100-04 Medicare Claims Processing Manual: Chapter 23 - Fee Schedule Administration and Coding Requirements

Medicare Claims Processing Manual
Chapter 23 - Fee Schedule Administration and Coding
Requirements
Table of Contents
(Rev. 13701; Issued: 06-16-26)
Transmittals for Chapter 23
10 - Reporting ICD Diagnosis and Procedure Codes
10.1 - General Rules for Diagnosis Codes
10.2 - Inpatient Claim Diagnosis Reporting
10.3 - Outpatient Claim Diagnosis Reporting
10.4 - ICD Procedure Code
10.5 - Coding for Outpatient Services and Physician Offices
10.6 - Relationship of Diagnosis Codes and Date of Service
20 - Description of Healthcare Common Procedure Coding System (HCPCS)
20.1 - Use and Maintenance of CPT-4 in HCPCS
20.2 - RESERVED
20.3 - Use and Acceptance of HCPCS Codes and Modifiers
20.4 - Deleted HCPCS Codes/Modifiers
20.5 - The HCPCS Codes Training
20.6 - Professional/Public Relations for HCPCS
20.7 - Use of the American Medical Association’s (AMA’s) Physicians’ Current Procedural
Terminology (CPT) Fourth Edition Codes, and Use of the Americian Dental Associations’s (ADA)
Current Dental Terminology-Fourth Edition (CDT) Codes on A/B MACs (A)’s, (B)’s, (HHH)’s, and
DME MACs’ Web Sites and Other Electronic Media
20.8 - Payment, Utilization Review (UR), and Coverage Information on CMS Quarterly HCPCS
Codes Update File
20.9 - National Correct Coding Initiative (NCCI)
20.9.1 - Correct Coding Modifier Indicators (CCMI) and HCPCS Codes Modifiers
20.9.1.1 - Instructions for Codes With Modifiers (A/B MACs (B) Only)
20.9.2 - Limiting Charge and CCI Edits
20.9.3 – Appeals
20.9.3.1 Procedure-to-Procedure (PTP) Edits
20.9.3.2 Medically Unlikely (MUEs) Edits
20.9.4 - Savings Report 	20.9.4.1 - Savings
Record Format
20.9.5 – Adjustments 	20.9.6 - Correct
Coding Edit (CCE) File Record Format
20.9.7 – National Correct Coding Initiative (NCCI) Edits Quarterly Updates

30 - Services Paid Under the Medicare Physician’s Fee Schedule
30.1 - Maintenance Process for the Medicare Physician Fee Schedule Database (MPFSDB)
30.2 - MPFSDB Record Layout
30.2.1 - Payment Concerns While Updating Codes
30.2.2 - MPFSDB Status Indicators
30.3 - Furnishing Pricing Files
30.3.1 - RESERVED
30.3.2 - A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for National
Codes
30.3.3 - Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor Data
30.3.4 - Responsibility to Obtain and Implement Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee Schedules
30.3.5 - File Specifications
40 - Clinical Diagnostic Laboratory Fee Schedule
40.1 - Access to Clinical Diagnostic Lab Fee Schedule Files
40.2 - A/B MAC (B) Record Layout for Clinical Laboratory Fee Schedule
40.3 - Institutional Claim Record Layout for Clinical Laboratory Fee Schedule
40.4 - Gap-Filled Fees Submitted to CMS by A/B MACs (B)
40.4.1 - A/B MACs (B) Forward HCPCS Gap Fill Amounts to A/B MACs (A) and (HHH)
50 - Fee Schedules Used by Medicare A/B MACs (A) and (HHH) Processing Institutional Claims
50.1 - Institutional Claim Record Layout for Hospice, Radiology and Other Diagnostic Prices and
Local HCPCS Codes
50.2 - Institutional Claim Record Layout for the Durable Medical Equipment, Prosthetic, Orthotic
and Supply Fee Schedule
50.3 - Institutional Claim Record Layout for the Outpatient Rehabilitation and CORF Services Fee
Schedule
50.4 - Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule
50.5 - RESERVED
50.6 - Physician Fee Schedule Payment Policy Indicator File Record Layout
50.7 - Institutional Claim Record Layout for the Mammography Fee Schedule
50.8 - Institutional Claim Record Layout for the Ambulance Fee Schedule
60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule
60.1 - Record Layout for DMEPOS Fee Schedule
60.2 - Quarterly Update Schedule for DMEPOS Fee Schedule
60.3 - Gap-filling DMEPOS Fees
60.3.1 - Payment Concerns While Updating Codes
60.4 - Process for Submitting Revisions to DMEPOS Fee Schedule to CMS
60.5 – Rural ZIP Code Claim Record Layout for Medicare Contractors Processing Rural DMEPOS
Fee Schedule Claims
70 - Parenteral and Enteral Nutrition (PEN) Fee Schedule
70.1- Record Layout for PEN Fee Schedule

80 - Reasonable Charges as Basis for A/B MAC (B)/DME MAC Payments
80.1 - Criteria for Determining Reasonable Charge
80.2 - Updating Customary and Prevailing Charges
80.3 - The Customary Charge
80.3.1 - Calculating Customary Charge
80.3.1.1 - Equity Adjustments in Customary Charge Screens
80.3.2 - Customary Charge Profile
80.4 - Prevailing Charge
80.4.1 - Rounding of Reasonable Charge Calculation
80.5 - Filling Gaps in A/B MAC (B) Reasonable Charge Screens
80.5.1 - Use of Relative Value Scale and Conversion Factors for Reasonable Charge Gap-
Filling
80.6 - Inflation Indexed Charge (IIC) for Nonphysician Services
80.7 - Determination of Comparable Circumstances
80.8 - Applying Criteria for Reasonable Charge Determinations
80.8.1 - Waiver of Deductible and Coinsurance
90 - Inherent Reasonableness Used for Payment of Nonphysician Services
100 - Competitive Bidding Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
Single Payment Amounts
100.1 - Record Layout for Competitive Bidding HCPCS Category File
100.2 - Record Layout for Competitive Bidding Pricing File
100.3 - Record Layout for Competitive Bidding ZIP Code Files
100.4 - Record Layout for Competitive Bidding Contract Supplier File
100.5 - Adjustments to the Single Payment Amounts to Reflect Changes in HCPCS Codes
Addendum - MPFSDB File Record Layout and Field Descriptions

10 - Reporting ICD Diagnosis and Procedure Codes
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
Proper coding is necessary on Medicare claims because codes are generally used in determining coverage
and payment amounts. CMS accepts only HIPAA approved ICD-9-CM or ICD-10-CM/ICD-10-PCS codes,
depending on the date of service. The official ICD-9-CM codes which were updated annually through
October 1, 2013 are posted at
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
The official annual updates and effective dates for any changes to ICD-10-CM and ICD-10-PCS codes are
posted at http://www.cms.gov/Medicare/Coding/ICD10/index.html .
See the following sections (10.1 - 10.6) for additional instructions about coding ICD diagnoses for inpatient,
outpatient, and other services.
10.1 - General Rules for Diagnosis Codes
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
The Official ICD-9-CM Coding Guidelines can be found at
http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm
The Official ICD-10-CM and ICD-10-PCS Coding Guidelines can be found with the annual ICD-10-CM
and ICD-10-PCS updates at http://www.cms.gov/Medicare/Coding/ICD10/index.html
The CMS understands that physicians may not always provide suppliers of DMEPOS with the most specific
diagnosis code, and may provide only a narrative description. In those cases, suppliers may choose to utilize
a variety of sources to determine the most specific diagnosis code to include on the individual line items of
the claim. These sources may include, but are not limited to: coding books and resources, contact with
physicians or other health professionals, documentation contained in the patient’s medical record, or
verbally from the patient’s physician or other healthcare professional.
Beneficiaries are not required to submit diagnosis codes on beneficiary-submitted claims. Beneficiary-
submitted claims are filed on Form CMS-1490S. For beneficiary-submitted claims, the A/B MAC (B) must
develop the claim to determine a current and valid diagnosis code and may enter the code on the claim.
10.2 - Inpatient Claim Diagnosis Reporting
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
On inpatient claims providers must report the principal diagnosis. The principal diagnosis is the condition
established after study to be chiefly responsible for the admission. Even though another diagnosis may be
more severe than the principal diagnosis, the principal diagnosis, as defined above, is entered. Entering any
other diagnosis may result in incorrect assignment of a Medicare Severity - Diagnosis Related Group (MS-
DRG) and an incorrect payment to a hospital under PPS. See Chapter 25, Completing and Processing the
Form CMS-1450 Data Set, for instructions about completing the claim.
Other diagnoses codes are required on inpatient claims and are used in determining the appropriate MS-
DRG. The provider reports the full codes for up to twenty four additional conditions if they coexisted at the
time of admission or developed subsequently, and which had an effect upon the treatment or the length of
stay.

