Sample PFS Searches

1. Choose Pricing Information for the Type of Information

2. Choose 1 of the following HCPCS Criteria:

   • Single HCPCS Code: Enter 1 procedure code
   • List of HCPCS Codes: Enter up to 5 codes
   • Range of HCPCS Codes
     • Enter a starting and ending procedure code to define the range
     • You can search for up to 300 codes at a time

   Tip: The PFS includes Level I CPT and Level II HCPCS codes.

   

   Figure 1: Pricing Information Search

3. Choose 1 of the following choices for the Medicare Administrative Contractor (MAC) criteria:

   • National Payment Amount: This choice searches for information for only the national payment amount. A MAC locality code of 0000000 shows for the national payment amount.
   • Specific MAC: Providers use a MAC locality code to search for information showing a specific geographic area. If you choose this alternative, a dropdown menu will appear in the Specific MAC field when you start typing or use arrow keys. A few of these areas, such as 01112 Northern California, have multiple listings. 
   • Specific Locality: This search allows you to drill down to specific cities if payment varies within a MAC for specific localities. For example, San Francisco-Oakland-Hayward (San Francisco County) is 0111205. Notice the number for San Francisco-Oakland-Hayward (San Francisco County) starts with the Northern California number 01112, followed with a 05.
   • All MACs: This choice searches for information for the entire nation. The results include the national payment amount and all MAC localities. This choice is helpful for states with multiple payment localities because it groups all localities together for a MAC. Medicare payment may vary within 1 MAC. But this choice doesn’t give locality names. You must know the MAC locality codes, like those given in the Specific Locality choice.

   Tip: MACs may have more than 1 of these locality codes. For example, the JE MAC includes 01182-Southern California; 01112-Northern California; 01212-Hawaii, Guam, American Samoa, and the Northern Mariana Islands; and 01312-Nevada.

   

   Figure 2: Pricing Information Search

4. Enter the HCPCS codes for the search.

5. Choose 1 of the following Modifier alternatives from the 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.

   

   Figure 3: Pricing Information Search

   Click the Search fees button after you choose the criteria to start your pricing search.

We’ll start with a pricing search using a list of Evaluation and Management (E/M) codes. We’ll then show how search results vary when using a code with a professional or technical component.

Figure 4 shows the top part of the Search Results page after choosing or inputting the following information in this order:

• 2023
• Pricing Information
• List of HCPCS Codes
• 99214 and 99215 as a list of HCPCS Codes
• All Modifiers
• 11202 South Carolina as the Specific MAC

Tip: To change the search criteria, type in a new code or other factor at the top of the page and then click on the Search fees button.

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See the results from our search in Figure 4. The PFS Look-Up Tool explains each code under the Short Description column.

Figure 4: Pricing Search Results for List of E/M Codes

1. HCPCS Code – The PFS Look-Up Tool displays 99214 and 99215 on separate rows with the pricing information shown to the right.
2. Modifier - There’s nothing displayed in this column. This field stays blank for services other than those codes with a professional or technical component (or both), with 1 exception: When allowed, CPT modifier 53 appears in this column.
3. Short Description – This column shows a short description of the code and the time a physician would spend during an exam.
4. Proc Stat - This column includes the Procedure Status Code. A is listed in this column for Active Code. This means the physician fee schedule pays this code separately, if covered.
5. MAC Locality - In Figure 4, the search shows 1120201. In this example, 1120201 is South Carolina, and 01 as the last 2 digits means that all of South Carolina’s pricing is statewide. If you use Northern California as an example, the Look-Up Tool shows several rows because pricing in California varies in several localities.

6. Non-Facility Price - Figure 4 displays $121.88 for 99214 and $171.09 for 99215. This column includes the fee schedule amount when you do a procedure in a non-facility setting like an office. (Non-facility fees apply to therapy procedures regardless of whether the physician provides them in facility or non- facility settings.)

