How do you determine fees for your office?

Several of my clients needed to learn more they should charge.  There are at least two ways to determine how much to charge for each code.  Get your list of codes that you are billing.  This step-by-step guide can help you choose the pricing of the codes.


1) Look for a blue hyperlink on the CMS website after “To start your search, go to…”

2) This will take you to an overview page.  Click the “Begin Search”

3) The next page is the “License for Use of Current Procedural Terminology.”  Hit “Accept” at the bottom of the page.

4) Select your year.

5) I use “All” for the type of information

6) HCPCS Criteria – I usually use Single, but you can filter it to what you need.

7) HCPCS code – Select your code.  For this, I will use 59400.

8) Modifiers – I use “All.”

9) MAC option-  I always restrict to “Specific Locality”

10) Specific Mac Locality –  I type in the state.  I will use Indiana for this guide.

11) Select “Search Fees”

12) The selections pull up a table with information on it.  It shows the code, a short description, MAC locality, Non-Facility Price, and so on.

The Non-Facility price is what is used for providers.  With my search, it is $2184.26.  Since OB/GYN is a specialty, I multiply that by 300%.  That is $6552.78.  I would assign code 59400 as $6552.78.

13) I generally choose 300% above the Medicare allowable for specialty physicians.  For physicians and non-physicians, I typically select 150% above the Medicare allowable.


The other way to determine the charge amount is if you are in-network with contracts.  You review your fee schedules given to you by the insurance company.  Review each code for the highest payment.  If United Healthcare pays the most for a specific code, price the code for more than that. For example, if United Healthcare pays $5900, you would want to charge $6200.

If you do not charge enough, the insurance will only pay that amount even if the contract shows it will pay more.  Therefore, it is important to review contracts based on the highest payment for that specific code.