The principal diagnosis should not under any circumstances be duplicated as an additional or secondary
diagnosis. If the provider reports duplicate diagnoses they are eliminated in Medicare Code Editor (MCE)
before GROUPER.
The Admitting Diagnosis Code is required for inpatient hospital claims subject to A/B MAC (A) review.
The admitting diagnosis is the condition identified by the physician at the time of the patient’s admission
requiring hospitalization. For outpatient bills, the field defined as Patient’s Reason for Visit is not required
by Medicare but may be used by providers for nonscheduled visits for outpatient bills.
10.3 - Outpatient Claim Diagnosis Reporting
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
For outpatient claims, providers report the full diagnosis code for the diagnosis shown to be chiefly
responsible for the outpatient services. For instance, if a patient is seen on an outpatient basis for an
evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported.
If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute
bronchitis), the definitive diagnosis is reported. If the patient arrives at the hospital for examination or
testing without a referring diagnosis and cannot provide a complaint, symptom, or diagnosis, the hospital
reports the encounter code that most accurately reflects the reason for the encounter.
Examples include:
• 	Z00.00 Encounter for general adult medical examination without abnormal findings
• 	Z00.01 Encounter for general adult medical examination with abnormal findings
• 	Z01.10 Encounter for examination of ears and hearing without abnormal findings
• 	Z01.118 Encounter for examination of ears and hearing with other abnormal findings
For outpatient claims, providers report the full diagnosis codes for up to 24 other diagnoses that coexisted in
addition to the diagnosis reported as the principal diagnosis. For instance, if the patient is referred to a
hospital for evaluation of hypertension and the medical record also documents diabetes, diabetes is reported
as another diagnosis.
Additional information and training is available on CMS Web site:
http://www.cms.gov/Medicare/Coding/ICD10/index.html
10.4 - ICD Procedure Codes
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
ICD procedure codes are required for inpatient hospital Part A claims only. Healthcare Common Procedure
Code System (HCPCS) codes are used for reporting procedures on other claim types. Inpatient hospital
claims require reporting the principal procedure if a significant procedure occurred during the
hospitalization. For information of the selection of the principal procedure, see the Official ICD-10-PCS
coding guidelines posted with the annual updates to ICD-10-PCS posted at
http://www.cms.gov/Medicare/Coding/ICD10/index.html
The principal procedure code and other procedure codes shown on the bill must be the full ICD-9-CM,
Volume 3, or ICD-10-PCS procedure code, including all applicable digits, up to seven digits.
Up to twenty four significant procedures other than the principal procedure may be reported.
10.5 - Coding for Outpatient Services and Physician Offices
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)

The Official ICD-10-CM Coding Guidelines include a section for Outpatient Services (hospital-based and
physician office). These guidelines can be found in the annual updates to ICD-10-CM posted at
http://www.cms.gov/Medicare/Coding/ICD10/index.html
A/B MACs (A), (B), (HHH), and DME MACs, physicians, hospitals, and other health care providers must
comply with the Official ICD-10-CM Coding Guidelines.
10.6 - Relationship of Diagnosis Codes and Date of Service
(Rev. 3081, Issued: 09-26-14, Effective: Upon Implementation of ICD-10, Implementation: Upon
Implementation of ICD-10)
Diagnosis codes must be reported based on the date of service (including, when applicable, the date of
discharge) on the claim and not the date the claim is prepared or received. A/B MACs (A), (B), (HHH), and
DME MACs are required to edit claims on this basis, including providing for annual updates each October.
Shared systems must maintain date parameters for diagnosis editing. Use of actual effective and end dates is
required when new diagnosis codes are issued or current codes become obsolete with the annual updates.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be
date-of-service compliant. Since ICD diagnosis codes are a medical code set, effective for dates of service
on and after October 1, 2004, CMS does not provide any grace period for providers to use in billing
discontinued diagnosis codes on Medicare claims. The updated codes are published in the Federal Register
each year as part of the Proposed Changes to the Hospital Inpatient Prospective Payment Systems in table 6
and effective each October 1.
All MACs will return claims containing a discontinued diagnosis code as unprocessable. For dates of
service beginning October 1, 2004, physicians, practitioners, and suppliers must use the current and valid
diagnosis code that is then in effect for the date of service. After the updated codes are published in the
Federal Register, CMS places the new, revised and discontinued codes on the ICD-9 or ICD-10 Web site as
applicable.
http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
or http://www.cms.gov/Medicare/Coding/ICD10/index.html.
The CMS sends the updated codes to All MACs on an annual basis via a recurring update notification
instruction. This is normally released to MACs each June, and contains the new, revised, and discontinued
diagnosis codes which are effective for dates of service on and after October 1 st .
20 - Description of Healthcare Common Procedure Coding System (HCPCS)
(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)
The HCPCS has been adopted as the code set for use in Health Insurance Portability and Accountability Act
(HIPAA) transactions, for reporting outpatient procedures, items, and services.
The HCPCS originated from the American Medical Association’s (AMA) “Physicians’ Current Procedural
Terminology, Fourth Edition” (CPT-4). It includes two levels of codes and modifiers. Level I contains only
the AMA’s CPT-4 codes. This level consists of all numeric codes. Level II contains alpha-numeric codes
primarily for items and nonphysician services not included in CPT-4, e.g., ambulance, DME, orthotics, and
prosthetics. These are alpha-numeric codes maintained by CMS.
The CMS monitors the system to ensure uniformity.
20.1 - Use and Maintenance of CPT-4 in HCPCS
(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)

There are over 7,000 service codes, plus titles and modifiers, in the CPT-4 section of HCPCS, which is
copyrighted by the AMA. The AMA and CMS have entered into an agreement that permits the use of
HCPCS codes and describes the manner in which they may be used. See §20.7 below.
• 	The AMA permits CMS, its agents, and other entities participating in programs administered by
CMS to use CPT-4 codes/modifiers and terminology as part of HCPCS;
• 	CMS shall adopt and use CPT-4 in connection with HCPCS for the purpose of reporting services
under Medicare and Medicaid;
• 	CMS agrees to include a statement in HCPCS that participants are authorized to use the copies of
CPT-4 material in HCPCS only for purposes directly related to participating in CMS programs, and
that permission for any other use must be obtained from the AMA;
• 	HCPCS shall be prepared in format(s) approved in writing by the AMA, which include(s)
appropriate notice(s) to indicate that CPT-4 is copyrighted material of the AMA;
• 	Both the AMA and CMS will encourage health insurance organizations to adopt CPT-4 for the
reporting of physicians’ services in order to achieve the widest possible acceptance of the system and
the uniformity of services reporting;
• 	The AMA recognizes that CMS and other users of CPT-4 may not provide payment under their
programs for certain procedures identified in CPT-4. Accordingly, CMS and other health insurance
organizations may independently establish policies and procedures governing the manner in which
the codes are used within their operations; and
• 	The AMA’s CPT-4 Editorial Panel has the sole responsibility to revise, update, or modify CPT-4
codes.
The AMA updates and republishes CPT-4 annually and provides CMS with the updated data. The CMS
updates the alpha-numeric (Level II) portion of HCPCS and incorporates the updated AMA material to
create the HCPCS code file. The CMS provides the file to A/B MACs (A), (B), (HHH), and DME MACs
and Medicaid State agencies. The file is also available via the CMS website.
It is the MAC’s responsibility to develop payment screens and limits within Federal guidelines and to
implement CMS’ issuances. The coding system is one of the tools used to achieve national consistency in
claims processing.
MACs may edit and abridge CPT-4 terminology within their claims processing area. However, MACs are
not allowed to publish, edit, or abridge versions of CPT-4 for distribution outside of the claims processing
structure. This would violate copyright laws. MACs may furnish providers/suppliers AMA and CMS
Internet addresses, and may issue newsletters with codes and approved narrative descriptions that instruct
physicians, suppliers and providers on the use of certain codes/modifiers when reporting services on claims
forms, e.g., need for documentation of services, handling of unusual circumstances. The CMS
acknowledges that CPT is a trademark of the AMA, and the newsletter must show the following statement in
close proximity to listed codes and descriptors:
"CPT Copyright 2017 American Medical Association. All rights reserved.
CPT® is a registered trademark of the American Medical Association."
(Please note that the use or reprinting of CPT content in any product or publication requires a
license. For more information about the licenses available, see CPT License Information.)
Applicable FARS/DFARS Restrictions Apply to Government Use