   Occasionally, Medicare pays institutions like hospitals under the PFS. When this occurs, Medicare pays them at the non-facility rate. Although the terminology might seem confusing at first, the higher payment makes sense because the facility handles the cost of supplying the staff and supplies.

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7. Facility Price - $93.88 shows for 99214 and $137.85 for 99215. This is the fee schedule amount when a physician provides this service in a facility setting, like a hospital or ambulatory surgical center (ASC).

8. Non-Facility Limiting Charge - $133.16 shows for 99214 and $186.91 for 99215.

   This is the most the providers listed below may charge a patient for the service:

   • Nonparticipating health care providers
   • Providers who don’t accept assignment
   • Providers who do the service in an office setting

   Medicare reduces the Medicare-approved amounts 5% for nonparticipating providers and suppliers. In other words, the amounts in this column add up to 115% of 95% of the amounts in column 5.

9. Facility Limiting Charge – Figure 6 shows $102.57 for 99214 and $150.61 for 99215.

   This is the most the providers listed below may charge a patient for the service:

   • Nonparticipating health care providers
   • Providers who don’t accept assignment
   • Providers who do the service in a facility setting

10. Conv Fact - This column displays the Conversion Factor for this code. We’ll explain this later when we discuss RVUs.

    Note: Site of Service Differential

    Under the PFS, some procedures have a separate Medicare fee schedule for a physician’s professional services when provided in a facility like a hospital or in a non-facility.

    Generally, Medicare pays more for procedures done in an office because you must supply clinical staff, supplies, and equipment. View this differential in the Non- Facility Price and Facility Price columns.

Figure 5 below shows other pricing information that displays for codes providers may bill globally or with a professional or technical component. Use the following information for this example:

• 2023
• Pricing Information
• 76706, abdominal aorta ultrasound, as the Single HCPCS Code
• 11202 South Carolina as the Specific MAC
• All Modifiers

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Figure 5: Pricing Search Showing Modifiers 26 and TC

1. In Figure 5, the first row is blank in the modifier column. When a provider doesn’t use a modifier with this code, it means this provider did both the technical and professional components of the procedure. The Non-Facility Price pricing amount is $100.23, NA for the Facility Price and $109.50 for the Non-Facility Limiting Charge. When you add the amounts for the professional component (modifier 26) and the technical component (TC), in the Non-Facility Limiting Charge column, they equal the amount in row 1. Under the Facility Limiting Charge, the search results show NA.
2. The second row shows information for CPT code 76706 submitted with modifier 26, which providers use when they perform only the professional component of the procedure. The search results display $25.51 for the Non-Facility Price and the Facility Price and $27.87 for the Non-Facility Limiting Charge and the Facility Limiting Charge.
3. The third row displays the results if you bill CPT code 76706 with HCPCS Level II modifier TC, Technical Component. TC means the provider billed for performing the ultrasound only, not for the interpretation. The search results display $74.72 under the Non-Facility Price, NA under the Facility Price, and $81.63 under Non-Facility Limiting Charge. Under the Facility Limiting Charge, the search results show NA.

Let’s use the Payment Policy Indicators Search to review the other information available in the PFS Look-Up Tool.

The Payment Policy Indicators include:

• Professional or technical modifiers if they apply
• The number of post-operative days included in a procedure
• Whether Medicare pays a code
• The level of physician supervision needed
• Whether you bill the service as a bilateral procedure

In Figure 6, we’ll search using a code with related professional or technical modifiers and then, in Figures 7-1 and 7-2, we’ll discuss the information given when you use a surgical code.

Tip: You don’t have to include a location or choose a MAC for the payment policy search because the policies shown are national.

Figure 6 shows a part of the Search results after choosing the following criteria:

• 2023
• Payment Policy Indicators
• Single HCPCS Code 76706
• All Modifiers

We used the same code, 76706, as we just did in a pricing search to compare the information given.

