Georgia Medicare Physician Services Benefit

::: hero

By Brevy Care Team · Last verified May 13, 2026

Physician services are the backbone of Medicare Part B and the single largest category of outpatient Medicare spending. Section 1861(q) of the Social Security Act defines "physicians' services" as professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls. Section 1861(r) defines who qualifies as a "physician" for Medicare purposes: doctors of medicine and osteopathy, dentists (for limited services), podiatrists, optometrists, and chiropractors (for manual spinal manipulation only). Section 1848 establishes the Medicare Physician Fee Schedule under the Resource-Based Relative Value Scale introduced by the Omnibus Budget Reconciliation Act of 1989 effective January 1, 1992. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) permanently repealed the Sustainable Growth Rate formula and replaced it with the Quality Payment Program consisting of the Merit-based Incentive Payment System and Advanced Alternative Payment Models. Section 1842 governs physician participation, assignment, and limiting charge rules that protect beneficiaries from unlimited balance billing. Section 1877 (Stark Law) prohibits physician self-referral for designated health services. This guide explains the federal statutory and regulatory framework, the MPFS payment formula, the MACRA QPP, participation status options, the limiting charge protection, the Stark Law framework, and how Georgia beneficiaries access physician services through hospital-employed groups, independent practices, multi-specialty clinics, and academic medical centers. :::

::: callout Key takeaways for Georgia Medicare physician services:

1. Section 1861(q) of the Social Security Act defines "physicians' services" as professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls. Section 1861(s)(2)(A) includes physician services within "medical and other health services" covered under Medicare Part B.

2. Section 1861(r) defines who qualifies as a "physician" for Medicare: doctors of medicine and osteopathy (MD/DO), doctors of dental surgery/medicine (for limited services typically tied to medical conditions), podiatrists, optometrists, and chiropractors (limited to manual spinal manipulation for subluxation only).

3. Section 1848 establishes the Medicare Physician Fee Schedule under the Resource-Based Relative Value Scale (RBRVS), enacted by OBRA 1989 and effective January 1, 1992. Payment equals (Work RVU x Work GPCI + Practice Expense RVU x PE GPCI + Malpractice RVU x MP GPCI) x Conversion Factor.

4. The MACRA 2015 Quality Payment Program permanently repealed the Sustainable Growth Rate formula. MIPS (Merit-based Incentive Payment System) adjusts physician payment by up to plus or minus 9% based on Quality, Cost, Improvement Activities, and Promoting Interoperability performance. Advanced APMs offer additional incentives for risk-bearing physicians.

5. Section 1842 participation status options include participating (PAR, accepts assignment for all services, 100% fee schedule), non-participating (non-PAR, 95% fee schedule, can balance bill up to the limiting charge), and opt-out (private contract with patient, no Medicare payment).

6. The Section 1842(g) limiting charge caps what a non-participating physician can charge at 115% of the non-PAR fee schedule (approximately 109% of the PAR fee schedule). Beneficiaries can refuse to pay above the limiting charge.

7. The Section 1877 Stark Law prohibits physician self-referral for designated health services (clinical lab, PT/OT/SLP, radiology, DME, home health, outpatient prescription drugs, hospital services, etc.) unless an exception in 42 CFR 411.353 through 411.357 applies. Stark is strict liability.

8. Palmetto GBA Jurisdiction J processes Part B physician claims for Georgia, Alabama, and Tennessee. Georgia has two Medicare physician fee schedule localities: Atlanta (higher GPCIs) and Rest of Georgia. :::

Federal Statutory and Regulatory Authority for Medicare Physician Services

Medicare physician services rest on a multi-statute framework that defines who can be a physician, what services are covered, how payment is calculated, and how participation works. Georgia beneficiaries and the families helping them coordinate care should understand the statutory backbone because most coverage and billing disputes resolve to one of these provisions.

Section 1861(q) of the Social Security Act: Physicians' Services

Section 1861(q) of the Social Security Act, codified at 42 U.S.C. 1395x(q), defines "physicians' services" as professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls. The provision is intentionally broad: almost any professional service furnished by a qualified physician within their scope of practice is potentially covered, subject to medical necessity under Section 1862(a)(1)(A) and the specific coverage rules of other Section 1861 provisions and CMS National Coverage Determinations.

Section 1861(r) of the Social Security Act: Who Qualifies as a Physician

Section 1861(r) defines who qualifies as a "physician" for Medicare purposes. The definition includes five categories:

Doctors of medicine or osteopathy (MD/DO). Authorized to practice medicine and surgery under State law. This is the primary category covering all physicians who deliver the full range of medical and surgical services.

Doctors of dental surgery (DDS) or dental medicine (DMD). Coverage applies only for services that under State law a doctor of medicine or osteopathy may perform. In practice, dentist coverage under Medicare is narrow: pre-transplant oral evaluations, dental services tied to specific medical conditions, and certain other defined services. Most routine dental care is not covered under Original Medicare.

Doctors of podiatric medicine (DPM). Coverage applies for services that would be physician services if furnished by a doctor of medicine or osteopathy and are not in the nature of inappropriate care. Routine foot care (nail trimming, callus care) is generally not covered absent specific medical conditions like diabetes with peripheral neuropathy.

