CMS Pub. 100-04, ch. 1, § 30.3.12.3

B3-17002

Effective January 1, 1991, the maximum allowable actual charge (MAAC) for nonparticipating physicians is replaced by the limiting charge. The limiting charge is the

maximum that the non-participating provider may charge the beneficiary. It also

effectively replaces the special charge limits for overpriced procedure, anesthesia

associated with cataract and iridectomy surgery, A-mode ophthalmic ultrasound and

intraocular lenses (IOLs, and designated specialty, because the limiting charge is always

less than or equal to the special charge limits.

The limiting charge applies to all of the following services/supplies, regardless of who

provides or bills for them, if the services/supplies are covered by the Medicare program

and are provided:

• Physicians’ services;

• Services and supplies furnished incident to a physician’s services that are

commonly furnished in a physician’s office;

• Outpatient physical therapy services furnished by an independently practicing

physical therapist;

• Outpatient occupational therapy services furnished by an independently practicing

occupational therapist;

• Diagnostic tests; and

(or authorized representative

of participating organization)

(if signer is authorized

representative of organization)

Office phone number (including area code)_____________________

Received by (name of carrier)

Effective date _____________

Initials of carrier official__________

According to the Paperwork Reduction Act of 1995, no persons are required to respond to

a collection of information unless it displays a valid OMB control number. The valid OMB

control number for this information collection is 0938-0373. The time required to

complete this information collection is estimated to average 15 minutes per response,

including the time to review instructions, search existing data resources, gather the data

needed and complete and review the information collection. If you have any comments

concerning the accuracy of the time estimate(s) or suggestions for improving this form,

please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,

Baltimore, Maryland 21244-1850.

• Radiation therapy services (including x-ray, radium, and radioactive isotope

therapy, and materials and services of technicians).

NOTE: This means that, effective for services/supplies provided on or after January 1,

1994, the limiting charge applies to drugs and biologicals provided incident to

physicians’ services, to physical therapy services provided by independently practicing

physical therapists, and to occupational therapy services provided by independently

practicing occupational therapists. These changes are made because of provisions in

OBRA 1993. OBRA 1993 expanded the limiting charge to apply to services/supplies

which the law permits Medicare to pay for under the physician fee schedule methodology

but which Medicare has chosen to pay for under some other method. “Incident to” drugs

and biologicals, previously excluded from the limiting charge because of their exclusion

from physician fee schedule payment, are, effective January 1, 1994, still excluded from

physician fee schedule payment but subject to the limiting charge. Also, OBRA 1993

applies the limiting charge to all of the above listed services/supplies, regardless of who

provides or bills for the services/supplies. No longer are services of suppliers and other

nonphysicians, such as physician assistants, nurse midwives, and independently

practicing physical and occupational therapists, excluded from the limiting charge.

Physicians, non-physician practitioners, and suppliers must take assignment on claims for

drugs and biologicals furnished on or after February 1, 2001, under §114 of the Benefits

Improvement and Protection Act (BIPA).

Effective January 1, 1993, the limiting charge is 115 percent of the fee schedule amount

for nonparticipating physicians.

EXAMPLE:

Participating fee schedule amount $2000

Nonparticipating fee schedule amount $1900 (95% of $2000)

Limiting charge $2185 ($1900 times 1.15)

Charges to either a payer for whom Medicare is secondary or to a payer under the indirect

payment procedure are not subject to the limiting charge if the physician accepts the

payment received as full payment (i.e., if there is no payment by the beneficiary).

The provider may round the limiting charge to the nearest dollar if they do so consistently

for all services.