PFS Quick Reference Search Guide

Search Steps

Step 1: Begin Search

Click Begin Search on the Physician Fee Schedule Look-Up Tool  webpage and then click Accept to show you’ve read and agree to the licensing agreement. The Search the Physician Fee Schedule webpage will appear. 

Figure 1: Search the Physician Fee Schedule webpage

Step 2: Year

Choose the PFS year for your search.

Step 3: Type of Information

Choose 1 of the following 5 types of information related to your search:

• Pricing Information - Search the maximum fee schedule amount by HCPCS code
• Payment Policy Indicators - This includes information such as global surgery days, multiple surgery indicators, and applicability of professional and technical components
• Relative Value Units (RVUs) – This includes RVU information for work, practice expense, and malpractice costs
• Geographic Practice Cost Index (GPCI) – Medicare set up a GPCI for every Medicare payment locality for each of the 3 parts of a procedure’s RVU
• All - This includes data for each of the above types of information
  
  Tip: If you choose Payment Policy Indicators from the Type of Information dropdown menu, no MAC dropdown menu appears.

Step 4: HCPCS Criteria

Note: This step won’t apply if you chose the GPCI Type of Information in Step 3.

Choose 1 of the following 3 alternatives:

• Single HCPCS Code – Click on Single HCPCS Code and type the code in the HCPCS Code field that appears at the bottom of the page
• List of HCPCS Codes – Click on List of HCPCS Codes and enter up to 5 codes in the HCPCS Code fields that appear at the bottom of the page

• Range of HCPCS Codes – Click on Range of HCPCS Codes and enter starting and ending procedure codes for the code range in the HCPCS Code fields that appear at the bottom of the page

  Tip: We recommend using a small range of codes. It takes longer for a larger range to populate.

Then, choose a modifier value from the Modifier dropdown menu:

• Global (Diagnostic Service) or Physicians Professional Service where the Professional or Technical concept doesn’t apply
• 26 Professional Component
• 53 Procedures which the physician ended before completion
• TC Technical Component

• All Modifiers

  Tip: If you don’t know which modifier to choose, choose All Modifiers. This choice brings up all the modifiers listed above, not all modifiers in the AMA or HCPCS code books.

Step 5: Medicare Administrative Contractor (MAC) Option

Note: This step only applies if you choose Pricing Information, GPCI, or All for the Type of Information in Step 3.

Choose 1 of the following 4 alternatives:

• National Payment Amount – Shown with a MAC locality code of 0000000.
• Specific MAC – Click Specific MAC, then start typing the name of the region or state you’d like. Once you start typing, MAC regions will appear below the box. Choose your MAC from the list that appears below the box.
• Specific Locality – Click Specific Locality, then start typing the name of the region or state you’d like. Once you start typing, MAC localities will appear below the box. Choose your locality from the list that appears below the box.
• All MACs – Displays information for the entire nation. Results include the national payment amount, as well as all MAC localities.

Step 6: Click Search Fees to see your search results

Search Tips

You have 2 ways to manage your search results:

1. Click the Download CSV button under your search results
2. Click the Copy link button under your search results

To download an Excel file of your search results:

1. Click the Download CSV button. A box will pop up at the top right of your screen asking if you want to open the file.
2. Click the Open button to see your search results in an Excel spreadsheet.

To save a file with your search results:

1. Click on the folder icon to the right of the Open button
2. Choose where you’d like to save your file on your computer

To delete your search results: Click on the trash can icon to the right of the folder icon

To copy a link to your search results:

1. Click on the Copy link button below your search results table. You’ll see a green check box to the right of the button and a message that says Link copied to clipboard.
2. Right click and select Paste to add the link to an email, a browser search bar, or any document you choose.

Participating & Nonparticipating

• Participating Medicare Providers and Suppliers enroll in Medicare and sign the Form CMS-460, Medicare Participating Physician or Supplier Agreement, agreeing to charge no more than Medicare-approved amounts and deductibles and coinsurance amounts.

  Providers and suppliers send in Assigned Claims on behalf of the patient. Medicare issues payment to the sender.

• Nonparticipating Providers and Suppliers who enroll in Medicare but decide not to sign the Form CMS-460 accept assignment on a case-by-case basis.

  Medicare reduces the Medicare-approved amounts for nonparticipants by 5% for services paid under the PFS. A Limiting Charge limits what you or the supplier may charge the patient when you choose not to accept assignment on the claim.

• The Limiting Charge equals 115% of the nonparticipating fee schedule amount and is the most the nonparticipant may charge a patient on an unassigned claim. The nonparticipating fee schedule amount is equal to 95% of the PFS.
• Nonparticipating providers or suppliers who don’t accept the assignment on the claim, send in Unassigned Claims. Medicare issues payment to the patient. Use the PFS Look-Up Tool to learn if payment policies such as payment of assistant at surgery services, applicability of certain modifiers, and physician supervision of diagnostic services affect HCPCS codes.

PFS Payment Rates

CMS updates the PFS quarterly. Medicare uses the PFS Payment Rates Formula to decide a service’s payment rate. 

Figure 2: Mathematical formula describing Medicare PFS payment rate

Relative Value Units (RVUs)

The PFS uses 3 separate RVUs to calculate a payment:

1. The Work RVU shows the Medicare PFS service’s relative time and intensity
2. The Practice Expense (PE) RVU shows the costs of supporting a practice, like renting office space, buying supplies and equipment, and staff costs
3. The Malpractice (MP) RVU shows the costs of malpractice insurance

Geographic Practice Cost Indices (GPCIs)

Medicare adjusts each of the 3 RVUs to account for geographic variations in the costs of practicing medicine in different areas of the country. Each kind of RVU has a related GPCI adjustment.

Conversion Factor (CF)

To decide the payment rate for a service, CMS systems multiply the sum of the geographically adjusted RVUs by a CF in dollars. The statute specifies the formula Medicare uses to update the CF every year.

Medicare uses a fee schedule, a complete listing of fees, to pay doctors or other providers and suppliers. We use this comprehensive listing of fee maximums to pay a physician or other providers and suppliers on a Fee- for-Service (FFS) basis. 

Medicare bases payment on whichever is less, the charge or PFS amount. CMS also develops fee schedules for ambulance services, clinical laboratory services, and DMEPOS.

For most codes, Medicare pays 80% of the allowed amount and the patient pays 20%. Examples of reductions from the published PFS amount include:

• Assistants at surgery get 16% of the PFS rate
• Medicare pays nurse practitioners, physician assistants, and clinical nurse specialists 85%
• Medicare pays physical and occupational therapy assistants 85%
• Medicare pays registered dietitians or nutrition providers for medical nutrition therapy services 85%
• Clinical social workers get 75%