Medicare provides public reference fee schedules for all kinds of medical services: E&M codes, laboratory and radiology services, DME, and drugs and injectables.
Making your own Medicare fee schedule provides a ready reference for your practice payments. The Medicare fee schedule has four components that are useful references for a pediatrician:
- Part 1: the physician fee schedule (PFS), which contains fees for all RVU-containing CPT and HCPCS codes, like sick and well evaluation and management (E&M codes), immunization administration codes, and procedure codes.
- Part 2: laboratory schedule, which contains fees for lab work (like urinalysis, CBC, rapid strep, and other codes, generally in the 80000-89999 CPT range.)
- Part 3: immunization and injectable schedule, which contains Medicare payments for Medicare-approved immunizations and injectable drugs.
- Part 4: DME, which contains Medicare payments for DME and supply codes.
Medicare fee schedule part 2: Clinical laboratory fee schedule)
| Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html. |
| Select a time period. The latest data will have the most recent year and most recent quarter. For example, Q3 (third quarter) is the most recent here of the 2018 files. |
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| Click to download the file (e.g. 18CLABQ3.) |
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| In the zip file, open the Excel file (e.g. CLFS 2018Q3.) |
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| The file can be used as-is for lab reference pricing, or you can combine it with the Medicare Physician Fee Schedule file into a single reference file. Column B is the HCPCS/CPT code, column G is the description of the HCPCS/CPT code, and column F is the payment rate. Note that INDICATOR is usually either N for National (i.e. the same fee schedule is paid everywhere in the United States) or L for Local (i.e. there are some variations based on geographic location.) All L indicators will have a price of $0.00 in this spreadsheet. You will have to find the local fee for these codes through your geographic MAC, although by and large the L-indicator codes are not used in primary care. |
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| To combine it with the PFS file, rearrange the columns so that the HCPCS column is in column A, the description is in column C, and the payment is in column F. To copy/paste an entire column at once, click on the letter column header, Ctrl-C, click on the target column header letter, then Ctrl-V. |
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| Once the columns are reorganized, copy and paste the result at the bottom of the PFS file. |
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