Doctors of optometry (OD). Coverage applies for services performed by such doctor that he or she is legally authorized to perform under State law. Optometrists can provide diabetic eye exams, glaucoma screening, and other covered services.

Chiropractors licensed by the State. Coverage is the most limited: only manual manipulation of the spine to correct a subluxation demonstrated by X-ray to exist. X-rays performed by chiropractors are NOT covered. Other services within the chiropractic scope (modalities, massage, nutritional counseling) are NOT covered.

Section 1861(s)(2)(A) of the Social Security Act: Part B Coverage

Section 1861(s)(2)(A) includes physicians' services and certain other services within "medical and other health services" covered under Medicare Part B. This is the operational coverage clause that brings physicians' services into Part B and triggers Part B cost-sharing rules: the annual Part B deductible ($283 in 2026) and 20% coinsurance.

Section 1848 of the Social Security Act: The Medicare Physician Fee Schedule

Section 1848 establishes the Medicare Physician Fee Schedule (MPFS) under the Resource-Based Relative Value Scale (RBRVS). Section 1848 was added by Section 6102 of the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989, Public Law 101-239) effective January 1, 1992.

Before 1992, Medicare paid physicians under a "customary, prevailing, and reasonable" (CPR) charge methodology that produced highly variable payments and was widely criticized for paying procedural specialties significantly more than cognitive specialties for the same time commitment. The RBRVS methodology developed by Harvard health economist William Hsiao and his team replaced CPR with a structured payment formula based on resource costs.

The MPFS Payment Formula

Medicare payment for a physician service under Section 1848 equals:

Payment = [(Work RVU x Work GPCI) + (Practice Expense RVU x PE GPCI) + (Malpractice RVU x MP GPCI)] x Conversion Factor

The components:

• Work RVU measures the physician's work effort: time required, technical skill, mental effort, judgment, and stress
• Practice Expense RVU measures overhead: office space, equipment, supplies, clinical staff, and administrative staff
• Malpractice RVU measures malpractice insurance costs
• Geographic Practice Cost Indices (GPCIs) adjust each component for geographic cost differences
• Conversion Factor (CF) converts RVUs to dollar amounts and is updated annually

Section 1848(c): Relative Value Units

Section 1848(c) directs the Secretary to establish RVUs for each physician service identified by CPT/HCPCS code. The American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) advises CMS on RVU values. CMS reviews and finalizes the values annually in the Physician Fee Schedule rule, with proposed rules published in summer and final rules in November.

RVUs are reviewed periodically. Section 1848(c)(2)(K) created the "misvalued code initiative" requiring CMS to periodically identify and review potentially misvalued codes.

Section 1848(e): Geographic Practice Cost Indices

Section 1848(e) establishes three GPCIs that adjust payment by locality:

• Work GPCI: physician work component
• Practice Expense GPCI: overhead component
• Malpractice GPCI: malpractice insurance component

GPCIs are reviewed at least every 3 years. Georgia has two Medicare physician fee schedule localities:

• Locality 1 (Atlanta): the Atlanta metropolitan statistical area, with higher GPCI values reflecting higher cost of living and practice expenses
• Locality 99 (Rest of Georgia): all Georgia counties outside the Atlanta MSA

Beneficiaries in Atlanta receive physician services at slightly higher payment rates than beneficiaries in rural Georgia for the same CPT codes due to GPCI adjustments. The Work GPCI has been statutorily floored at 1.000 by repeated Congressional action; the floor has expired in some periods and been restored in others.

Section 1848(b): Conversion Factor and Updates

Section 1848(b) governs the annual conversion factor and its update. The conversion factor is the dollar amount that multiplies RVUs to produce payment.

Historical conversion factor framework:

• 1992 through 1997: Annual updates based on the Medicare Economic Index (MEI) and other factors
• 1998 through 2014: Sustainable Growth Rate (SGR) formula under BBA 1997
• 2015 onward: MACRA 2015 permanent SGR repeal; updates set by statute

The Sustainable Growth Rate Era and Its Repeal

The Balanced Budget Act of 1997 Section 4503 established the Sustainable Growth Rate formula. The SGR tied physician payment updates to growth in gross domestic product. The SGR proved unworkable because:

• Volume of physician services grew faster than GDP
• The formula's cumulative feature meant required offsets compounded over time
• By the late 2000s, statutory SGR called for greater than 20% cuts to physician payment

Congress passed 17 separate "doc fix" patches between 2003 and 2015 to prevent SGR-mandated cuts. Each patch was temporary, requiring the next Congress to act, and creating substantial uncertainty for physicians and beneficiaries.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, Public Law 114-10), signed April 16, 2015, permanently repealed the SGR formula. Title I of MACRA replaced SGR with:

• Statutory updates: statutory annual updates set by Congress per MACRA, replacing the SGR formula, with differentiated rates for qualifying APM participants beginning 2026
• MIPS: Merit-based Incentive Payment System
• Advanced APMs: incentives for risk-bearing alternative payment models

Section 1848(q): The Merit-based Incentive Payment System

Section 1848(q), added by MACRA 2015, established MIPS effective January 1, 2017. MIPS consolidated three prior physician quality programs (PQRS, Value-Based Modifier, Meaningful Use) into a single performance-based payment adjustment program.

