Form CMS-10422 Reimbursement Template - Physician Services (Increased P

Attachment 4.19-B page XXXX
Reimbursement Template -Physician Services
Increased Primary Care Service Payment 42 CFR 447.405, 447.210, 447.415
Attachment 4.19-B: Physician Services 42 CFR 447.405 Amount of Minimum Payment
The state reimburses for services provided by physicians meeting the requirements of 42 CFR
447.400(a) at the Medicare Part B fee schedule rate using the Medicare physician fee schedule
rate in effect in calendar years 2015 and 2016 or, if greater, the payment rates that would be
applicable in those years using the calendar year 2009 Medicare physician fee schedule
conversion factor. If there is no applicable rate established by Medicare, the state uses the rate
specified in a fee schedule established and announced by CMS.
☐ The rates reflect all Medicare site of service and locality adjustments.
☐ The rates do not reflect site of service adjustments, but reimburse at the Medicare rate

applicable to the office setting.
☐ The rates reflect all Medicare geographic/locality adjustments.
☐ The rates are statewide and reflect the mean value over all counties for each of the specified

evaluation and management and vaccine billing codes.
The following formula was used to determine the mean rate over all counties for each
code:________________________________________________________________
Method of Payment
☐ The state has adjusted its fee schedule to make payment at the higher rate for each E&M and

vaccine administration code.
☐ The state reimburses a supplemental amount equal to the difference between the Medicaid

rate in effect on July 1, 2009 and the minimum payment required at 42 CFR 447.405.
Supplemental payment is made: ☐monthly ☐quarterly ☐semi-annually ☐annually
Primary Care Services Affected by this Payment Methodology
☐ This payment applies to all Evaluation and Management (E&M) billing codes 99201 through

99499.
☐ The State did not make payment as of July 1, 2009 for the following codes and will not make

payment for those codes under this SPA (specify codes).
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Attachment 4.19-B page XXXX
☐ The state will make payment under this SPA for the following codes which have been added

to the fee schedule since July 1, 2009 (specify code and date added).
___________________________________________________________________________
___________________________________________________________________________

Effective Date of Payment
This reimbursement methodology applies to services delivered on and after January 1, 2013,
ending on _________ but not prior to December 31, 2016. All rates are published at (insert
agency website).

Supercedes Page: _____