Medicare Part B

Medicare Part B Reimbursement Information

The reimbursement rates for Medicare Part B vary somewhat throughout the US because they are calculated based on the average cost of living for a given region. The rates given in this section are for two counties in the San Francisco Bay Area where the cost of living (and hence rates you’ll be shown) are somewhat higher than the national average. The full part B fee schedule for the region is linked here but the rates are filed by billing (CPT) code and there are over ten thousand separate fees listed. To Make things simple I’ll stick to the rates paid for the most common medical services.

Also remember, if you have Medicare Part B you’re only responsible for twenty percent of any of these rates once you’ve met your $147 annual deductible.

Office visits:

Most codes for seeing a doctor begin with the number 992. A 99201, for example, is what a doctor would bill if he saw a new patient in his office for a very brief visit. (This is a code most doctors never use by the way). If a doctor were to bill this code Medicare would approve a total of $50.83; $40.66 would be paid by Medicare and $10.17 would be the patient’s portion after meeting their deductible.

The most common codes a doctor will use for follow up office visits are 99213 (follow up office visit, low complexity) and 99214 (follow up office visit, moderate complexity). A 99213 pays $83.08 in this region ($66.46 from Medicare and $16.62 from the patient). A 99214 pays $121.45 ($97.16 from Medicare and $24.29 from the patient).

For new patient visits most doctors will bill 99203 (low complexity) or 99204 (moderate complexity) These codes pay $122.69 and $184.52 respectively. So, if you see a new doctor and your medical case is moderately complex you could expect to pay almost $37 for that visit. Most people don’t see a new doctor every year, though, and most medical cases aren’t all that complex.

The highest rate for a doctor visit you’ll see on that list is for a 99291. That’s what a doctor will bill when they see you for the first time during a hospital admission and you’re in the intensive care unit (usually you have to also be on a ventilator to justify that code). That code pays $302.77 (so you would owe just over $60 of co-insurance for that encounter)

X-Rays:

Most Radiology codes start with a 7. For example a 71020 is the code for a two view chest x-ray and Medicare approves $36.86 for that test (so the co-insurance would be $7.37). a Three view x-ray of the lower back (72100) pays $44.03 so the co-insurance is $8.80. MRIs might cost as little as $342 for a simple MRI of the elbow without using any contrast dye (73221) to as much as nearly $900 for complex diagnostic MRIs used in the workup of some cancers. Most MRIs cost less than $600, though, so the co-insurance is normally less than $120.

Blood tests:

Medicare Part B now covers most routine blood tests at 100% but, if you do have to pay a co-insurance, it probably won’t be much. The billing codes for blood and pathology tests usually begin with 8 and, though some of the most routine tests are missing from the linked fee schedule, here is the price list for most of them. Medicare pays between $10 and $30 for most standard blood tests so the co-insurance (if you did pay) would be between $2 and $6 per test.