Fee schedules, relative value units, conversion factors and/or related components are not
assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The
AMA does not directly or indirectly practice medicine or dispense medical services. The
AMA assumes no liability for data contained or not contained herein.
If only a small portion of the terminology is used, MACs do not need to show the copyright legend. MACs
may also print the code and approved narrative description in development requests relating to individual
cases.
The CMS provides MACs a quarterly update file of HCPCS codes and instructions to retrieve the update via
CMS mainframe telecommunication system.
20.2 – RESERVED
20.3 - Use and Acceptance of HCPCS Codes and Modifiers
(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)
The HCPCS is updated quarterly to reflect changes in the practice of medicine and provision of health care.
The CMS provides a file containing the updated HCPCS codes to A/B MACs (A), (B), (HHH), and DME
MACs and Medicaid State agencies 60 to 90 days in advance of the implementation of each update.
Distribution consists of an electronic file of the updated HCPCS codes, file characteristics, record layout,
and a listing of added, revised and deleted codes. MACs are required to update their HCPCS codes file and
map all new, revised, and deleted codes to appropriate payment information.
An updated list of the HCPCS codes for Durable Medical Equipment Medicare Administrative Contractors
(DME MAC) and A/B MAC (B) jurisdictions is updated quarterly to reflect codes that have been added or
discontinued (deleted) during each year. A recurring update notification will be published to notify the
DME MACs and A/B MACs (B) that the list has been updated and is available on the CMS Web site.
https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.
Both the DME MACs and the A/B MACs (B) publish this list to educate providers on which MAC they
should bill for codes provided on this list.
Physicians and suppliers must use HCPCS codes on the Form CMS-1500 or its electronic equivalent and
providers must use HCPCS codes on the Form CMS-1450 or its electronic equivalent for most outpatient
services. The procedure, item, or service can be further described by using 2-position modifiers contained in
HCPCS.
Modifiers to HCPCS Level I codes for medicine, anesthesia, surgery, radiology, and pathology are on the
HCPCS codes file from CMS. Modifiers for Level II alpha-numeric codes are with the Level II codes
published by CMS. Alpha-numeric and CPT-4 modifiers may be used with either alpha-numeric or CPT-4
codes. A/B MACs (A, B and HHH) and DME MACs are required to accept up to four 2-position numeric or
alpha modifiers and process both modifiers completely through the claims processing system (including any
manual portion) as far as payment history. It is not acceptable merely to be able to accept multiple modifiers
and then drop one before complete systems processing. Dropping of a modifier leads to incomplete and
inaccurate pricing profiles.
Series “Q,” “K,” and “G” in the Level II coding are reserved for CMS assignment. “Q,” “K,” and “G” codes
are temporary national codes for items or services requiring uniform national coding between one year’s
update and the next. Sometimes “temporary” codes remain for more than one update. If “Q,” “K,” or “G”
codes are not converted to permanent codes in the Level I or Level II series in the following update, they
will remain active until converted or until CMS notifies MACs to delete them. All active “Q,” “K,” and “G”
codes at the time of update will be included on the update file for MACs. In addition, deleted codes are
retained on the file for informational purposes, with a deleted indicator, for four years.

Series “S” Level II codes are reserved for use by the BCBSA and other private insurers. These codes
provide for reporting needs unique to those organizations. Each State defines its own Medicaid coverage,
payment, and utilization levels. The CMS does not impose Medicare requirements on Medicaid programs.
The HCPCS simply provides a system for identifying services that can be expanded to meet everyone’s
needs.
20.4 - Deleted HCPCS Codes/Modifiers
(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)
Claims for services in a prior year are reported and processed using the HCPCS codes/modifiers in effect
during that year. For example, a claim for a service furnished in November 2019 but received by an A/B
MAC (A), (B), or (HHH), or DME MAC in 2020, should contain codes/modifiers valid in 2019 and is
processed using the prior year’s pricing files.
HCPCS codes (Level I CPT-4 and Level II alpha-numeric) are updated on a quarterly basis. Each quarter
(January, April, July and October), CMS releases the HCPCS file to A/B MACs (A), (B), (HHH), and DME
MACs. The HCPCS file contains the CPT-4 and the alpha-numeric updates. All MACs are notified of the
release date via a one-time notification instruction. The file contains new, deleted, and revised HCPCS
codes which are effective for the upcoming quarter.
The Health Insurance Portability and Accountability Act (HIPAA) requires that medical code sets must be
date of service compliant.
Providers can purchase the American Medical Association’s CPT-4 coding book that is published each
October that contains new, revised, and discontinued CPT-4 codes for the upcoming year. In addition, CMS
posts on its Web site the alpha-numeric HCPCS file. Providers are encouraged to access CMS web site to
see the new, revised, and discontinued alpha-numeric codes. The CMS web site to view the HCPCS update
is https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.
A/B MACs (B) and DME MACs must reject services submitted with discontinued HCPCS codes. A/B
MACs (A) and (HHH) must return to the provider (RTP) claims containing deleted codes.
See the Medicare Claims Processing Manual, Chapter 22, “Remittance Notices to Providers.”
20.5 - The HCPCS Codes Training
(Rev. 1, 10-01-03)
HO-442.5
A large number of changes to HCPCS codes may necessitate the training of physician, supplier and provider
personnel. If this is necessary, MACs must schedule the sessions in conjunction with the State medical
records association or the State hospital or medical/physician associations. All MACs should schedule
sessions in the major population centers of their service area.
All MACs should use the following guidelines in planning training sessions.
• 	Limit the training sessions to a manageable size to encourage questions and answers.
• 	A/B MACs (B) should limit sessions to office staffs of homogenous medical specialties, e.g., do not
include DME suppliers with staff from physicians’ offices.
• 	Invite office personnel who complete bills and claims to attend.
• 	In conducting the training, emphasize the use of the new HCPCS/CPT-4 manuals and the proper
completion of the claim forms using the new codes.

Be alert to a specific physician/supplier/provider having difficulty with HCPCS. Provide follow up training
focused to the individual situation. Review and discuss specific billing problems over the phone or by mail.
If many problems develop with a specific provider, the MAC schedules a visit to provide the specific
training needed. Training is the A/B MACs (A)’s, (B)’s, (HHH)’s, and DME MACs’ responsibility.
20.6 - Professional/Public Relations for HCPCS
(Rev. 1, 10-01-03)
A/B MACs (A), (B), (HHH), and DME MACs must perform the following professional/public relations
activities:
• 	Designate a knowledgeable person as a focal point for physician, supplier and provider inquiries.
This person must be able to address coding and payment questions.
• 	Notify physicians, suppliers and providers by newsletter and Web site at least 30 days before codes
are changed, added or deleted. Also, notify them when general problems arise including coding
issues.
• 	A/B MACs (B) should share Level III codes/modifiers with the Medicaid State agency in the A/B
MAC (B)’s jurisdiction.
• 	Advise physicians and providers to obtain new copies of CPT-4 annually from the AMA. Orders can
be placed by calling 1-800-621-8335 or order online at www.ama-assn.org/catalog
• 	A/B MACs (A) and (HHH) supply providers with CMS’ alpha-numeric code updates and with any
local codes. See §20 for sources. A/B MACs (B) supply the current HCPCS local codes/modifiers
(alpha-numeric W-Z) since they are the only source.
• 	A/B MACs (A), (B), (HHH), and DME MACs inform physicians, suppliers, and providers when the
annually and quarterly updated HCPCS codes become available and effective in the claims
processing system.
• 	All codes/modifiers contained in the current version of the HCPCS will be recognized and processed
unless they have been deleted or are indicated as not valid for Medicare.
• 	It is important for physicians, practitioners, suppliers, and providers to note that code/modifier
recognition does not imply that a service is covered by Medicare. In addition, a separate code does
not mean that the payment level will be different from similar services identified by different codes.
• 	Since local changes can occur throughout the year, continue professional relations activities to
provide as much information as possible to providers.
20.7 - Use of the American Medical Association’s (AMA’s) Physicians’ Current
Procedural Terminology (CPT) Fourth Edition Codes, and Use of the American Dental
Association’s (ADA’s) Current Dental Terminology-Fourth Edition (CDT) Codes, on
A/B MACs (A)’s, (B)’s, (HHH)’s, and DME MACs’ Web Sites and Other Electronic
Media
(Rev. 12573, Issued: 04-09-24; Effective:08-10-20; Implementation: 08-10-20)
See Business Requirements at http://www.cms.hhs.gov/manuals/pm_trans/R43CP.pdf
CMS AMA-ADA-AHA Medical Codes
Overview

The Centers for Medicare & Medicaid Services (CMS) staff may access the following copyright protected
medical codes and descriptors:
• 	American Medical Association’s Current Procedural Terminology – AMA/CPT
• 	American Dental Association’s Current Dental Terminology – ADA/CDT
• 	American Hospital Association’s National Uniform Billing Codes – AHA/NUBC UB-04
CMS signed licensing agreements with the AMA, ADA, and AHA giving staff limited use of CPT, CDT,
and NUBC data codes and descriptors.
Access the CPT, CDT, or NUBC codes
Prior to accessing the codes, CMS staff must accept the terms and conditions of an association's licensing
agreement.
• 	American Medical Association’s Current Procedural Terminology – AMA/CPT
o 	AMA Terms and Conditions
o 	AMA CPT Exhibits Directory
• 	American Dental Association’s Current Dental Terminology – ADA/CDT
o 	ADA Terms and Conditions
o 	ADA CDT Exhibits Directory
• 	American Hospital Association’s National Uniform Billing Codes – AHA/NUBC
o 	AHA Terms and Conditions
o 	AHA NUBC Exhibits Directory
Any proposed usage not covered by the current agreement requires the completion of a
https://surveys.cms.gov/jfe/form/SV_4UsBJoFDNs9qQD4. CMS, then, will negotiate your “new use” with
the appropriate association.
20.8 - Payment, Utilization Review (UR), and Coverage Information on CMS Quarterly
HCPCS Codes Update File
(Rev. 10320, Issued: 08-28-2020, Effective: 12-01-2020, Implementation: 12-01-2020)
The file CMS provides for the quarterly update of HCPCS codes contains fields for payment, UR, and
coverage information to assist in developing front-end edit screens. Coverage information is not all
inclusive, but should be used mainly as a guide in establishing specific review limits. A/B MACs (B) must
establish reasonable developmental guidelines, review screens, and relative value units, as appropriate. A/B
MACs (B) must assure that their system processes claims in accordance with CMS policies and procedures,
including changes that may occur between HCPCS codes updates.
Where CMS determines that nationally uniform temporary codes/modifiers are needed to implement
policy/legislation between HCPCS codes updates, the codes/modifiers, definitions and policy are issued as
Level II codes/modifiers prefixed with “Q” or “K” or “G.” Questions may arise in updating that require A/B
MAC (B) staff to refer to a physician’s or supplier’s pricing history. Therefore, keep an electronic backup
of HCPCS codes for the two prior years with linkages to pricing profiles. Perform required computer
analysis as necessary.
The HCPCS terminology seldom includes a place of service designation. Where place of service affects
pricing, pricing is obtained from the place of service field on the claim record.