MIPS has four performance categories:

Quality (30% of MIPS score in 2024 forward). Clinicians select 6 quality measures from a CMS-approved list, reporting on at least 50% of eligible patients. Specialty measure sets and qualified clinical data registry (QCDR) measures are also available.

Cost (30% of MIPS score). CMS calculates cost measures from claims data: Total Per Capita Cost (TPCC), Medicare Spending Per Beneficiary (MSPB), and Episode-Based Cost Measures (EBCMs) for specific conditions and procedures. Clinicians do not submit cost data; CMS attributes patients to clinicians based on claims patterns.

Improvement Activities (15% of MIPS score). Clinicians attest to performing 1-4 improvement activities (varies by group size) from a CMS-approved list. Activities span care coordination, patient engagement, achieving health equity, and other domains.

Promoting Interoperability (25% of MIPS score). Clinicians use certified electronic health record technology (CEHRT) to perform required actions: e-prescribing, health information exchange, patient access to records, public health and clinical data reporting.

Each clinician receives an annual MIPS composite score (0-100). Performance is assessed against a threshold; clinicians above the threshold receive positive adjustments, clinicians below receive negative adjustments. The MIPS payment adjustment is applied 2 years after the performance year (2024 performance year affects 2026 payment).

MIPS maximum payment adjustments are capped by statute and have scaled up since the program launched in 2019. MIPS is budget-neutral: positive adjustments are funded by negative adjustments.

Advanced Alternative Payment Models

Section 1833(z) created bonuses for physicians participating in qualifying Advanced APMs. Advanced APMs are alternative payment models that:

• Require use of certified EHR technology
• Provide payment based on quality measures comparable to MIPS
• Either require participants to bear financial risk OR be a Medical Home Model

Examples of qualifying Advanced APMs include the Medicare Shared Savings Program (Track 2/3/Enhanced), Comprehensive Primary Care Plus (CPC+), Next Generation ACO Model (now sunset), Comprehensive Care for Joint Replacement (CJR, two-sided risk), and various oncology and kidney care models.

Qualifying APM Participants (QPs) receive:

• Lump-sum bonus payment on Medicare physician services for applicable performance years
• Higher annual conversion factor update beginning 2026 compared to non-QPs
• Exemption from MIPS reporting and adjustment

Section 1842 of the Social Security Act: Participation, Assignment, and Limiting Charge

Section 1842 governs physician participation in Medicare and the assignment and limiting charge rules. The framework protects beneficiaries from excessive billing while preserving physician flexibility.

Three participation status options:

1. Participating Physician (PAR). The physician signs a Medicare participation agreement annually and agrees to accept assignment for ALL Medicare-covered services. In exchange:

• Receives 100% of the fee schedule allowed amount
• Higher reimbursement than non-PAR
• Listed in the Medicare physician finder
• Receives certain administrative simplifications
• Cannot balance bill above the fee schedule

2. Non-Participating Physician (Non-PAR). The physician does NOT sign the annual participation agreement but is still enrolled in Medicare. The physician can accept assignment on a case-by-case basis. When non-PAR:

• Receives 95% of the PAR fee schedule when assignment is accepted
• Can balance bill up to the limiting charge for non-assigned services
• Less attractive Medicare reimbursement than PAR
• Can still see Medicare patients

3. Opt-Out (Private Contracting). The physician opts out of Medicare entirely and enters a private contract with each Medicare patient. Under opt-out:

• Two-year opt-out period (renewable)
• Private contract with each Medicare patient acknowledging no Medicare payment
• No Medicare payment to physician or patient
• Patient pays full physician fee out of pocket
• Common among concierge medicine, some psychiatry, plastic surgery, and high-end specialties
• Medigap does NOT cover opt-out physician services

Section 1842(g): The Limiting Charge

Section 1842(g) limits what a non-participating physician can charge a Medicare beneficiary for non-assigned services. The limiting charge is 115% of the non-PAR fee schedule, which equals approximately 109.25% of the PAR fee schedule (because non-PAR is 95% of PAR, and 115% of 95% is 109.25%).

Worked calculation:

• PAR fee schedule for service: $100
• Non-PAR fee schedule: $95 (95% of PAR)
• Limiting charge: $109.25 (115% of $95)

If a non-participating physician does not accept assignment:

• Medicare pays the beneficiary (not the physician) 80% of the non-PAR fee schedule = $76
• The physician can charge the patient up to the limiting charge of $109.25
• Patient's out-of-pocket: $109.25 - $76 = $33.25

Compare to a participating physician who accepts assignment:

• Medicare pays the physician directly 80% of the PAR fee schedule = $80
• Patient owes 20% coinsurance = $20
• With Medigap, the $20 is covered

The limiting charge protects beneficiaries from unlimited balance billing. Physicians who violate the limiting charge can face sanctions including civil monetary penalties and exclusion from Medicare.

Section 1862(a)(1)(A): Reasonable and Necessary

Section 1862(a)(1)(A) requires that all Medicare services be reasonable and necessary for the diagnosis or treatment of illness or injury. The standard applies to all physician services and is the foundational medical necessity requirement.

