Program Operations Manual System (POMS)
DI 39545.625 Developing Fee Schedules
Each State is required to develop a fee schedule to be used by the DDS for payment of consultative examinations (CEs).
B. Procedure – developing a fee schedule
DDSs may use a Federal fee schedule or a fee schedule used by another agency in that State to purchase similar services. The other agency could be the DDS parent agency, another agency within the same department or bureau as the DDS or any other agency in the State, provided similar types of tests and services purchased by the DDS are also purchased by the other agency.
When possible, the DDS should crosswalk items in the State fee schedule to the American Medical Association’s (AMA) Current Procedural Terminology (CPT) coding system.
NOTE: Crosswalk refers to the process of converting the DDS code for an examination to the Medicare code for the same or similar examination.
If the DDS does not use an existing State fee schedule, the maximum payment rate will be based on the Medicare fee schedule. If the Federal fee schedule has different fees for different parts of the State, the DDS may establish one fee per test or service for the entire State, provided the fee is reasonable. DDSs should be familiar with the principles of CPT coding and link purchase items, where possible, to one or more specific procedural codes.
If State regulations or the parent agency requires the DDS to adopt a “usual and customary fee” schedule, establish procedures to verify such fees are reasonable and do not exceed the highest rate paid by other agencies in the State for similar services. The CE provider’s file will reflect the fee charged by the provider and the basis for determining such fee is acceptable. If the provider performs similar services for other State agencies, the file should include verification that these fees do not exceed what other agencies pay.
If the DDS has difficulty obtaining specific examinations or tests under either options DI 39545.625B.1. or DI 39545.625B.2., the DDS will submit a written waiver request to the RO Disability Program Administrator. Waiver request should include the following:
documentation of the difficulties in obtaining the necessary testing/source;
specific proposed fees with an explanation of how those fees were derived;
an analysis of projected change in annual medical costs.