Skip to Main Content
 
 
 
Web Content Viewer

Web Content Viewer

Fee Schedule Assistance

Illinois Locality/Area and County Information

Locality/Area Counties
12 Bond, Calhoun, Clinton, Jersey, Macoupin, Madison, Monroe, Montgomery, Randolph, St. Clair, Washington
15 DuPage, Kane, Lake, Will
16 Cook
99 All Other Counties

[Return to Top]

Maine, Massachusetts, New Hampshire, Rhode Island, Vermont
Locality/Area and County Information

Locality/Area State Counties
01 MA Middlesex, Norfolk, and Suffolk
99 MA All Other Counties
03 ME York and Cumberland
99 ME All Other Counties
40 NH Entire State
01 RI Entire State
50 VT Entire State

[Return to Top]

New York Locality/Area and County Information

Locality/Area Counties
01 Manhattan
02 Bronx, Brooklyn, Nassau, Rockland, Staten Island, Suffolk, Westchester
03 Columbia, Delaware, Dutchess, Greene, Orange, Putnam, Sullivan, Ulster
04 Queens
99 Albany, Oneida, Allegany, Onondaga, Broome, Ontario, Cattaraugus, Orleans, Cayuga, Oswego, Chautauqua, Otsego, Chemung, Rensselaer, Chenango, Saratoga, Clinton, Schenectady, Cortland, Schoharie, Erie, Schuyler, Essex, Seneca, Franklin, Steuben, Fulton, St. Lawrence, Genesee, Tioga, Hamilton, Tompkins, Herkimer, Warren, Jefferson, Washington, Lewis, Wayne, Livingston, Wyoming, Madison, Yates, Monroe Montgomery, Niagara

[Return to Top]

Locate and Download Fee Schedule Pricing

  • To download the fee schedule pricing, click the file-type icon displayed in the last four right-side columns of each fee schedule table
  • Select the fee schedule pricing file that corresponds to the claim date of service
  • Begin with the most recent updated or revised fee schedule
  • Schedules are listed in order of effective date for each category
  • If you do not locate the code(s)/pricing information in the most recent applicable fee schedule—then select the next recent schedule
  • Continue this process until you locate the code(s) you are researching

[Return to Top]

Description of Medicare Physician Fee Schedule Database Policy Indicators

CPT/HCPCS

Represents the Procedure Code: Each CPT code and alphanumeric HCPCS codes other than B, C, E, K, and L codes will be included. Codes are listed in alpha and then numeric order. Not all codes in the database will be used by providers. For example, injection codes (i.e., J codes) and laboratory codes (i.e., codes beginning with 8), etc., do not apply to the specialty of surgery.

Modifier

Modifier (if one applies): For services other than those codes with a professional and/or technical component, this field will be blank with one exception. When CPT modifier 53 is allowed, it will appear.

For diagnostic tests, a blank in this field denotes the global service. Physicians should continue to bill using the code without a modifier when furnishing both the professional and technical components of the service. When furnishing the professional component of a diagnostic, the 26 modifier would apply. When furnishing the technical component of a diagnostic service, the TC would apply.

26 = Professional component
TC = Technical component
53 = Discontinued procedure

The presence of CPT modifier 53 indicates that separate RVUs and a fee schedule amount have been established for procedures which the physician terminated before completion. This modifier is used only with colonoscopy code 45378 and screening colonoscopy codes G0105 and G0121. Any other codes billed with modifier 53 are subject to carrier medical review and priced by individual consideration.

Short Description

This field includes a brief description of the procedure code.

Procedure Status Indicators

This field indicates whether the code is in the fee schedule and whether it is separately payable if the service is covered. The presence of an active (or valid) status code does not mean the service is covered by Medicare. A service may be valid according to the list but may not be considered covered due to other criteria such as medical necessity or global surgery rules. 