Section 1877: The Stark Physician Self-Referral Prohibition

Section 1877 of the Social Security Act, commonly called the Stark Law after former Representative Pete Stark, prohibits physicians from making referrals to entities for "designated health services" (DHS) in which the physician (or immediate family member) has a financial relationship, unless an exception applies.

Designated health services include:

• Clinical laboratory services
• Physical therapy, occupational therapy, and outpatient speech-language pathology
• Radiology and certain other imaging services
• Radiation therapy services and supplies
• Durable medical equipment
• Parenteral and enteral nutrients, equipment, and supplies
• Prosthetics, orthotics, and prosthetic devices and supplies
• Home health services
• Outpatient prescription drugs
• Inpatient and outpatient hospital services

Stark Law was enacted in stages:

• 1989 (OBRA 1989 Section 6204): Stark I, prohibition for clinical laboratory referrals
• 1993 (OBRA 1993 Section 13562): Stark II expanded to all DHS

Stark exceptions are detailed in 42 CFR 411.353 through 411.357. Key exceptions include:

• In-office ancillary services exception (allows referrals within a group practice)
• Group practice exception
• Employment relationship exception
• Personal services arrangement exception
• Fair market value compensation exception
• Space and equipment rental exceptions
• Risk-sharing arrangements exception

Stark Law penalties include:

• Denial of payment for services furnished in violation
• Civil monetary penalties per service plus multiples of the amount claimed, as set by statute
• Exclusion from Medicare

Stark is a strict liability statute (intent is not required), making compliance a major concern for physician practices. The 2020 "Stark Sprint" (Section 50101 final rule effective January 19, 2021) updated several exceptions to facilitate value-based payment arrangements.

Federal Regulatory Framework

42 CFR Part 414 Subpart B: Physician Services

42 CFR 414.20 through 414.84 implement Section 1848 MPFS:

• Definition of physician services
• RVU components and calculation
• GPCIs
• Conversion factor
• Site-of-service differential
• Telehealth payment rules
• Specific service rules (multiple procedure payment reduction, bilateral procedure reduction, etc.)

42 CFR 410.20: Physician Services

42 CFR 410.20 sets forth the conditions for physician services coverage:

• Service furnished by a physician or under physician supervision
• Service medically necessary under Section 1862(a)(1)(A)
• Service consistent with physician scope of practice under State law
• Service properly documented

42 CFR Part 414 Subpart N: Quality Payment Program

42 CFR 414.1305 through 414.1525 implement MACRA 2015 QPP:

• MIPS eligibility and exclusion rules
• Performance categories and weighting
• Scoring methodology
• Advanced APM criteria
• Qualifying APM participant determination

42 CFR 411.353-411.357: Stark Law Exceptions

These provisions detail the exceptions to the Section 1877 physician self-referral prohibition. CMS periodically issues updates to the exceptions to reflect changing healthcare arrangements.

Common CPT Codes for Physician Services

Physician services use the AMA's Current Procedural Terminology (CPT) coding system organized into:

Evaluation and Management Codes

Office and outpatient E/M (most common physician services):

• 99202-99205: New patient (5 levels of complexity)
• 99211-99215: Established patient (5 levels)

Hospital and facility E/M:

• 99221-99223: Initial hospital care
• 99231-99233: Subsequent hospital care
• 99238-99239: Hospital discharge

Nursing facility:

• 99304-99310: Nursing facility services

Home services:

• 99341-99345: Home services new patient
• 99347-99350: Home services established patient

Surgery Codes

Surgical CPT codes range from 10000 through 69999, organized by body system. Examples:

• 27447: Total knee arthroplasty
• 47562: Laparoscopic cholecystectomy
• 49560: Repair initial incisional hernia
• 66984: Cataract extraction

Radiology and Pathology

• 71045-71048: Chest X-ray
• 70551-70553: MRI brain
• 80048: Basic metabolic panel
• 85025: CBC with automated differential

Medicine Codes

• 93000-93010: EKG
• 93306-93350: Echocardiogram
• 95812-95816: EEG

Palmetto GBA Jurisdiction J: Georgia's Medicare Administrative Contractor

Palmetto GBA serves as the Medicare Administrative Contractor for Jurisdiction J Part B, covering Georgia, Alabama, and Tennessee. Palmetto:

• Processes physician claims under Section 1848 MPFS
• Issues Local Coverage Determinations (LCDs) for physician services
• Conducts medical reviews and audits
• Administers participation enrollment
• Provides provider education

Phone: 1-877-567-9230. Website: palmettogba.com.

Georgia Physician Landscape

Georgia beneficiaries access physician services through diverse channels reflecting the state's healthcare market structure.

