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: Durable medical equipment (DME), which contains Medicare payments for DME and supply codes.
Medicare fee schedule part 4: Durable Medical Equipment fee schedule
| Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html. |
| Select a time period. The latest data will have the most recent year and highest letter. In this particular case, since DME18-D (orange arrow) links to no updates, we will select DME18-C (green arrow) in this case. |
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| Download the file (e.g. DME18-C.zip). |
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| In the zip file, open the DMEPOS file (e.g. DMEPOS_JUL.xls) |
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| The relevant columns in this file are the HCPCS code column (column A), the HCPCS code description column (column DJ), and the appropriate state column for your state. |
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| Each state has two columns, nonrural (NR) and rural (R). To determine if you're in a rural or nonrural location, look in the DMERuralZip file (e.g. DMERuralZip_Q32018). If your zip code is listed, then use the rural (R) payments as a guide. |
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| Delete all state columns that are irrelevant for your location. |
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| If you are in a rural area, combine the nonrural and rural fee schedules into a single column. If the rural column shows 0.00 (green arrow), the rural payment for that HCPCS is the same as the nonrural payment. If the rural column shows a nonzero value (orange arrow), the higher rural column payment applies to rural areas. |
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| To simply combine the rural/nonrural fees in this way, you can create a formula to take the maximum of the two columns into a third column. |
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| To propagate the formula down to the bottom of the sheet, select the cell with the formula, Ctrl-C to copy it, click on an empty cell, drag down to the bottom, then type Ctrl-V. |
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| To save the values so you can delete the two source columns, select the resulting column (here column J), |
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| Now you can delete the two source columns. |
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| Copy and paste the columns so that the HCPCS code is in column A, the HCPCS description is in column C, and the payment column is in column F. |
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| Select the three resulting DME columns and copy them. |
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| Paste the data to the bottom of the PFS data. |
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