A/B MACs (A) and (HHH) also develop editing screens using HCPCS based on payment and coverage
policies from CMS. A/B MAC
20.9 - National Correct Coding Initiative (NCCI)
(Rev. 14428, Issued:06-16-26; Effective:07-16-26; Implementation:07-16-26)
The Centers for Medicare & Medicaid Services (CMS) developed the NCCI program to promote national
correct coding methodologies and to control improper coding leading to inappropriate payment in Part B
claims. CMS developed its coding policies based on coding conventions defined in the American Medical
Association’s CPT Professional codebook, CMS national and local policies and edits, coding guidelines
developed by national societies, analysis of standard medical and surgical practices, and a review of current
coding practices. An overview of the NCCI program for Procedure-to-Procedure (PTP) edits, Medically
Unlikely Edits (MUEs), Add-on Code (AOC) edits and additional information sources are found on the
Medicare NCCI Edits webpage.
The Medicare NCCI Policy Manual (also known as the Coding Policy Manual) shall be used by Medicare
Administrative Contractors (MACs) as a general reference tool that explains the rationale for NCCI edits.
The purpose of the NCCI PTP edits is to prevent improper payment when incorrect Healthcare Common
Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) code combinations are
reported. The Medicare NCCI Edits webpage contains separate tables of edits for physicians/practitioners
and outpatient hospital services. Additional information regarding types of tables is available in the How to
Use The Medicare National Correct Coding Initiative (NCCI) Tools MLN booklet.
The purpose of the NCCI MUE program is to prevent improper payments when services are reported with
incorrect units of service (UOS). CMS developed MUEs to reduce the paid claims error rate for Part B
claims. An MUE for a HCPCS/CPT code is the maximum UOS that a provider or supplier would report
under most circumstances for a single beneficiary on a single date of service. The Medicare NCCI Medically
Unlikely Edits (MUEs) webpage contains separate tables of edits for physicians/practitioners, outpatient
hospital services, and durable medical equipment.
An AOC is a HCPCS/CPT code that describes a service that, with rare exception, is performed in
conjunction with another primary service by the same practitioner. An AOC is rarely eligible for payment if
it is the only procedure reported by a practitioner.
CMS posted the Correspondence Language Manual for Medicare Services on the Medicare NCCI
Correspondence Language Manual webpage for use by the Medicare Contractors to answer routine
correspondence inquiries about the NCCI PTP and MUE edits. The general correspondence language
paragraphs explain the rationale for the edits. The section-specific examples add further explanation to the
PTP or MUE edits and are sorted by edit rationale and HCPCS/CPT code section (00000, 10000, 20000,
etc.). Please refer to the Introduction of the Correspondence Language Manual for additional guidance about
its use.
20.9.1 - Correct Coding Modifier Indicators (CCMI) and HCPCS Codes Modifiers
(Rev . 10878, Issued: 07-15-2021, Effective:08-16-2021; Implementation:08-16-2021)
The National Correct Coding Initiative (NCCI) File Formats continue to include a Correct Coding Modifier
Indicator (CCMI) for the Column One / Column Two Correct Coding edit file. This indicator determines
whether an NCCI PTP-associated modifier causes the code pair to bypass the edit. The CCMI will be either
a “0,” “1,” or a “9.” The definitions of each are:

0 = an NCCI PTP-associated modifier is not allowed and will not bypass the edit.
1 = an NCCI PTP-associated modifier is allowed and will bypass the edit.
9 = The use of NCCI PTP-associated modifiers is not specified. This indicator is used for all code pairs that
have a deletion date that is the same as the effective date. This indicator prevents blank spaces from
appearing in the indicator field.
20.9.1.1 - Instructions for Codes With Modifiers (A/B MACs (B) Only)
(Rev. 13216; Issued:05-09-25; Effective: 06-03-25; Implementation:06-03-25)
A. General
MACs subject all line items for the same beneficiary, same NPI, and same date of service to NCCI edits.
All line items for the same beneficiary, same NPI, and same date of service shall be subject to NCCI PTP
edits. If the CCMI of a PTP edit is “0”, the Column Two code is not eligible for payment even if an NCCI
PTP-associated modifier is appropriately appended to one of the codes. If the CCMI of a PTP edit is “1”, the
edit may be bypassed and the Column Two code of the edit may be eligible for payment if an NCCI PTP-
associated modifier is appropriately appended to one of the codes. If the 2 codes of a code pair edit have the
same NCCI PTP-associated anatomic modifier, the edit will not be bypassed unless an additional NCCI
PTP-associated modifier is appended to 1 of the codes indicating the reason to bypass the edit.
The use of modifiers that are not NCCI PTP-associated modifiers shall not bypass an NCCI PTP edit.
NCCI PTP-associated modifiers are the following:
Anatomic modifiers : E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI
Global surgery modifiers: 24, 25, 57, 58, 78, 79
Other modifiers: 27, 59, 91, XE, XS, XP, XU
B. Modifiers 59 or XE, XP, XS, XU
Modifiers 59 or XE, XP, XS, XU and other NCCI PTP-associated modifiers shall not be used to bypass a
PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record
must satisfy the criteria required by any NCCI PTP-associated modifier that is used. Find further
information on modifiers 59 or XE, XP, XS, XU in the Coding Policy Manual available on the CMS
website.
Use of modifiers 59 or XE, XP, XS, XU does not require a different diagnosis for each HCPCS/CPT coded
procedure. Conversely, different diagnoses are not adequate criteria for use of modifiers 59 or XE, XP, XS,
XU.
Modifiers 59 or XE, XP, XS, XU shall not be used with the following codes:
• 	77427 Radiation treatment management, 5 treatments
• 	Evaluation & Management (E&M) services
When a provider or supplier submits a claim for any of the codes specified above with modifiers 59 or XE,
XP, XS, XU, the A/B MAC must process the claim as if the modifier were not present. In addition to those
messages specified in §20.9.1 above, A/B MACs shall convey additional messaging per instructions in Pub.
100-09, Chapter 6 and Pub. 100-04, Chapter 22.
Examples of appropriate use of modifiers 59 and XE, XP, XS, XU can be found in the Fact Sheet Proper Use
of Modifiers 59, XE, XP, XS, & XU.

1. Modifier 59 or XE are used appropriately when the procedures are performed in
different encounters on the same day.
2. Modifier 59 or XP are used appropriately when the procedures are performed by
different practitioners.
3. Modifier 59 or XS are used appropriately for different anatomic sites during the same
encounter only when procedures are performed on different organs, or different
anatomic regions, or in limited situations on different, non-contiguous lesions in different
anatomic regions of the same organ.
4. Other specific appropriate uses of modifiers 59 or XE, XU.
There are 3 other limited situations in which 2 services may be reported as separate and distinct because
they are separated in time and describe non-overlapping services even though they may occur during the
same encounter.
a. Modifier 59 or XE is used appropriately for 2 services described by timed codes provided during the
same encounter only when they are performed sequentially. There is an appropriate use for modifiers 59
or XE that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15
minutes, per hour). If 2 timed services are provided in blocks of time that are separate and distinct (i.e.,
the same time block is not used to determine the unit of service for both codes), modifier 59 may be used
to identify the services.
b. Modifier 59 or XU is used appropriately for a diagnostic procedure, which precedes a therapeutic
procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
When a diagnostic procedure precedes a surgical procedure or on-surgical therapeutic procedure and is the
basis on which the decision to perform the surgical procedure is made, that diagnostic test may be
considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure
and is not interspersed with services that are required for the therapeutic intervention; (b) it clearly
provides the information needed to decide whether to proceed with the therapeutic procedure; (c) it does
not constitute a service that would have otherwise been required during the therapeutic intervention; and
d) it is not specifically prohibited. If the diagnostic procedure is an inherent component of the surgical
procedure, it should not be reported separately.
c. Modifier 59 or XU is used appropriately for a diagnostic procedure, which occurs subsequent to a
completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or
necessary follow-up to the therapeutic procedure. When a diagnostic procedure follows the surgical
procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a
separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure
and is not interspersed with or otherwise commingled with services that are only required for the
therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required
during the therapeutic intervention. If the post-procedure diagnostic procedure is an inherent component
or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-
surgical therapeutic procedure, it should not be reported separately.
5. Modifiers 59 or XE, XP, XS, XU are used inappropriately if the basis for their use is that
the narrative description of the 2 codes is different.