Tip: For the technical component of certain diagnostic imaging procedures, Medicare bases payment on the lower of the Outpatient Prospective Payment System (OPPS) cap or fee schedule amount. The PFS search results don’t show payment adjustments. The PFS Look-Up Tool displays full payments as well as OPPS payments. Also, the PFS Look-Up Tool can’t display multiple procedures payment reductions (MPPRs) since too many combinations of HCPCS codes exist.

Figure 6: Payment Policy Indicators Search Results

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1. Modifier – As in our pricing search for this code, the screen displays 3 rows, showing that providers can report code 76706, abdominal aorta ultrasound, with no modifier, modifier 26, or a TC modifier. All the other columns in this example display the same information for each row under the column heading.
2. Proc Stat – This column, which shows Procedure Status Indicator, shows an A, meaning an active code in the Pricing Search.
3. PCTC – This column shows the Professional Component and Technical Component Indicators. A 1 shows in this example, which means the code is a diagnostic test or radiology service. You can use Modifiers 26 and TC when sending in this code on a claim.
4. Global – XXX shows in this example, which means the global surgery concept isn’t applicable to this code.
5. MULT SURG – This column displays zeros, which means no payment adjustment rules for multiple procedures apply.

6. BILT SURG – This column displays zeros, which means the 150% payment adjustment for bilateral procedure doesn’t apply. The PFS bases RVUs on the procedure done as a bilateral procedure. If you report the procedure with modifier 50 or report it twice on the same day (for example, with RT and LT modifiers with a 2 in the units field), Medicare bases payment for both sides on the lower of:

   • The total actual charges for both sides
   • 100% of the fee schedule amount for a single code

   All the other columns include the figure 0 or letters XXX showing that these indicators don’t apply, or Medicare doesn’t allow them for code 76706. Let’s now do a search using a surgical code to see what information shows in these columns.

The example below shows PFS search results when searching for CPT code 47480, Incision of gallbladder.

Understanding information shown in these search results helps you understand policies such as bundled procedures or whether you need a CPT modifier with a code to get paid. This includes modifiers for assistant surgeons, bilateral surgery, and multiple procedures.

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Figure 7.1: Payment Policy Indicators Search Using a Surgical Code

1. Modifier – The Modifier column has no information listed.
2. Short Description – This column shows a short description of the code.
3. Proc Stat – This column displays an A showing this code is active.
4. PCTC – This column displays a 0. The 0 indicator refers to codes that describe physician services. Examples include visits, consultations, and surgical procedures. The concept of PC and TC don’t apply since the PFS doesn’t split physician services into professional and technical components.
5. Global – This field gives the time frames that apply to payment for each surgical procedure or another indicator that says whether it applies to the global concept of the service. Figure 7-1 lists 090 which means code 47480 is major surgery with a 1-day preoperative period and 90-day postoperative period included in the fee schedule payment amount.

6. MULT SURG – This column shows which payment adjustment rule for multiple procedures, including certain physical therapy procedures, applies to the service. In Figure 7-1, a 2 shows that standard payment adjustment rules for multiple procedures apply. Payment is based on the lower of the billed amount, or:

   • 100% of the fee schedule amount for the highest valued procedure
   • 50% of the fee schedule amount for the second through the fifth highest valued procedures

   The Medicare system reviews other procedures and considers them for payment.

7. BILT SURG – This field gives an indicator for bilateral services subject to a payment adjustment. CMS defines Bilateral surgeries as procedures done on both sides of the body during the same operative session or on the same day. In Figure 7-1, we see 0, which means the 150% payment adjustment for bilateral procedures doesn’t apply. If you report this procedure with modifier 50 or with modifiers RT and LT, Medicare bases payment for the 2 sides on the lower of:
   • The total actual charge for both sides
   • 100% of the fee schedule amount for a single code

8. ASST SURG – This column shows whether the PFS pays assistants at surgery. Figure 7-1 shows a 2, which means payment restriction for assistants at surgery doesn’t apply to this procedure.

