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 they agree to accept Medicare's approved amount for the service as full payment, while Joan's provider not accepting assignment can charge more, leading to different reimbursement calculations.

Mary Presents for an Examination at Dr