C. Modifier 91
Modifier 91 may be appended to laboratory procedure(s) or service(s) to indicate a repeat test or procedure
on the same day when appropriate. If a HCPCS/CPT code has an MUE that is adjudicated as a claim line
edit, (i.e., MUE Adjudication Indicator (MAI) equal to “1”) appropriate use of CPT modifiers (i.e., 59 or
XE, XP, XS, XU, 76, 77, 91, anatomic) may be used to report the same HCPCS/CPT code on separate lines
of a claim. This modifier indicates to the Medicare contractors that the physician had to perform a repeat
clinical diagnostic laboratory test that was distinct or separate from a lab panel or other lab services
performed on the same day, and was performed to obtain medically necessary subsequent reportable test
values. This modifier must not be used to report repeat laboratory testing due to laboratory errors, quality
control, or confirmation of results.
For example, if a laboratory performs all tests included in a panel of laboratory tests and repeats one of these
component tests as a medically reasonable and necessary service on the same date of service, the
HCPCS/CPT code corresponding to the repeat laboratory test may be reported with modifier 91 appended.
D. Reserved for future use
E. Coding for Noncovered Services and Services Not Reasonable and Necessary
For information on this topic, see the Claims Processing Manual, Chapter 1 and MLN Booklet: Medicare
Advance Written Notices of Noncoverage ICN 006266.
Use of HCPCS Code A9270
HCPCS code A9270 (Non-covered item or service), will not be accepted under any circumstances for
services or items billed to A/B MACs. However, in cases where there is no specific procedure code for an
item or supply and no appropriate Not Otherwise Classified (NOC) code available, A9270 must continue to
be used by suppliers to bill DME MACs for statutorily non-covered items or supplies and items or supplies
that do not meet the definition of a Medicare benefit.
Claims Processing Instructions
At A/B MAC and DME MAC discretion, claims submitted using the GY modifier may be auto denied. If the
GZ and GA modifiers are submitted for the same item or service, treat the item or service as having an
invalid modifier and therefore unprocessable.
Effective for dates of service on and after July 1, 2011, A/B MACs shall automatically deny claim line(s)
items submitted with a GZ modifier. A/B MACs shall not perform complex medical review on claim line(s)
items submitted with a GZ modifier. All MACs shall make all language published in educational outreach
materials, articles, and on their websites, consistent to state all claim line(s) items submitted with a GZ
modifier shall be denied automatically and will not be subject to complex medical review.
20.9.2 - Reserved for future use
(Rev. 4465; Issued: 11-15-19, Effective: 01-30-19, Implementation: 01-30-19)
20.9.3 – Appeals
(Rev. 13216; Issued:05-09-25; Effective: 06-03-25; Implementation:06-03-25)
When a request for review is received as a result of an initial determination based on a correct coding
initiative edit, and after determining that the reviews were coded correctly, the reviewer must come to the
same conclusion as the initial determination (i.e., the review does not result in an increase in payment). If the
review determines that a correct coding modifier not submitted with the initial claim could have been
appended to either code of an edit code pair, the reviewer may change the initial determination only if the

correct coding initiative edit has a modifier indicator of “1.” If the correct coding initiative edit modifier
indicator is a “0,” the reviewer must come to the same conclusion as the initial determination. If the
conclusion is the same as the initial determination, the review determination must repeat the generic
language that appears in the Medicare Summary Notice (MSN) or remittance advice notice pertaining to the
correct coding edit. In addition, MACs must include the more detailed explanation of the correct coding
initiative edit which can be found in the standard correspondence language for MACs in the Medicare NCCI
Correspondence Language Manual on the Medicare NCCI Edits webpage.
• 	MUEs are set high enough to allow for medically likely daily frequencies of services provided in most
settings. Because MUEs are based on current coding instructions and practices, MUEs are prospective
edits applicable to the time period for which the edit is effective. A change in an MUE is not retroactive
and has no bearing on prior services unless specifically updated with a retroactive effective date. In the
unusual case of a retroactive MUE change, MACs are not expected to identify claims but should reopen
impacted claims that providers or suppliers bring to their attention.
• 	Since MUEs are auto-deny edits, denials may be appealed. Appeals shall be submitted to the appropriate
MAC not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS/CPT code
with an MAI of “1” or “3” may pay correctly coded correctly counted medically necessary UOS in
excess of the MUE value.
• 	A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of
an ABN shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening
or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI
of “3”, MACs will review the records to determine if the provider or supplier actually furnished units in
excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable
and necessary. If the units were actually provided, but one of the other conditions is not met, a change in
denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding
to a determination that the item/service is not reasonable and necessary under section 1862(a)(1)). This
may also be true for certain edits with an MAI of “1.” The CMS interprets the notice delivery
requirements under Section 1879 of the Social Security Act (the Act) as applying to situations in which a
provider or supplier expects the initial claim determination to be a reasonable and necessary denial.
Consistent with NCCI program guidance, denials resulting from MUEs are not based on any of the
statutory provisions that give liability protection to beneficiaries under section 1879 of the Social
Security Act. Thus, ABN issuance based on an MUE is NOT appropriate. A provider or supplier may not
issue an ABN in connection with services denied due to an MUE and cannot bill the beneficiary for UOS
denied based on an MUE.
• 	If a procedure is performed bilaterally and the HCPCS/CPT code descriptor does not state that it is a
unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier
50 and one (1) unit of service. For specific instructions for Ambulatory Surgical Centers, see the
Medicare Claims Processing Manual, Chapter 14, Section 40.5.
When modifier 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 units
and anatomic modifiers will be denied for incorrect coding. MACs may reopen or allow resubmission of
those claims in accordance with their policies and with the policy in the Medicare Claims Processing
Manual, Chapter 34, Section 10.1.
Clerical errors (which include minor errors and omissions) may be treated as reopenings.

• 	Providers or suppliers may change and resubmit their own claims where possible but during reopening
MACs may, when necessary, correct the claim to modifier 50 from an equivalent 2 units of bilateral
anatomic modifiers. The original submitted version of the claim is retained in the Medicare IDR
(Integrated Data Repository).
• 	Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and
report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are
based on the assumption that correct modifiers are used.
• 	A/B MACs shall include with the review determination the more detailed explanation of the correct
coding initiative edit, which can be found in the standard correspondence language for A/B MACs in the
Medicare NCCI Correspondence Language Manual.
• 	MACs shall assign MSN 15.6. CARC 151 with Group Code CO for claims that fail the MUE edits,
when the UOS on the claim exceeds the MUE value, and deny the entire claim line(s) for the relevant
HCPCS/CPT code.
20.9.3.1- Procedure-to-Procedure (PTP) Edits
(Rev. 14428, Issued:06-16-26; Effective:07-16-26; Implementation:07-16-26)
All PTP edits have a CCMI.
A denial of services due to a PTP edit is a coding denial, not a medical necessity denial. The presence of an
Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on a
PTP.
PTP edits with a CCMI of “0”:
On appeal, if the CCMI is a “0”, and the provider or supplier coded the claim correctly, there are no
circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the
same day by the same provider or supplier. If the reviewer determines that the claim was coded incorrectly
then, the review determination must repeat the generic language that appears in the MSN or remittance
advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed explanation of
the NCCI edit, which can be found in the standard correspondence language for MACs in the Medicare
NCCI Correspondence Language Manual.
PTP edits with a CCMI of “1”:
On appeal, if the correct coding initiative edit modifier indicator is a “1”, the reviewer must determine
whether the claim was coded correctly. For example, the reviewer should determine whether the provider or
supplier reported an incorrect code, a medically unnecessary service, or simply neglected to use a modifier.
The reviewer may change the initial determination only if the correct coding initiative edit has a modifier
indicator of “1” and the reviewer determines that an NCCI PTP-associated modifier could have been
appended to either code of a correctly coded edit code pair. If the reviewer determines that the claim was
coded incorrectly then, the review determination must repeat the generic language that appears in the MSN
or remittance advice notice pertaining to the NCCI edit. In addition, MACs must include the more detailed
explanation of the NCCI edit, which can be found in the standard correspondence language for MACs in the
Medicare NCCI Correspondence Language Manual.