   

   Figure 7.2: Search Using a Surgical Code

9. CO SURG – This field in Figure 7-2 includes an indicator 1, which means the PFS pays co-surgeons, each of a different specialty. Medicare needs supporting documentation to prove the medical necessity of 2 surgeons for this procedure.
10. Team SURG – This field in Figure 7-2 shows indicator 0, meaning Medicare rules don’t allow a team of surgeons (more than 2 surgeons of different specialties) for this procedure.
11. PHYS SUPV – Health care providers must do diagnostic tests, with certain exceptions, under the supervision of a physician. This field shows the level of supervision needed. In this example, 09 means that this concept doesn’t apply.

Before starting an RVU or GPCI search, it’s important to understand the definition of RVUs and GPCIs. The PFS bases the pricing for each code on the following 3 parts:

1. RVU – RVUs show the resources needed to provide a physician fee schedule service. The PFS uses 3 separate RVUs to calculate payment under:
   • Work RVUs show the time and intensity associated with providing a service and equal about 50% of the total payment
   • Practice Expense (PE) RVUs show costs like renting office space, buying supplies and equipment, and staff
   • Malpractice (MP) RVUs show the relative costs of purchasing malpractice insurance
2. GPCI – To calculate the payment for every provider’s service, the Medicare system adjusts parts of the fee schedule (physician work, PE, and MP RVUs) with a GPCI. The GPCIs show the costs of physician work, practice expense, and malpractice expense in a specific area compared to the national average costs for each part.
3. Conversion Factor (CF) – Typically, CMS updates the CF each year. Until 2015, CMS used the Medicare Economic Index (MEI) adjusted up or down to calculate the annual update, depending on how actual expenditures compared to a target rate called the sustainable growth rate (SGR). The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the SGR update formula for payments under the PFS. Effective January 1, 2023, the Physician Fee Schedule update factor is 0.00% and the CF is 33.0607. The application of the CF converts RVUs to dollar amounts.

Tip: If you search for code 99215 instead of 99214, you’ll see a 2.80 in the Work RVU column, showing a higher relative value. Look back at the pricing search we did with these 2 codes. You’ll see that the payment for 99215 is higher than for 99214.

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We’ll first show an RVU search and then show a GPCI search.

RVU Search

Using the PFS Look-Up Tool, we chose:

• 2023
• Relative Value Units for the Type of Information
• 99214 for the Single HCPCS Code
• All Modifiers

Figure 8 shows a part of the screen displayed after making these choices. This figure shows the following 5 columns that interest most providers:

Figure 8: RVU Search

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The PFS Look-Up Tool shows the following Practice Expense (PE) RVUs displayed in 5 columns:

1. 1.73 under Transitioned Non-FAC PE RVU
2. 1.73 under Fully Implemented Non-FAC PE RVU
3. 0.82 under Transitioned Facility PE RVU
4. 0.82 under Fully Implemented Facility PE RVU
5. 0.14 under MP RVU (Malpractice RVU)

In Figure 8, the Work RVU column is 1.92.

Chapter 23 (PDF) of the Medicare Claims Processing Manual includes information on the other columns displayed in an RVU search.

Tip: To see how MP RVUs vary, enter a different code in an RVU search and compare to this result for 99214.

GPCI Search

Finally, let’s do a GPCI search for 2023. Remember, we don’t enter a HCPCS code here because the same GPCI applies for all codes in an area. We’ll decide whether we want a GPCI for:

• National Payment Amount
• Specific MAC
• Specific Locality
• All MACs

Figure 9 shows a screen for GPCIs when choosing All MACs.

Figure 9: GPCI Search

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Remember that MAC Locality 0000000 is national, as shown in Figure 9. The value of 1.000 shows in each of the 3 GPCI columns: GPCI WORK, GPCI PE, and GPCI MP. For specific localities, any values higher or lower than 1.000 mean higher or lower geographic classification values than the national average.

For our example, location 0111205 shows a value of 1.082, 1.374, and 0.452 in these 3 separate columns.

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