Indicator Description
A Active code: These codes are separately paid under the physician fee schedule if covered. There will be RVUs and payment amounts for codes with this status. The presence of an “A” indicator does not mean that Medicare has made a national coverage determination regarding the service; carriers remain responsible for coverage decisions in the absence of a national Medicare policy.
B Bundled code: Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for is subsumed by the payment for the services to which they are incident. (An example is a telephone call from a hospital nurse regarding care of a patient.)
C Carriers price the code: Carriers will establish RVUs and payment amounts for these services, generally on an individual case basis, following review of documentation such as an operative report.
E Excluded from Physician Fee Schedule by regulation: These codes are for items and/or services that the CMS chose to exclude from the fee schedule payment by regulation. No RVUs are shown and no payment may be made under the fee schedule for these codes. Payment for them, when covered, generally continues under reasonable charge procedures.
I Not valid for Medicare purposes: Medicare uses another code for reporting of, and payment for, these services (code not subject to a 90-day grace period).
M Measurement Codes: Used for reporting purposes only.
N Noncovered Services: These services are not covered by Medicare.
P Bundled/Excluded codes: There are no RVUs and no payment amounts for these services. No separate payment should be made for them under the fee schedule.

If the item or service is covered as incident to a physician service and is provided on the same day as a physician service, payment for it is bundled into the payment for the physician service to which it is incident. (An example is an elastic bandage furnished by a physician incident to physician service.)

If the item or service is covered as other than incident to a physician service, it is excluded from the fee schedule (i.e., colostomy supplies) and should be paid under the other payment provision of the Act.
Q
Therapy functional information code. Used for required reporting purposes only.
R Restricted Coverage: Special coverage instructions apply.
T Injections: There are RVUs and payment amounts for these services, but they are only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider. If any other services payable under the physician fee schedule are billed on the same date by the same provider, these services are bundled into the physician services for which payment is made. (Note: This is a change from the previous definition, which states that injection services are bundled into any other services billed on the same date.)
X Statutory Exclusion: These codes represent an item or service that is not in the statutory definition of “physician services” for fee schedule payment purposes. No RVUs or payment amounts are shown for these codes, and no payment may be made under the physician fee schedule. (Examples are ambulance services and clinical diagnostic laboratory services.)

PC/TC Indicator

This indicator describes physician services that have global concept, professional or technical components. These include diagnostic and therapeutic radiology services, certain diagnostic tests that involve a physician’s interpretation and physician pathology services.

The indicators identify TC and professional component (26) for these services, among other things. 

Indicator Description
0 Physician Service Codes: Identifies codes that describe physician services. Examples include visits, consultations and surgical procedures. The concept of PC/TC does not apply since physician services cannot be split into professional and technical components. Modifiers 26 and TC cannot be used with these codes. The total RVUs include values for physician work, practice expense and malpractice expense. There are some codes with no work RVUs.
1 Diagnostic Tests for Radiology Services: Identifies codes that describe diagnostic tests. Examples are pulmonary function tests or therapeutic radiology procedures, e.g., radiation therapy. These codes have both a professional and technical component. Modifiers 26 and TC can be used with these codes. The total RVUs for codes reported with a 26 modifier include values for physician work, practice expense and malpractice expense. The total RVUs for codes reported with a TC modifier include values for practice expense and malpractice expense only. The total RVUs for codes reported without a modifier include values for physician work, practice expense and malpractice expense.
2 Professional Component Only Codes: This indicator identifies stand-alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test.

An example of a professional component only code is CPT code 93010 – Electrocardiogram; interpretation and report. Modifiers 26 and TC cannot be used with these codes. The total RVUs for professional component only codes include values for physician work, practice expense, and malpractice expense.
3 Technical Component Only Codes: This indicator identifies stand-alone codes that describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic test only. An example of a technical component only code is CPT code 93005 – Electrocardiogram; tracing only, without interpretation and report. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with these codes. The total RVUs for technical component only codes includes values for practice expense and malpractice expense only.
4 Global Test Only Codes: This indicator identifies stand-alone codes that describe selected diagnostic tests for which there are associated codes that describe (a) the professional component of the test only, and (b) the technical component of the test only. Modifiers 26 and TC cannot be used with these codes. The total RVUs for global procedure only codes include values for physician work, practice expense and malpractice expense. The total RVUs for global procedure only codes equals the sum of the total RVUs for the professional and technical components only codes combined.
5 Incident To Codes: This indicator identifies codes that describe services covered incident to a physician’s service when they are provided by auxiliary personnel employed by the physician and working under his/her direct personal supervision. Payment may not be made by carriers for these services when they are provided to hospital inpatients or patients in a hospital outpatient department. Modifiers 26 and TC cannot be used with these codes
6 Laboratory Physician Interpretation Codes: This indicator identifies clinical laboratory codes for which separate payment for interpretations by laboratory physicians may be made. Actual performance of the tests is paid for under the lab fee schedule. Modifier TC cannot be used with these codes. The total RVUs for laboratory physician interpretation codes include values for physician work, practice expense and malpractice expense.
7 Physical Therapy service for which payment may not be made: Payment may not be made if the service is provided to either a patient in a hospital outpatient department or to an inpatient of the hospital by an independently practicing physical or occupational therapist.
8 Physician Interpretation Codes: This indicator identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for a hospital inpatient. This applies only to code 85060. No TC billing is recognized because payment for the underlying clinical laboratory test is made to the hospital, generally through the Prospective Payment System (PPS) rate. No payment is recognized for code 85060 furnished to hospital outpatients or nonhospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test.
9 Not Applicable: Concept of a professional/technical component does not apply.

