Mary presents for an examination at Dr. Frank's office. The coder assigns an Evaluation and Management code 99213 to the day's service. The provider's charge for a 99213 code is $100. After calculating the allowable amount and determining Medicare allows 100% of the MFPS and it will pay 80% of the Medicare provider fee schedule allowable amount, Mary receives a bill from Dr. Frank's office for $24. Joan Little presents for an examination at Dr. Kappan's office, and she is assigned an Evaluation and Management code of 99213 for the day's service, with a provider charge of $100. After calculating the allowable amount and determining Medicare allows 95% of the MFPS and it will pay 80% of the Medicare provider fee schedule allowable amount, Joan receives a bill from Dr. Frank's office for $45. Why would Joan's Medicare reimbursement be calculated differently from Mary's when the providers' charges for the CPT code 99213 are the same and the same payer was billed?

Question

Quizplus · Accepted Answer

Mary's provider accepting assignment means Medicare pays the provider directly at the Medicare-approved rate, and the patient is responsible for the coinsurance. Joan's provider not accepting assignment can charge up to 15% over the Medicare-approved amount, leading to a higher bill for Joan.

Mary Presents for an Examination at Dr