General Instructions on PTPs:
• 	MACs shall assign CARC 236 with Group Code CO and MSN 16.8 for claims that fail the PTP edits,
and deny when this procedure or procedure/modifier combination is not compatible with another
procedure or procedure/modifier combination provided on the same day according to the NCCI program
or workers compensation state regulations/ fee schedule requirements.
20.9.3.2- Medically Unlikely Edits (MUEs)
(Rev. 14428, Issued:06-16-26; Effective:07-16-26; Implementation:07-16-26)
All HCPCS/CPT codes with MUE values have an MAI.
MUEs for HCPCS/CPT codes with an MAI of “1”: MUEs for HCPCS/CPT codes with an MAI of “1” will
be adjudicated as a claim line edit.
MUEs for HCPCS/CPT codes with an MAI of “2”: MUEs for HCPCS/CPT codes with an MAI of “2” are
absolute date of service edits. These are “per day edits based on policy”. HCPCS/CPT codes with an MAI
of “2” have been rigorously reviewed and vetted within CMS and obtain this MAI designation because UOS
on the same date of service in excess of the MUE value would be considered contrary to statute, regulation,
or subregulatory guidance. Subregulatory guidance includes clear correct coding policy that is binding on
both providers or suppliers and the MACs. As stated in CR 8853, while Qualified Independent Contractors
(QICs) are not bound by subregulatory guidance, they should understand the policy nature of the MAI “2”
indicator when considering whether to pay UOS in excess of the MUE value if claim denials based on these
edits are appealed.
Limitations created by anatomical or coding restrictions are incorporated in correct coding policy, both in
the Health Insurance Portability & Accountability Act of 1996 (HIPAA) mandated coding descriptors and
CMS approved coding guidance as well as specific guidance in the CMS and NCCI Policy manuals. For
example, it would be contrary to correct coding policy to report more than 1 unit of service for "ventilation
assist and management . . . initial day" because such usage could not accurately describe 2 initial days of
management occurring on the same date of service as would be required by the code descriptor.
CMS establishes edits with an MAI of “2” based directly on regulation, statute or subregulatory guidance.
MUEs for HCPCS/CPT codes with an MAI of “3”: MUEs for HCPCS/CPT codes with an MAI of “3” are
date of service edits. These are “per day edits based on clinical benchmarks”. If claim denials based on these
edits are appealed, MACs may pay UOS in excess of the MUE value if there is adequate documentation of
medical necessity of correctly reported units. If MACs have pre-payment evidence (e.g. medical review) that
UOS in excess of the MUE value were actually provided, were correctly coded, and were medically
necessary, the MACs may bypass the MUE for a HCPCS/CPT code with an MAI of “3” during claim
processing, reopening, or redetermination, or in response to effectuation instructions from a reconsideration
or higher level appeal.
General Instructions on MUEs:
• 	MUEs are set high enough to allow for medically likely daily frequencies of services provided in most
settings. Because MUEs are based on current coding instructions and practices, MUEs are prospective
edits applicable to the time period for which the edit is effective. A change in an MUE is not retroactive
and has no bearing on prior services unless specifically updated with a retroactive effective date. In the
unusual case of a retroactive MUE change, MACs are not expected to identify claims but should reopen
impacted claims that providers or suppliers bring to their attention.

• 	Since MUEs are auto-deny edits, denials may be appealed. Appeals shall be submitted to the appropriate
MAC not the NCCI contractor. MACs adjudicating an appeal for a claim denial for a HCPCS/CPT code
with an MAI of “1” or “3” may pay correctly coded correctly counted medically necessary UOS in
excess of the MUE value.
• 	A denial of services due to an MUE is a coding denial, not a medical necessity denial. The presence of
an ABN shall not shift liability to the beneficiary for UOS denied based on an MUE. If during reopening
or redetermination medical records are provided with respect to an MUE denial for an edit with an MAI
of “3”, MACs will review the records to determine if the provider or supplier actually furnished units in
excess of the MUE, if the codes were used correctly, and whether the services were medically reasonable
and necessary. If the units were actually provided, but one of the other conditions is not met, a change in
denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding
to a determination that the item/service is not reasonable and necessary under section 1862(a)(1)). This
may also be true for certain edits with an MAI of “1.” CMS interprets the notice delivery requirements
under Section 1879 of the Social Security Act (the Act) as applying to situations in which a provider or
supplier expects the initial claim determination to be a reasonable and necessary denial. Consistent with
NCCI program guidance, denials resulting from MUEs are not based on any of the statutory provisions
that give liability protection to beneficiaries under section 1879 of the Social Security Act. Thus, ABN
issuance based on an MUE is NOT appropriate. A provider or supplier may not issue an ABN in
connection with services denied due to an MUE and cannot bill the beneficiary for UOS denied based on
an MUE.
• 	If a procedure is performed bilaterally and the HCPCS/CPT code descriptor does not state that it is a
unilateral or bilateral procedure, report bilateral surgical procedures on a single claim line with modifier
50 and one (1) unit of service. For specific instructions for Ambulatory Surgical Centers, see the
Medicare Claims Processing Manual, Chapter 14, Section 40.5.
When modifier 50 is required by manual or coding instructions, claims submitted with 2 lines or 2 units
and anatomic modifiers will be denied for incorrect coding. MACs may reopen or allow resubmission of
those claims in accordance with their policies and with the policy in the Medicare Claims Processing
Manual, Chapter 34, Section 10.1.
Clerical errors (which include minor errors and omissions) may be treated as reopenings.
• 	Providers or suppliers may change and resubmit their own claims where possible but during reopening
MACs may, when necessary, correct the claim to modifier 50 from an equivalent 2 units of bilateral
anatomic modifiers. The original submitted version of the claim is retained in the Medicare IDR
(Integrated Data Repository).
• 	Providers or suppliers shall use anatomic modifiers (e.g., RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and
report procedures with differing modifiers on individual claim lines when appropriate. Many MUEs are
based on the assumption that correct modifiers are used.
• 	A/B MACs shall include with the review determination the more detailed explanation of the correct
coding initiative edit, which can be found in the standard correspondence language for A/B MACs in the
Medicare NCCI Correspondence Language Manual.

• 	MACs shall assign MSN 15.6. CARC 151 with Group Code CO for claims that fail the MUE edits,
when the UOS on the claim exceeds the MUE value, and deny the entire claim line(s) for the relevant
HCPCS/CPT code.
20.9.4 Reserved for future use
(Rev. 4465; Issued: 11-15-19, Effective: 01-30-19, Implementation: 01-30-19)
20.9.4.1 Reserved for future use
(Rev. 4465; Issued: 11-15-19, Effective: 01-30-19, Implementation: 01-30-19)
20.9.5 - Adjustments
(Rev. 1, 10-01-03)
A/B MACs (B) adjust for underpayment if the wrong, lower paying code is paid on the first of multiple
claims submitted. If the wrong, higher paying code is paid on the first of multiple claims submitted, A/B
MACs (B) pay the subsequent claim(s) and initiate recovery action on the previously paid claim(s).
20.9.6 - Correct Coding Edit (CCE) File Record Format
(Rev. 10233; Issued: 07-24-20, Effective: 06-16-20, Implementation: 06-16-20)
The following record layout for the Correct Coding Edit (CCE) File is available to the Shared Systems, A/B
MACs (B), and the Regional Offices via Network Data Mover and CMS Data Center.
A/B MAC (B)/Shared Systems Record Format
Field 	Type 	Record
Position
Length
Comprehensive Column 1 Code or
Mutually Exclusive Column 1 Code
Character 	1 	5
Component Column 2 Code or
Mutually Exclusive Column 2 Code
Character 	6 	5
Prior Rebundled Code Indicator
“*” rebundled prior to 1996 edits
“•” rebundled 1/1/1996 or later
Character 	11 	1
Correspondence Language Reference 	Character 	12 	12
Effective Date (4 position year followed by
Julian day)
Numeric 	24 	7
Deletion Date (4 position year followed by
Julian day)
Numeric 	31 	7
Modifier Indicators
“0” No CCE modifier allowed
“1” CCE modifier acceptable
“9” Use of CCE modifier not specified
Numeric 	38 	1

Field 	Type 	Record
Position
Length
Savings Type Indicator Edit
“1” CCE
“2” Mutually Exclusive
Character 	39 	1
20.9.7 - National Correct Coding Initiative (NCCI) Edits Quarterly Updates
(Rev. 10878, Issued: 07-15-2021, Effective:08-16-2021; Implementation:08-16-2021)
Medicare Administrative Contractors (MACs) receive quarterly updates to National Correct Coding
Initiative (NCCI) edits, indicating the version and the effective date, through a recurring update notification.
At this time, the official method for providers or suppliers to receive the National Correct Coding Initiative
(NCCI) edits is through the CMS website.
30 - Services Paid Under the Medicare Physician’s Fee Schedule
(Rev. 1717, Issued: 04-24-09, Effective: 07-01-09, Implementation: 07-06-09)
Following is a general description of services paid under the Medicare Physicians’ Fee Schedule (MPFS).
A. Physician’s Services
Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for physicians’ services
based on the MPFS. The Medicare allowed charge for such physicians’ services is the lower of the actual
charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after the
deductible is met for most services paid based on the fee schedule. Exceptions to the rule, e.g., services for
which deductible is not applicable, are specifically identified for the service where the exception applies.
The Physicians Fee Schedule is used when paying for the following physicians’ services.
• 	Professional services (including attending physicians’ services furnished in teaching settings) of
doctors of medicine and osteopathy (including osteopathic practitioners), doctors of optometry,
doctors of podiatry, doctors of dental surgery and dental medicine, and chiropractors;
• 	Services covered incident to physicians’ services other than certain drugs covered as incident to
services;
• 	Physical and occupational therapy, and speech-language pathology services furnished by physical
therapists, occupational therapists, and speech-language pathologists in private practices;
• 	Diagnostic tests other than clinical laboratory tests. See chapter 16 for payment for clinical
diagnostic laboratory tests;
• 	Radiology services; and
• 	Monthly capitation payment (MCP) for physicians’ services associated with the continuing medical
management of end stage renal disease (ESRD) services.
The fee schedule is not used to pay for direct medical and surgical services of teaching physicians in
hospitals that have elected cost payment under §1861(b)(7) of the Act.