Global Surgery

This indicator provides the postoperative time frames that apply to payment for each surgical procedure or another indicator that describes the applicability of the global concept to the service.

Indicator Description
000 Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.
010 Minor procedure with preoperative relative values on the day of the procedure and postoperative relative values during a 10-day postoperative period included in the fee schedule amount; evaluation and management services on the day of the procedure and during the 10-day postoperative period generally not payable.
090 Major surgery with a one-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.
MMM Maternity codes; usual global period does not apply.
XXX Global concept does not apply to the code.
YYY MAC determines whether the global concept applies and establishes postoperative period, if appropriate, at the time of pricing.
ZZZ The code is related to another service and is always included in the global period of the other service.

Multiple Procedure (Modifier 51)

This indicator indicates which payment adjustment rule for multiple procedures applies to the service.

Indicator Description
0 No payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.
1 Standard payment adjustment rules in effect before 1/1/1996, for multiple procedures apply. In the 1996 MPFSDB, this indicator only applied to codes with procedure status of ‘D.’ If a procedure is reported on the same day as another procedure with an indicator of 1, 2 or 3, Medicare ranks the procedures by the fee schedule amount and the appropriate reduction to this code is applied (100 percent, 50 percent, 25 percent, 25 percent, 25 percent and by report). MACs base payment on the lower of (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
2 Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2 or 3, MACs rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent and by report). MACs base payment on the lower of (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.
3 Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (that is, another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified on the Form CMS-1500 or its electronic equivalent claim. The multiple endoscopy rules apply to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a nonendoscopic procedure). If an endoscopic procedure is reported with only its base procedure, the base procedure is not separately paid. Payment for the base procedure is included in the payment for the other endoscopy.
4 Diagnostic imaging services subject to MPPR methodology. TC of diagnostic imaging services subject to a 50 percent reduction of the second and subsequent imaging services furnished by the same physician (or by multiple physicians in the same group practice, for example, same group National Provider Identifier [NPI]) to the same beneficiary on the same day, effective for services 1/1/2010 and after. PC of diagnostic imaging services are subject to a 25 percent payment reduction of the second and subsequent imaging services effective 11/2012.
5 Selected therapy services subject to MPPR methodology. Subject to 20 percent of the practice expense component for certain therapy services furnished in office or other noninstitutional settings, and 25 percent reduction of the practice expense component for certain therapy services furnished in institutional settings (effective for services 1/1/2011, and after).

Subject to 50 percent reduction of the practice expense component for certain therapy services furnished in both institutional and noninstitutional settings (effective for services 4/1/2013, and after).
6 Diagnostic cardiovascular services subject to the MPPR methodology.

Full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, i.e., same group NPI) to the same patient on the same day. If the procedure also has a PC/TC Indicator of 3 or 4 the contractor will calculate the reduction for the global procedure whether another procedure is billed on the same day.
7 Diagnostic ophthalmology services subject to the MPPR methodology.

Full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician (or by multiple physicians in the same group practice, that is, same group NPI) to the same beneficiary on the same day (effective for services 1/1/2013, and after).
9 Concept does not apply.

