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The Medicare Directory of Prevailing Charges: Fee Screen Year 1984

Introduction

This directory contains Fee Screen Year 1984 Medicare reimbursement data based on physician charges submitted to Medicare during the calendar year 1982 in each of the reasonable charge localities within each Part B carrier's service area.

Maps are provided for each State which outlines the separate charge districts (localities) the Carriers use in reimbursing claims under the Medicare program. The counties within each locality are listed to aid in identifying the exact geographic breakdowns. More detailed locality information can be obtained on selected carriers by referring to AppendixA in the back of the directory.

The directory was compiled from magnetic tapes submitted by each of the carriers. Every effort has been made to minimize errors in the data displayed for each of the carriers however because of differences in coding systems it may sometimes be necessary to consult directly with the carrier for clarification.

EXPLANATION OF MEDICARE CHARGE DATA

The dollar amounts shown in the directory are the prevailing charges in the indicated locality for each of the services listed. Except where there are unusual circumstances or medical complications so that more than the normal service is provided, these figures represent the highest dollar amounts that Medicare can use in determining the medical insurance benefits which can be paid on Medicare claims for services in the locality. Others factors, explained below, are also used in determining the medical insurance benefit that is payable.

How The Medicare Allowed Amount Is Determined

Under the law, the allowed amount for a given service shown on a medical insurance claim is generally the lowest of (1) the actual charge made by the physician for the service; (2) the customary charge generally made for that service by the physician; (3) the prevailing charge, which is the charge most physicians in the locality would find acceptable for that service; or (4) the charge that would be recognized by the carrier for its own (non-Medicare) subscribers or policyholders for the service.

The rules that are applicable in calculating the amounts allowed for physicians' services also apply to other services covered under the medical insurance program.

How The Medicare Prevailing Charge Is Determined

Under the law, just before the beginning of each fiscal year Medicare must review the actual charges billed by physicians in the preceding calendar year. The mid-point of these actual charges by a physician for a service is established as his customary charge for that service. The prevailing charge is then established at the 75th percentile of all the individual physician's customary charge for each service. In effect, the prevailing charge for any given service is the amount which is high enough to cover I full the customary charges of those physicians whose billings accounted for at least 75 percent of all claims for that service in the locality in the preceding calendar year.

The amount of prevailing charge recognized under Medicare is also affected by an additional program restraint. In accordance with Medicare law, prevailing charge levels for physicians services for any fiscal year after fiscal year 1973 may not exceed the fiscal year 1973 level except to the extent justified by an economic index that reflects changes in the costs of physician practice and in general earnings levels.

The prevailing charge data represents the Maximum amounts upon which reimbursement is based with the Medicare Part B program. It also reflects the influence of the Economic Index Provisions. For each locality, prevailing charges are listed for 29 medical services performed by General Practitioners (GP) and for 100 physicians services performed by medical Specialists. Where the carrier makes no specialty differentiation in its screens, the top of the page states "combined locality designation". Blank spaces in the prevailing charge columns indicate that (a) prevailing charge data was not collected for GP specialty category, (b) the procedure is not performed in the locality, or (c) the carrier does not use the same definition of the procedure as listed. When an asterisk ( *) appears beside a charge, it means that the charge is adjusted by the application of economic index. When a letter "P" appears next to a charge, the amount represents the Professional component only. The letter "L" stands for the lowest charge levels applying to selected laboratory and durable medical equipment screens. The physician procedure (excluding lab and DME) lists represent the amounts established at the "freeze" level and will continue to be in effect until October 1, 1985.

When reviewing the specialist charge screen data, it should be noted that the amounts represent the prevailing charge screen for the specialist who most frequently performs these procedures. Therefore, the procedure list in Table A contains the category of medical specialists for which charge screen data was collected for the 103 procedures. Seven additional procedures are listed for durable medical equipment.

If you have any questions about the data or locality information displayed in this directory, please direct your questions to James Barnett (301) 594- 6743), Health Care Financing Administration, Bureau of Program Operations, Room 367 Meadows East Building, 6325 Security Boulevard, Baltimore, Maryland 21207. For technical questions involving computer programming of the data, contact our Bureau of Support Services (301) 594-0810).

Originally published: Monday, February 18, 2019; most-recently modified: Friday, May 29, 2020

 

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