Major Hospital-Employed Physician Groups

Georgia hospital systems operate large physician employment networks:

• Emory Healthcare physicians (Emory Clinic, Emory University Hospital Group, Emory specialty practices)
• Piedmont Healthcare Physicians (Piedmont Physicians Group statewide)
• Wellstar Medical Group
• Northeast Georgia Physicians Group
• Memorial Health Physicians (Savannah)
• Augusta University Medical Associates
• Atrium Health Navicent physicians
• Phoebe Physician Group (Albany)
• Grady physicians

Multi-Specialty Independent Groups

• The Longstreet Clinic (Gainesville)
• Medical Associates of North Georgia
• Cumberland Pediatrics and Internal Medicine
• Northside Family Medicine
• Georgia Heart Institute (cardiology)
• Northwest Georgia Oncology Centers

Academic Medical Centers

• Emory University School of Medicine (Atlanta)
• Augusta University Medical College of Georgia (Augusta)
• Mercer University School of Medicine (Macon, Savannah, Columbus campuses)
• Morehouse School of Medicine (Atlanta)
• Philadelphia College of Osteopathic Medicine Georgia (Suwanee)

Federally Qualified Health Centers

Georgia has a network of Federally Qualified Health Centers operating sites statewide. FQHCs employ physicians and provide comprehensive primary care including physician services on a sliding-fee scale.

State Medical Licensing Boards

• Georgia Composite Medical Board (MD/DO licensing): 404-656-3913
• Georgia Board of Dentistry (DDS/DMD): 404-651-8000
• Georgia Board of Podiatry Examiners (DPM): 478-207-2440
• Georgia Board of Optometry (OD): 478-207-2440
• Georgia Board of Chiropractic Examiners: 478-207-2440

Worked Examples for Georgia Beneficiaries

The following examples illustrate how the federal framework applies to Georgia beneficiaries in common physician service scenarios. Names and details are illustrative.

Example 1: Margaret, Age 78, Atlanta: Participating Internist Annual Visit at Piedmont

Margaret sees Dr. Smith, a participating Medicare physician at Piedmont Primary Care Atlanta. Her established patient evaluation and management visit (CPT 99214, level 4) is billed at the Medicare fee schedule at the Atlanta Locality 1 GPCI-adjusted rate.

Margaret has Original Medicare with Medigap Plan G. At her first Medicare-covered service of the year, she pays the Part B annual deductible of $283. After the deductible, Medicare pays 80% of the approved amount directly to Dr. Smith (assignment). Margaret's 20% coinsurance is covered by her Medigap Plan G; she has no out-of-pocket cost beyond the deductible at the start of the year.

The participating physician status means Dr. Smith cannot bill Margaret more than the fee schedule amount: no balance billing.

Outcome: Margaret receives her annual visit with the deductible paid at the start of the year and zero additional out-of-pocket cost.

Example 2: Robert, Age 82, Savannah: Non-Participating Dermatologist with Limiting Charge

Robert sees Dr. Jones, a non-participating dermatologist in Savannah, for a skin lesion evaluation (CPT 99213, established patient, level 3). The Locality 99 (Rest of Georgia) PAR fee schedule rate applies. The non-PAR fee schedule is 95% of the PAR rate. The limiting charge is 115% of the non-PAR fee schedule (approximately 109% of the PAR rate).

Dr. Jones does not accept assignment for this visit. Dr. Jones bills Robert up to the limiting charge. Medicare pays Robert (not the physician) 80% of the non-PAR fee schedule amount. Robert pays the limiting charge to Dr. Jones and receives the Medicare reimbursement. Robert's net out-of-pocket is the difference between the limiting charge and what Medicare pays.

If Robert had seen a participating dermatologist who accepts assignment, his out-of-pocket would be 20% of the PAR fee schedule amount, or $0 with Medigap.

Outcome: Robert pays $29.93 out of pocket for a service that would have cost $0 with a participating physician and Medigap. He decides to ask his next dermatology referral whether the physician accepts assignment.

Example 3: Linda, Age 75, Macon: Mohs Surgery at Atrium Navicent

Linda has a basal cell carcinoma on her right cheek confirmed by biopsy. She is referred to Dr. Brown, a Mohs surgery specialist at Atrium Health Navicent. Dr. Brown is a participating Medicare physician. The Mohs procedure is performed in-office with multiple stages.

CPT codes billed:

• 17311: Mohs micrographic technique, first stage (head/neck) - approximately $620 at Locality 99
• 17312: Each additional stage (Linda needs 2 additional stages) - approximately $370 each
• 13152: Repair (intermediate, complex closure)

Total billed: approximately $1,500. Medicare pays 80% after the Part B deductible. Linda's Medigap Plan G covers the 20% coinsurance.

Outcome: Linda's Mohs surgery is fully covered between Medicare and Medigap; she has no out-of-pocket cost beyond the deductible already met earlier in the year.

Example 4: Charles, Age 80, Augusta: Cardiologist at AU (MIPS-Participating)

Charles has new-onset atrial fibrillation. He is referred to Dr. Wilson, a cardiologist at Augusta University Medical Associates. AU Medical Associates is a MIPS-participating group practice with a high composite score (above the 75th percentile of MIPS scores nationally).

Charles's first visit includes:

• 99214 (established patient E/M, level 4)
• 93000 (EKG, complete with interpretation)
• 93306 (echocardiogram, complete)

The total billed under Medicare physician fee schedule at AU's locality is approximately $400. Medicare pays 80% after Charles's deductible. The MIPS performance bonus AU receives is not visible to Charles: it adjusts AU's Medicare payment for the entire performance year through a multiplier applied at the practice level.

