BASIC (09-06)

DI 39545.675 Exhibit 3 – DDS Guide to Establishing a Fee Schedule

The following guide is for DDSs that elect to use the Medicare fee schedule to establish the DDS fee schedule. It is not intended for DDSs that currently use a fee schedule based on fees paid by other agencies in the State.

A. Obtain a copy of the Medicare physician fee schedule

CMS website

  • Identify the State Medicare carrier and obtain a copy of the Medicare Provider Program Fee Schedule and the Clinical Laboratory Fee Schedule for the current year.

  • NOTE: States with different “localities” should obtain applicable Medicare Provider Program Fee Schedules from each carrier for each locality.

  • Obtain annual updates of the Medicare fee schedule to ensure that the DDS fee schedule is current.

B. Obtain a current procedural terminology (CPT) codebook

AMA website

  • DDSs should obtain a copy of the CPT and purchase updates each year. The AMA publishes the CPT Codebook annually.

  • CMS bases Medicare fees upon services and procedures using CPT coding system.

  • CPT is also available online from the SSA Digital Library. Click Code Manager .

C. Identify a CPT code for each CE service the DDS orders

Use the DDS CE list of special examinations and ancillary studies to identify the CPT code used for the same or similar service.

D. Use the Medicare fee schedule to determine the Medicare fee for each service ordered by the DDS

  • Document the DDS code that matches the CPT code for each specific exam/ancillary study.

  • Annotate the CPT code as the control code. For each CPT control code, document the DDS fee along with each Medicare fee.

E. Compare and ensure the DDS fee schedule does not exceed the regulatory requirements (20 CFR 404.1624)

Using the Medicare fee schedule as the basis for the DDS fee schedule is not intended to increase the DDS CE fees. DDSs should negotiate the best possible fee for the service.

In States with different localities, it may not be necessary to create a different DDS fee schedule for each locality. The highest fee paid should not be readily adopted. The existence of different “locality” schedules may help the DDS negotiate more competitive rates with providers. If a DDS is unable to obtain providers in certain areas who will accept the Medicare rate, they should contact the RO for further guidance.

F. Maintain fee schedule documentation

  • DDS should ensure RO has a current copy of its fee schedule documentation.

  • Medicare fees are subject to change. When notified of any Medicare fee changes review the fee schedule and revise the chart.

  • Prepare a new chart when the new Medicare fees are published each year.

The following chart is an example of how to document the fee schedule regardless of whether it is based on the Medicare fee schedule or a State agency fee schedule.

(DDS NAME) CE FEE SCHEDULE - FEE SCHEDULE YEAR YYYY

SERVICE

STATE/DDS CODE

CPT CODE

CPT PAGE

STATE FEE

MEDICARE FEE

DDS FEE

Ankle x-ray

00001

73600

260

$25.00

$30.00

$30.00

Internal Medicine Exam

60001

99243

16

$105.00

$84.00

$92.00

WAIS III