When processing a claim, A/B MACs (B) continue to determine if a service is reasonable and necessary to
treat illness or injury. If a service is not reasonable and necessary to treat illness or injury for any reason
(including lack of safety and efficacy because it is an experimental procedure, etc.), A/B MACs (B) consider
the service noncovered notwithstanding the presence of a payment amount for the service in the Medicare
fee schedule. The presence of a payment amount in the MPFS and the Medicare physician fee schedule
database (MPFSDB) does not imply that CMS has determined that the service may be covered by Medicare.
The nature of the status indicator in the database does not control coverage except where the status is N for
noncovered.
A/B MACs (B) pay the above-mentioned physician services according to the physician fee schedule when
billed by the following entities:
• 	A physician or physician group including optometrists, dentists, oral and maxillofacial surgeons,
podiatrists, and chiropractors;
• 	A privately practicing physical therapist, (for outpatient physical therapy services);
• 	A privately practicing speech-language pathologist (for outpatient speech-language services);
• 	A privately practicing occupational therapist (for outpatient occupational therapy services);
• 	A nonphysician practitioner including a nurse practitioner, a physician assistant, and a clinical nurse
specialist beginning January 1, 1998, with respect to services these practitioners are authorized to
furnish under state law: payment is equal to 85 percent of the participating physician fee schedule
amount for the same service;
• 	A nurse midwife: payment is equal to 65 percent of the participating physician fee schedule amount
for the same service;
• 	A registered dietitian or nutrition professional, for medical nutrition therapy services provided as of
January 1, 2002: payment is equal to 85 percent of the participating physician fee schedule amount
for the same service;
• 	An audiologist, for services rendered to beneficiaries not in a skilled nursing facility (SNF) Part A
covered stay;
• 	A clinical psychologist who renders services in community mental health centers (CMHCs) on or
after July 1, 1988, and in all settings on or after July 1, 1990;
• 	A clinical social worker: The fee schedule for CSW services is set at 75 percent of the fee schedule
for comparable services furnished by clinical psychologists;
• 	Another entity that furnishes outpatient physical therapy, occupational therapy, and speech- language
pathology services. This could be a rehabilitation agency, a public health agency, a clinic, a skilled
nursing facility, a home health agency (for beneficiaries who are not eligible for home health benefits
because they are not home bound beneficiaries entitled to home health benefits), hospitals (when
such services are provided to an outpatient or to a hospital inpatient who is entitled to benefits under
Part A but who has exhausted benefits during a spell of illness, or who is not entitled to Part A
benefits) and comprehensive outpatient rehabilitation facilities (CORFs). The fee schedule also
applies to outpatient rehabilitation services furnished under an arrangement with any of the
enumerated entities that are to be paid on the basis of the physician fee schedule;
• 	The supplier of the technical component of any radiology or diagnostic service;
• 	An independent laboratory doing anatomic pathology services; and

• 	Services billed by entities authorized to bill for physicians, suppliers, etc. under the reassignment
rules.
B. Hospice Services
The Physicians Fee Schedule is used when paying for hospice physician’s services by the A/B MAC (HHH).
Regular hospice services are paid under the hospice rate schedule (see chapter 11.)
C. Outpatient Rehabilitation Services
Effective with services furnished on or after January 1, 1999, A/B MACs (A) pay for outpatient
rehabilitation services based on the MPFS. Services included are physical therapy, speech-language
pathology, occupational therapy, and certain audiology and CORF services.
Effective with services furnished on or after July 1, 2000, A/B MACs (A) pay for all CORF services under
the MPFS.
Effective with claims with dates of service on or after July 1, 2003, OPTs/Outpatient Rehabilitation
Facilities (ORFs), (74X bill type) are required to report all their services utilizing HCPCS. A/B MACs (A)
are required to make payment for these services under the MPFS unless the item or service is currently being
paid under the orthotic fee schedule or the item is a drug, biological, supply or vaccine.
The MPFS applies when these services are furnished by rehabilitation agencies, (outpatient physical therapy
providers and CORFs), hospitals (to outpatients and inpatients who are not in a covered Part A stay), SNFs
(to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services
from the SNF), and HHAs (to individuals who are not homebound or otherwise are not receiving services
under a home health plan of treatment). The MPFS is used as a method of payment for outpatient
rehabilitation services furnished under arrangement with any of these providers. The MPFS allowed charge
for these services is the lower of the actual charge or the fee schedule amount. The Medicare payment for
the services is 80 percent of the allowed charge after the Part B deductible is met. This is a final payment.
The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs).
CAHs are paid on a reasonable cost basis.
Application of the Outpatient Mental Health Treatment Limitation (A/B MACs (A))
In accordance with §1833 of the Act, payment is made at 62½ percent of the approved amount for outpatient
mental health treatment services. This provision will continue to be implemented in accordance with the
Act when these services are furnished to beneficiaries by CORFs. Therefore, make payment at 62½ percent
of 80 percent of the approved amount (or in effect 50 percent) for outpatient mental health treatment
services.
D. SNF Services
Effective with services furnished on or after April 1, 2001, A/B MACs (A) pay for Part B services furnished
to SNF Part B inpatients and outpatients (22X and 23X types of bill) under the MPFS and other applicable
fee schedules. Thus, where a fee schedule exists for the type of service, the fee amount (or charge if less
than the applicable fee amount) is paid. Fee schedules made effective for SNF on this date include:
Therapy, Lab, and DMEPOS.
Effective for services furnished by a SNF on and after January 1, 2002, A/B MACs (A) pay SNFs for
radiology, other diagnostic, and other services under the MPFS. Payment is the lower of billed charges or
the fee schedule amount. In either case, any applicable deductible and coinsurance amounts are subtracted
from the payment amount prior to payment. Coinsurance is calculated on the Medicare payment amount
after the subtraction of any applicable deductible amount.

If there is no fee schedule for the service or item being billed, A/B MACs (A) and (HHH) are to make
payment based on cost. Consequently, all services billed under Part B are to be billed using HCPCS codes,
whether the beneficiary resides in a certified bed or a noncertified bed.
30.1 - Maintenance Process for the Medicare Physician Fee Schedule Database
(MPFSDB)
(Rev. 1, 10-01-03)
The CMS calculates the fee schedule payment amounts and releases them to the A/B MACs (B) in the
Medicare Physician Fee Schedule Database (MPFSDB). A/B MACs (B) implement those payment amounts
on January 1 of each year. The CMS maintains the payment files centrally and is responsible for
recalculating any revised payment amounts. Any revisions initiated by Central Office (fee schedule
amounts or payment policy indicators) are issued to the A/B MACs (B) on a quarterly basis.
The information for the ongoing maintenance of the MPFSDB is stated below.
• 	CMS calculates the new fee schedule amounts. The CMS Central Office issues the revised data to
the ROs in the same format of the MPFSDB.
• 	A/B MACs (B) receive a file containing data with revisions for the quarter. This file is released
electronically via CMS’ Mainframe Telecommunications System.
• 	A/B MACs (B) must allow providers 30 days notification before revised payment amounts are
implemented. The revised payment amounts are implemented the beginning of the following
quarter.
• 	CMS furnishes the recalculated payment amounts to the A/B MACs (B) in data files to ensure
accuracy. A/B MACs (B) overlay these files into their existing file, to eliminate the potential for
errors.
• 	A/B MACs (B) must make adjustments on those claims that were processed incorrectly if the
adjustment is requested by the physician/supplier. Adjustments are made retroactively to January 1
of the current year, unless otherwise specified. This directive applies in all instances unless the
situation requires special consideration. In those instances, instructions on handling adjustments will
be provided on a case-by-case basis.
Separate instructions are issued describing the data exchange for the A/B MACs (A) and (HHH)
• 	.In summary, A/B MACs (A) and (HHH) receive the revised payment amounts two to three weeks
after the A/B MACs (B) receive the data from CMS. A/B MACs (A) and (HHH) do not implement
the revised payment amounts prior to the A/B MACs (B)’s implementation date.
• 	A/B MACs (B) are required to furnish the revised payment information to the State Medicaid
Agencies upon their request one month following receipt of the data from CMS. Those State
agencies with Internet access capability will download the data directly from CMS Web site.
The CMS publishes a schedule for Medicare Physician Fee Schedule updates and participation physician
enrollment procedures annually for all MACs.
30.2 - MPFSDB Record Layout
(Rev. 4298, Issued: 05-03-19, Effective: 01-01-19, Implementation 10-07-19)
The CMS MPFSDB includes the total fee schedule amount, related component parts, and payment policy
indicators. The record layout is provided in the Addendum below.