Charles's Medigap Plan F covers the 20% coinsurance and the Part B deductible (Plan F was discontinued for new enrollees in 2020 but existing enrollees retained coverage).

Outcome: Charles receives comprehensive cardiology evaluation; AU Medical Associates' MIPS performance results in a positive payment adjustment for the practice that Charles never sees.

Example 5: Patricia, Age 73, Columbus: Chiropractor Limited Coverage

Patricia has chronic low back pain and seeks chiropractic care. She visits Dr. Adams, a chiropractor in Columbus. Under Section 1861(r), Medicare covers only manual manipulation of the spine to correct a subluxation demonstrated by X-ray.

Dr. Adams performs:

• Initial evaluation
• X-ray of lumbar spine (Dr. Adams performs in office)
• Manual spinal manipulation (CPT 98940, spinal manipulation 1-2 regions)
• Therapeutic ultrasound
• Massage therapy

What Medicare covers:

• Manual spinal manipulation (98940): COVERED (approximately $35)
• X-ray performed by chiropractor: NOT COVERED
• Evaluation: NOT COVERED separately
• Ultrasound: NOT COVERED
• Massage: NOT COVERED

Patricia pays the Part B deductible plus 20% coinsurance for the covered manipulation ($7 after deductible). For the non-covered services, Patricia pays the full chiropractor fees out of pocket (approximately $200).

Outcome: Patricia learns that Medicare's chiropractic coverage is narrow; she budgets accordingly for future visits.

Example 6: Henry, Age 85, Athens: Opt-Out Concierge Primary Care

Henry has been with Dr. Davis, a concierge primary care physician in Athens, for 10 years. In 2023 Dr. Davis opted out of Medicare under Section 1842. Henry now has two options:

Option 1: Stay with Dr. Davis under a private contract. Henry signs a 2-year private contract acknowledging Medicare will not pay for Dr. Davis's services. Henry pays Dr. Davis's full fees out of pocket plus an annual concierge membership fee of $3,000. Medigap Plan G does NOT cover opt-out physician services. Each visit costs $250 out of pocket.

Option 2: Switch to a Medicare-participating PCP. Henry can transfer his care to a Medicare-participating primary care physician. His Medigap Plan G will cover the 20% coinsurance after the Part B deductible. Office visits would cost $0 out of pocket after the deductible.

Henry chooses Option 1 because of his long-term relationship with Dr. Davis and his preference for concierge service (longer visits, after-hours access, care coordination). Emergency room visits, hospital care, and specialist visits remain covered by Medicare: only Dr. Davis is opted out.

Outcome: Henry pays approximately $5,000-$8,000 per year out of pocket for Dr. Davis's services in addition to his Medicare premiums and Medigap premium. He values the relationship and accepts the cost.

Common Mistakes to Avoid

1. Assuming all physicians take Medicare. Some physicians have opted out under Section 1842, particularly in concierge medicine, plastic surgery, psychiatry, and some specialty practices. Always confirm Medicare participation status before scheduling a non-emergency visit.

2. Confusing participating with non-participating. Participating (PAR) physicians accept assignment for all Medicare services and receive 100% of the fee schedule. Non-participating (non-PAR) physicians can balance bill up to the limiting charge. Always ask whether a physician accepts assignment.

3. Not knowing the limiting charge protection. Non-participating physicians cannot charge more than 115% of the non-PAR fee schedule (approximately 109% of the PAR fee schedule). Beneficiaries can refuse to pay above the limiting charge. If charged more, file a complaint with Palmetto GBA.

4. Believing Medicare covers all chiropractic services. Section 1861(r) limits chiropractor coverage to manual manipulation of the spine to correct a subluxation. X-rays, modalities, and other services are NOT covered.

5. Believing Medicare covers all dental services. Section 1861(r) coverage of dentists is narrow. Most routine dental care (cleanings, fillings, dentures) is NOT covered under Original Medicare. Some Medicare Advantage plans offer supplemental dental coverage.

6. Believing Medicare covers all foot care. Section 1861(r) covers podiatrists for services that would be physician services if furnished by an MD/DO. Routine foot care (toenail trimming, callus care) is generally NOT covered absent specific medical conditions like diabetes with peripheral neuropathy.

7. Failing to understand the Part B deductible. The Part B annual deductible ($283 in 2026) applies before Medicare pays anything for physician services. After the deductible is met, Medicare pays 80% of the approved amount.

8. Misunderstanding the MIPS impact on patients. MIPS adjustments apply to physician payment, not patient cost-sharing. Patients do not see the MIPS adjustment in their Medicare Summary Notice.

9. Not coordinating with Medigap. Medigap supplements cover the 20% coinsurance and other gaps in Original Medicare. Choose physicians who accept Medicare assignment to maximize Medigap coverage.

10. Forgetting that opt-out physicians do not work with Medigap. When a physician opts out under Section 1842, Medigap does not cover the visit. Beneficiaries pay full fees out of pocket.

11. Missing the Stark Law's impact on practice arrangements. Stark prohibits physician self-referral for designated health services unless an exception applies. This affects how physicians can refer to imaging, lab, PT, and other ancillary services.

