Thursday, January 28, 2016

Examples for the limiting charge after applying the EHR and PQRS negative adjustments



Non-Par Non-Assigned Claim No EHR/PQRS Adjustment:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
Adjustment Total $5.00
MPFS Allowed Amount $100-$5.00= $95.00
Limiting Charge Allowed= $95.00 x 115%= $109.25

Non-Par Non-Assigned Claim with EHR Adjustment:
Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1% EHR negative adjustment $.95 (95 x.01)
Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
Limiting Charge Allowed= $94.05 x 115%= $108.16

Non-Par Non-Assigned Claim with PQRS Adjustment:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1.5% PQRS negative adjustment $1.43 (95 x.015)
Adjustment Total $ 6.43
MPFS Allowed Amount $100-$6.43= $93.57
Limiting Charge Allowed= $93.57 x 115%= $107.61

Non-Par Non-Assigned Claim with EHR + e-prescribing:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x.02)
Adjustment Total $ 6.90
MPFS Allowed Amount $100-$6.90= $93.10
Limiting Charge Allowed= $93.10 x 115%= $107.07

Non-Par Non-Assigned Claim with EHR without 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
1% EHR negative adjustment $.95 (95 x .01)
EHR Adjustment Total $5.95
MPFS Allowed Amount $100-$5.95= $94.05
1.5% PQRS negative adjustment $1.41 ($94.05 x .015)
PQRS Adjustment Total $94.05-$1.41=$92.64
MPFS Allowed Amount $92.64
Limiting Charge Allowed= $92.64 x 115%= $106.54

Non-Par Non-Assigned Claim with EHR with 2014 e-Prescribing Adjustment + PQRS:

Original Fee Schedule Amount: $100
5% non-PAR status: $5 (100 x .05)
2% EHR negative adjustment $1.90 (95 x .02)
EHR Adjustment Total $6.90
MPFS Allowed Amount $100-$6.90= $93.10
1.5% PQRS negative adjustment $1.40 (93.10 x .015)
PQRS Adjustment Total $93.10-$1.40=$91.70
MPFS Allowed Amount $91.70


Limiting Charge Allowed= $91.70 x 115%= $105.46

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