Bilateral Surgery (Modifier 50)

This indicates services subject to a payment adjustment:

Indicator Description
0 150 percent payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier 50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100. Payment should be based on the fee schedule amount of $125 since it is lower than the total actual charges for the left and right sides ($200).

The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.
1 150 percent payment adjustment for bilateral procedure applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of (a) the total actual charge for both sides, or (b) 150 percent of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.
2 150 percent payment adjustment for bilateral does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier 50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base payment for both sides on the lower of (a) the total actual charges by the physician for both sides, or (b) 100 percent of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100.

Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The RVUs are based on the bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.
3 The usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier 50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100 percent of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.
9 Concept does not apply.

Assistant at Surgery

Indicates services where assistant at surgery may be paid. Assistant at surgery modifiers include modifier 80 if the services are by a MD or DO, and modifier AS if by an NP, PA, or CNS.

Indicator Description
0 Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
1 Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.
2 Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.
9 Concept does not apply.

Co-surgeons (Modifier 62)

This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.

Indicator Description
0 Co-surgeons not permitted for this procedure.
1 Co-surgeons could be paid, though supporting documentation is required to establish the medical necessity of two surgeons for the procedure.
2 Co-surgeons permitted and no documentation required if the two-specialty requirement is met.
9 Concept does not apply.

Team Surgery (Modifier 66)

This field provides an indicator for services for which team surgeons may be paid.

Indicator Description
0 Team surgeons not permitted for this procedure.
1 Team surgeons could be paid, though supporting documentation required to establish medical necessity of a team; pay by report.
2 Team surgeons permitted; pay by report.
9 Concept does not apply.

Physician Supervision

This field is for use in post payment review.

Indicator Description
1 Procedure must be performed under the general supervision of a physician.
2 Procedure must be performed under the direct supervision of a physician.
3 Procedure must be performed under the personal supervision of a physician.
4 Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician.
5 Not subject to supervision when furnished personally by a qualified audiologist, physician, or nonphysician practitioner. Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when appropriate to the circumstances of the test.
6 Procedure must be performed by a physician or a PT who is certified by the ABPTs as a qualified electrophysiological clinical specialist, and is permitted to provide the procedure under state law.

Procedure may also be performed by a PT with ABPTS certification without physician supervision.
21 Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.

Procedure may also be performed by a PT with ABPTS certification without physician supervision.
22 May be performed by a technician with online real-time contact with physician.
66 May be performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.
6A Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
77 Procedure must be performed by a PT with ABPTS certification (TC and PC) or by a PT without certification under direct supervision of a physician (TC and PC), or by a technician with certification under general supervision of a physician (TC only; PC always physician).
7A Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
9 Concept does not apply.

Diagnostic Imaging Family Indicator

This field identifies the applicable diagnostic service family for that HCPCS code with a multiple procedure indicator of “4.”  For services effective 1/1/2011, and after, family indicators 01–11 will not be populated.

Indicator Description
01 Family 1 Ultrasound (Chest/Abdomen/Pelvis – Non Obstetrical) 02 = Family 2 CT and CTA (chest/thorax/abdomen/pelvis)
02 Family 2 CT and CTA (chest/thorax/abdomen/pelvis)
03 Family 3 CT and CTA (head/brain/orbit/maxillofacial/neck)
04 Family 4 MRI and MRA (chest/abdomen/pelvis)
05 Family 5 MRI and MRA (head/brain/neck)
06 Family 6 MRI and MRA (spine)
07 Family 7 CT (spine)
08 Family 8 MRI and MRA (lower extremities)
09 Family 9 CT and CTA (lower extremities)
10 Family 10 MR and MRI (upper extremities and joints)
11 Family 11 CT and CTA (upper extremities)
88 Subject to the reduction of the TC diagnostic imaging (effective for services 1/1/2011, and after). Subject to the reduction of the PC diagnostic imaging (effective for services 1/1/2012, and after).
99 Concept does not apply

[Return to Top]

CMS Physician Fee Schedule Search and RVU Information

CMS maintains the Physician Fee Schedule Search tool to help you locate Medicare fee schedule pricing. 

Access to the physician fee schedule relative value unit and database indicator information is available on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html

This information is from the CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23.

[Return to Top]

Fee Schedule Assistance
Web Content Viewer
Complementary Content