12. Believing all imaging in a physician's office is covered. Imaging and laboratory services in a physician's office must meet Stark Law's in-office ancillary services exception or another exception to be covered.

13. Not understanding telehealth coverage. Medicare expanded telehealth coverage during the COVID-19 public health emergency. Some telehealth flexibilities remain (mental health, behavioral health); others have expired or are time-limited. Verify current telehealth coverage for your specific service before scheduling.

14. Assuming Medicare Advantage uses the same fee schedule. MA plans negotiate their own physician payment rates with network physicians and may use prior authorization. Beneficiaries should verify network status before scheduling a non-emergency visit.

::: accordion

What are Medicare physician services?

Section 1861(q) of the Social Security Act defines "physicians' services" as professional services performed by physicians, including surgery, consultation, and home, office, and institutional calls. Almost any service furnished by a qualified physician within their scope of practice is potentially covered under Medicare Part B, subject to medical necessity and specific coverage rules.

Who qualifies as a "physician" under Medicare?

Section 1861(r) defines five categories: doctors of medicine or osteopathy (MD/DO), doctors of dental surgery or medicine (DDS/DMD, for limited services), doctors of podiatric medicine (DPM), doctors of optometry (OD), and chiropractors (limited to manual spinal manipulation for subluxation only).

How does Medicare pay physicians?

Section 1848 of the Social Security Act establishes the Medicare Physician Fee Schedule under the Resource-Based Relative Value Scale. Payment equals (Work RVU x Work GPCI + Practice Expense RVU x PE GPCI + Malpractice RVU x MP GPCI) x Conversion Factor. RVUs reflect resource costs, GPCIs adjust for geographic cost differences, and the Conversion Factor converts RVUs to dollar amounts.

What is RBRVS?

The Resource-Based Relative Value Scale is the methodology Medicare uses to set physician payment, developed by Harvard health economist William Hsiao and adopted by OBRA 1989 effective January 1, 1992. RBRVS replaced the prior "customary, prevailing, and reasonable" charge methodology with a structured formula based on resource costs.

What was the Sustainable Growth Rate?

The Sustainable Growth Rate (SGR), enacted by BBA 1997, tied physician payment updates to growth in gross domestic product. The SGR proved unworkable because physician service volume grew faster than GDP. Congress passed 17 patches between 2003 and 2015 to prevent SGR-mandated cuts before MACRA 2015 permanently repealed it.

What is MACRA?

The Medicare Access and CHIP Reauthorization Act of 2015 (Public Law 114-10) permanently repealed the SGR and established the Quality Payment Program. MACRA created MIPS (Merit-based Incentive Payment System) and the Advanced APM pathway, effective January 1, 2017.

What is MIPS?

The Merit-based Incentive Payment System under Section 1848(q) adjusts physician payment by up to plus or minus 9% based on performance in four categories: Quality, Cost, Improvement Activities, and Promoting Interoperability. MIPS adjustments apply 2 years after the performance year.

What is an Advanced APM?

An Advanced Alternative Payment Model is a CMS-approved payment model that requires participants to bear financial risk, use certified EHR technology, and base payment on quality measures. Qualifying APM Participants (QPs) receive a 5% bonus through 2024 (paid 2019-2026) and a higher conversion factor update starting 2026.

What is a participating Medicare physician?

A participating (PAR) physician signs a Medicare participation agreement annually and agrees to accept assignment for all Medicare-covered services. PAR physicians receive 100% of the fee schedule and cannot balance bill above the fee schedule amount.

What is a non-participating Medicare physician?

A non-participating (non-PAR) physician does NOT sign the annual participation agreement but is still enrolled in Medicare. Non-PAR physicians can accept assignment on a case-by-case basis. When non-PAR, they receive 95% of the PAR fee schedule and can balance bill up to the limiting charge.

What is the limiting charge?

The limiting charge under Section 1842(g) caps what a non-participating physician can charge a Medicare beneficiary for non-assigned services. The cap is 115% of the non-PAR fee schedule (approximately 109% of the PAR fee schedule). Beneficiaries cannot be charged more than the limiting charge.

What does it mean for a physician to opt out of Medicare?

A physician who opts out under Section 1842 enters a 2-year (renewable) private contract with each Medicare patient. Medicare pays nothing for opt-out physician services. The patient pays the full fee out of pocket. Medigap does NOT cover opt-out physicians. Common in concierge medicine and some specialties.

Does Medicare cover dental care?

Medicare's dental coverage under Section 1861(r) is narrow. Most routine dental care (cleanings, fillings, dentures, extractions) is NOT covered under Original Medicare. Limited dental services tied to specific medical conditions (pre-organ-transplant evaluation, etc.) may be covered. Some Medicare Advantage plans offer supplemental dental.

Does Medicare cover chiropractic services?

Medicare covers only manual manipulation of the spine to correct a subluxation under Section 1861(r). X-rays performed by chiropractors, modalities (ultrasound, electrical stimulation), and other services within the chiropractic scope are NOT covered.

Does Medicare cover podiatric services?

Section 1861(r) covers podiatrists for services that would be physician services if furnished by an MD/DO. Routine foot care (toenail trimming, callus care) is generally NOT covered. Diabetic foot care for beneficiaries with diabetes and peripheral neuropathy is covered with specific requirements.

