Payment Rates Non-Institutional Providers

PAYMENT RATES NON-INSTITUTIONAL PROVIDERS

Medicare Ambulatory Surgical Center (ASC) Procedures and Payment Groups (Formerly: ASC Base Eligibility File)

This file contains the procedure codes which may be performed in an ASC under the Medicare program and the ASC payment group assigned to each of the procedure codes. The ASC payment group determines the amount that Medicare pays for facility services furnished in connection with a covered procedure. This file is updated annually, usually in April.

Annual Physician Fee Schedule Payment Amount - National

This file contains one record for each unique combination of carrier, locality, procedure, and certain modifiers. Additionally, the file contains the Relative Value Units (RVUs) associated with the service and the Geographic Practice Cost Indices (GPCIs) associated with each locality. This file is available after publication in the Federal Register, usually in late November. The current year file will be updated periodically to incorporate mid-year changes. Updated files will be available on April 1, July 1, and October 1. Files purchased after January 1, will contain pricing data for carrier-priced services for the prior year. The files for the years 1992-1995 contain transition and full fee amounts. Files for the year 1996 forward contain only the full fee amounts because the transition period has ended.

Annual Physician Fee Schedule Payment Amount File - Selected Carrier

This file contains locality-specific pricing amounts for services covered by the Medicare Physician Fee Schedule. The file contains one record for the unique combination of carrier, locality, procedure, and certain modifiers. Additionally, the file contains the Relative Value Units (RVUs) associated with the service and the Geographic Practice Cost Indices (GPCIs) associated with the locality. This file is a subset of the Annual Physician Fee Schedule Payment Amount File -- National. This file is available after publication in the Federal Register, usually in late November. The current year file will be updated periodically to incorporate mid-year changes. Updated files will be available on April 1, July 1, and October 1. Files purchased after January 1, will contain pricing data for carrier-priced services for the prior year. The files for the years 1992-1995 contain transition and full fee amounts. Files for the year 1996 forward contain only the full fee amounts because the transition period has ended.

Clinical Diagnostic Lab Fee Schedule - National/Carrier

This file contains the carrier-specific fee schedules and national limitation amounts for the clinical laboratory services that are covered under the Clinical Diagnostic Laboratory Fee Schedule. The 1995 file contains pricing amounts for all clinical laboratory codes. For 1995 and 1996, each carrier's data are contained in a separate file; a total of 55 separate files are on the diskette. For 1997 and forward, all carrier-specific fee schedules and national limitation amounts will be contained in one file. For each unique combination of procedure, carrier, and locality, these files contain the carrier 60% and 62 % fee schedules and the 60% and 62% national limitation amounts. The locality field on these files identifies states for multi-state-carriers. This file is usually released in December for the following year.

Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule

This file contains a fee schedule amount, floor, ceiling, jurisdiction, and category for each unique combination of procedure code, modifier code (where applicable), and state of provider and beneficiary. The file is sorted in ascending DMEPOS category/procedure code/modifier order. The DMEPOS fee schedule will be updated on a quarterly basis, with the January 1, implementation date being the primary update. In addition to the January file, updated files will be available in early April, July, and October. These files will be complete replacement files for the DMEPOS fee schedule, not only the quarterly changes.

National Physician Fee Schedule Relative Value File

This file contains information on procedure codes covered under the Medicare Physician Fee Schedule. For more than 10,000 physician services, the file contains the associated Relative Value Units (RVUs), a fee schedule coverage indicator, and various payment policy indicators needed for payment adjustments (i.e., payment of assistant at surgery, team surgery, billable medical supplies, etc.). The file contains one record for each unique combination of procedure code and modifier. This file is available after publication in the Federal Register, usually in late November. Current year file will be updated periodically to incorporate mid-year changes. Updated files will be available on April 1, July 1, and October 1. This file will contain a separate file of the Geographic Practice Cost Indicies (GPCIs) for 1997 and forward.