under Oregon workers' compensation for group 6 is $2108.00. The ASC is paid $2108.00 for providing the facility used by Dr. Cotter for the surgery.
Outpatient Physical Therapy:
Dr. Cotter prescribes physical therapy for Mr. Jones. Mr. Jones goes to Salem Hospital for his therapy. The hospital bills a total of $129.00:
$30.00 for CPT® code 97032 (RVU is 0.44);
$51.00 for CPT® code 97140 (RVU is 0.71); and,
$48.00 for CPT® code 97110 (RVU is 0.76).
The applicable conversion factor for each of these CPT® codes is
The maximum allowable under the fee schedule for:
CPT® code 97032 is $28.28 (0.43 x $65.79);
CPT® code 97140 is $46.05 (0.70 x $65.79); and,
CPT® code 97110 is $49.34 (0.75 x $65.79).
Salem Hospital is paid $122.33 ($28.28 + $46.05 + $48.00) for the outpatient therapy services. On the final reimbursement, $48 is paid for services under CPT® code 97110 since it is the lesser of the fee schedule and the actual charge.
Emergency Room visits:
Mr. Jones goes to the emergency room at Providence Portland Medical Center on July 14, 2008 and is examined by Dr. Meyer. Providence bills: $250.00 using revenue code 0981 and CPT® code 99284 (RVU is 3.17) for services provided by Dr. Meyer and $335.00 for the use of the emergency room, using revenue code 0450 and also using CPT® code 99284 as required by Medicare for a total of $585.00.
The charges for the physician's services ($250.00) are subtracted from the billed total ($585.00) and paid using the applicable conversion factor ($64.79) and RVU. The adjusted cost/charge ratio is applied to the remaining balance of $335.00 ($585.00 - $250.00). The adjusted cost/charge ratio for Providence Portland Medical Center (see Bulletin 290) is (0.512).
Providence Portland Medical Center is paid:
$205.38 (3.17 x $64.79) for services provided by Dr. Meyer; the adjusted cost/charge ratio(0.512) is multiplied by the remaining balance of $335.00 for a payment of $171.52. Providence Portland Medical Center is paid a total of $376.90 ($205.38 + $171.52) for the services provided to Mr. Jones.
Dr. Hill sees Mr. Jones at Willamette Falls Hospital emergency room on July 14, 2008. Dr. Hill orders x-rays. Willamette Falls bills:
$335.00 for use of the emergency room using revenue code 0450 and CPT® code 99284; and,
$110.00 using revenue code 0329 and CPT® code 72110-TC2 for taking the x-rays for a total of $445.00.
Willamette Falls is paid:
The adjusted cost/charge ratio of 0.564 for Willamette Falls Hospital is multiplied by the balance of $445.00 for a payment of $250.98 for services provided on July 14, 2008.
Dr. Hill bills $250.00 using CPT® code 99284 (RVU is 3.17) for the services he provided in the emergency room on July 14, 2007. Dr Hill is paid $189.53 (3.17 x $59.79).
Dr. Scott bills $55.00 for interpreting the x-rays using CPT® code 72110-263 (RVU is 0.42). Dr. Scott is paid $28.56 (0.42 x $ 68.00) for the report interpreting the July 14, 2007 x-rays.
2"TC" is the modifier used for the technical component of a service
3 "26" is the modifier used for the professional component of a service.
Medical Fee Dispute Request:
When a dispute about fees exists between a provider and an insurer, a provider, insurer, or injured worker may request review by the director. A request for review must be submitted to the director within 90 days of the date the aggrieved party knew or should have known that the dispute existed.
Use these forms to request review:
Medical Fee Dispute Resolution Request (Form 2842)
Medical Fee Dispute Resolution Worksheet (Form 2842a)
Questions? Contact us at 503-947-7606 or e-mail firstname.lastname@example.org.