What is the Stark Law?

The Stark Law (Section 1877) prohibits physicians from making referrals to entities for "designated health services" in which the physician or family member has a financial relationship, unless an exception applies. Stark is strict liability with significant penalties.

What are designated health services under Stark?

Designated health services include clinical lab, PT/OT/SLP, radiology, radiation therapy, DME, parenteral/enteral nutrition, prosthetics/orthotics, home health, outpatient prescription drugs, and inpatient and outpatient hospital services.

What is the Part B deductible for physician services?

The Part B annual deductible is $283 in 2026. The deductible applies before Medicare pays anything for physician services. After the deductible is met, Medicare pays 80% of the approved amount and the beneficiary owes 20% coinsurance (often covered by Medigap).

What is the difference between Medicare Part B physician services and Medicare Advantage?

Original Medicare Part B pays physicians under the MPFS with PAR/non-PAR/opt-out participation status. Medicare Advantage plans negotiate their own physician payment rates with network physicians and may impose prior authorization. MA plans must cover the same services as Original Medicare but may use different cost-sharing.

Does Medicare cover telehealth physician visits?

Medicare expanded telehealth coverage during the COVID-19 public health emergency. Some flexibilities remain (mental health and behavioral health are permanent; others were extended through 2024-2025). Verify current telehealth coverage for your specific service before scheduling.

How do I find a participating Medicare physician in Georgia?

Use Medicare.gov physician finder (medicare.gov/care-compare) to search for participating physicians by location and specialty. Verify Medicare assignment status when scheduling. GeorgiaCares (1-866-552-4464) can help.

What if I am charged more than the limiting charge?

If a non-participating physician charges more than the limiting charge (115% of non-PAR fee schedule), you can refuse to pay the excess and file a complaint with Palmetto GBA at 1-877-567-9230. The physician may face sanctions for limiting charge violations.

How does Medicare's two-Georgia-locality structure affect physician payment?

Georgia has two Medicare physician fee schedule localities: Atlanta (Locality 1, higher GPCIs) and Rest of Georgia (Locality 99). The same CPT code is paid at slightly different rates in the two localities due to GPCI differences. Beneficiary cost-sharing is proportionate.

What is the Medicare physician fee schedule conversion factor for 2026?

The 2026 conversion factor is published by CMS in the annual Physician Fee Schedule final rule. The MACRA framework provides 0% statutory update through 2025; beginning 2026, qualifying APM Participants receive a 0.75% update vs. 0.25% for non-QPs. CAA 2024 provided additional conversion factor mitigations.

Where can Georgia families get help with Medicare physician services questions?

GeorgiaCares (the State Health Insurance Assistance Program) at 1-866-552-4464. Medicare Rights Center at 1-800-333-4114. Palmetto GBA at 1-877-567-9230 for claims questions. Atlanta Legal Aid at 404-377-0701 for legal assistance. :::

::: cta Get help understanding your Georgia Medicare physician services coverage.

Brevy's eldercare guides at brevy.com help Georgia families understand the federal statutory framework for Medicare physician services, the Physician Fee Schedule, the MACRA Quality Payment Program, assignment and limiting charge protections, and how to find Medicare-participating physicians across Georgia. Below are key contacts for physician services questions, complaints, and appeals.

Medicare and Federal Resources:

• Medicare general inquiries: 1-800-MEDICARE (1-800-633-4227)
• Medicare.gov for physician finder, plan finder, and current fee schedule
• Palmetto GBA Jurisdiction J (Georgia Part B Medicare Administrative Contractor): 1-877-567-9230
• KEPRO (Georgia Quality Improvement Organization, appeals): 1-844-455-8708
• Social Security Administration (Medicare enrollment): 1-800-772-1213
• HHS Office for Civil Rights: 1-800-368-1019
• HHS Office of Inspector General (fraud hotline): 1-800-447-8477

Georgia State Resources:

• GeorgiaCares (SHIP free Medicare counseling): 1-866-552-4464
• Georgia DCH Medicaid Member Services: 1-866-211-0950
• Georgia Composite Medical Board (MD/DO license verification): 404-656-3913
• Georgia Board of Dentistry (DDS/DMD): 404-651-8000
• Georgia Board of Podiatry Examiners (DPM): 478-207-2440
• Georgia Board of Optometry (OD): 478-207-2440
• Georgia Board of Chiropractic Examiners: 478-207-2440

Advocacy and Legal Assistance:

• Medicare Rights Center (national free counseling): 1-800-333-4114
• Center for Medicare Advocacy: 1-860-456-7790
• Atlanta Legal Aid Society: 404-377-0701
• Georgia Legal Services Program: 1-800-498-9469

Community and Information Services:

• 211 Georgia: dial 211
• Eldercare Locator: 1-800-677-1116
• VA Benefits: 1-800-827-1000

This guide is informational, not legal or medical advice. Medicare physician services rules, payment rates, and participation policies change annually. Always verify current Medicare participation status and coverage with Medicare.gov or 1-800-MEDICARE before scheduling care, and consult a qualified physician or benefits counselor for advice on your specific situation. :::