30.2.1 - Payment Concerns While Updating Codes
(Rev. 1, 10-01-03)
The following instructions apply in situations where the CMS CO does NOT provide pricing guidance via
the Medicare Physician Fee Schedule Database (MPFSDB) for physicians’ services.
If a new code appears, A/B MACs (B) make every effort to determine whether the procedure, drug or supply
has a pricing history and profile. If there is a pricing history, map the new code to previous customary and
prevailing charges or fee schedule amounts to ensure continuity of pricing.
Since there are different kinds of coding implosions and explosions, the way the principle is applied varies.
For example, when the code for a single procedure is exploded into several codes for the components of that
procedure, the total of the separate relative value unit or other charge screens established for the components
must not be higher than the relative value units or other charge screens for the original service. However,
when there is a single code that describes two or more distinct complete services (e.g., two different but
related or similar surgical procedures), and separate codes are subsequently established for each, continue to
apply the payment screens that applied to the single code to each of the services described by the new codes.
If there is no pricing history or coding implosion and explosion, A/B MACs (B) must make an individual
consideration determination for pricing and payment of a covered service.
Conversely, when the codes for the components of a single service are combined in a single global code,
A/B MACs (B) establish the payment screens for the new code by totaling the screens used for the
components (i.e., use the total of the customary charges for the components as the customary charge for the
global code; use the total of the prevailing charges for the components adjusted for multiple surgical rules if
applicable as the prevailing charge for the global code, etc.). However, when the codes for several different
services are imploded into a single code, A/B MACs (B) set the payment screens at the average (arithmetic
mean), weighted by frequency, of the payment screens for the formerly separate codes.
30.2.2 - MPFSDB Status Indicators
(Rev. 4418, Issued: 10-18- 19, Effective: 01-01- 20 Implementation: 11- 19 19)
A = 	Active code. These codes are separately paid under the physician fee schedule if
covered. There will be RVUs and payment amounts for codes with this status.
The presence of an “A” indicator does not mean that Medicare has made a national
coverage determination regarding the service; A/B MACs (B) remain responsible
for coverage decisions in the absence of a national Medicare policy.
B = 	Payment for covered services are always bundled into payment for other services
not specified. There will be no RVUs or payment amounts for these codes and no
separate payment is ever made. When these services are covered, payment for
them is subsumed by the payment for the services to which they are incident (an
example is a telephone call from a hospital nurse regarding care of a patient).
C = 	A/B MACs (B) price the code. A/B MACs (B) will establish RVUs and payment
amounts for these services, generally on an individual case basis following review
of documentation such as an operative report.
D =* 	Deleted/discontinued codes.
E = 	Excluded from physician fee schedule by regulation. These codes are for items
and/or services that CMS chose to exclude from the fee schedule payment by
regulation. No RVUs or payment amounts are shown and no payment may be

made under the fee schedule for these codes. Payment for them, when covered,
continues under reasonable charge procedures.
F = 	Deleted/discontinued codes. (Code not subject to a 90 day grace period.) These
codes are deleted effective with the beginning of the year and are never subject to
a grace period. This indicator is no longer effective beginning with the 2005 fee
schedule as of January 1, 2005.
G = 	Not valid for Medicare purposes. Medicare uses another code for reporting of,
and payment for, these services. (Code subject to a 90 day grace period.) This
indicator is no longer effective beginning with the 2005 fee schedule as of January
1, 2005.
H =* 	Deleted modifier. For 2000 and later years, either the TC or PC component shown
for the code has been deleted and the deleted component is shown in the data base
with the H status.
I = 	Not valid for Medicare purposes. Medicare uses another code for reporting of,
and payment for, these services. (Code NOT subject to a 90 day grace period.)
J= 	Anesthesia services (no relative value units or payment amounts for anesthesia
codes on the database, only used to facilitate the identification of anesthesia
services.)
L = 	Local codes. A/B MACs (B) will apply this status to all local codes in effect on
January 1, 1998 or subsequently approved by central office for use. A/B MACs
(B) will complete the RVUs and payment amounts for these codes.
M= 	Measurement codes, used for reporting purposes only.
N = 	Non-covered service. These codes are carried on the HCPCS tape as noncovered
services.
P = 	Bundled/excluded codes. There are no RVUs and no payment amounts for these
services. No separate payment is made for them under the fee schedule.
If the item or service is covered as incident to a physician service and is provided
on the same day as a physician service, payment for it is bundled into the payment
for the physician service to which it is incident (an example is an elastic bandage
furnished by a physician incident to a physician service).
If the item or service is covered as other than incident to a physician service, it is
excluded from the fee schedule (for example, colostomy supplies) and is paid
under the other payment provision of the Act.
Q = 	Therapy functional information code (used for required reporting purposes only).
This indicator is no longer effective beginning with the 2020 fee schedule as of
January 1, 2020.
R = 	Restricted coverage. Special coverage instructions apply.
T = 	There are RVUs and payment amounts for these services, but they are only paid if
there are no other services payable under the physician fee schedule billed on the
same date by the same provider. If any other services payable under the physician
fee schedule are billed on the same date by the same provider, these services are
bundled into the physician services for which payment is made.

X = 	Statutory exclusion. These codes represent an item or service that is not in the
statutory definition of “physician services” for fee schedule payment purposes.
No RVUs or payment amounts are shown for these codes and no payment may be
made under the physician fee schedule. (Examples are ambulances services and
clinical diagnostic laboratory services.)
*Codes with these indicators had a 90 day grace period before January 1, 2005
30.3 - Furnishing Pricing Files
(Rev. 1, 10-01-03)
The CMS provides a schedule for activities related to furnishing these pricing files in advance each year.
The CMS will provide the completed physician fee schedule, the Durable Medical Equipment and
Prosthetics and Orthotics and Supplies (DMEPOS) fee schedules and clinical lab data to United Mine
Workers and Indian Health Services. A/B MACs (A), (B), (HHH), and DME MACs are informed where to
access the files for FTP (File Transfer Protocol) download.
30.3.1 - RESERVED
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
30.3.2 - A/B MAC (A), (B), or (HHH) Furnishing Physician Fee Schedule Data for
National Codes
(Rev. 4131, Issued: 09-14-18, Effective: 12-17-18, Implementation: 12-17-18)
A/B MACs (A), (B), and (HHH) are responsible for furnishing fee schedules to related providers, suppliers,
physicians, and practitioners with billing relationships.
A/B MACs (A), (B), and (HHH) may also receive requests for this information from the State Agencies.
The data is available on the CMS website. The MACs shall direct State Agencies to the appropriate pages
on the website to download the data directly.
The CMS will provide the Medicare physician, ambulance, DMEPOS, and clinical laboratory fee schedules
and the zip code file to the A/B MACs (A) and (HHH), Palmetto GBA (the Specialty MAC or S MAC for
Railroad Retirement Board), the Indian Health Services, and the United Mine Workers. MACs DO NOT
NEED TO SEND FILES TO THOSE ENTITIES.
Fee schedules also are available for the public on the CMS Web site.
30.3.3 - Furnishing Other Fee Schedule, Prevailing Charge, and Conversion Factor
Data
(Rev. 1, 10-01-03)
B3-4620.3
A/B MACs (B) use the file format in §30.3.5 to furnish fee schedule (Excluding Physician Fee Schedule),
prevailing charge, and conversion factor information to Palmetto GBA (S MAC for RRB), A/B MACs (A)
or (HHH), State Agencies, Indian Health Services, and United Mine Workers.
A/B MACs (B) furnish statewide (or A/B MAC (B)-wide for areas less than an entire State) pricing data for
certified registered nurse anesthetist conversion factors. Furnish all fee schedules and conversion factors on
tape unless the receiving entity agrees that a paper listing is acceptable.
Clinical Lab pricing files subject to national limitation amounts and DMEPOS pricing files subject to
national floor and ceiling limitation amounts will be furnished by CMS to all entities except the State

Medicaid Agencies. The Center for Medicaid and State Operations will provide those pricing files to the
State Medicaid Agencies.
In addition to the above pricing files, A/B MACs (B) furnish Palmetto GBA (the S MAC for RRB) with a
tape file of locality prevailing charges for ambulance services and inflation indexed prevailing charges for
non-physician services subject to the IIC.
Send pricing files for the RRB S MAC to:
Medicare Systems RRB - AG-430
Palmetto GBA
Building One
2300 Springdale Drive
Camden, SC 29020
For Indian Health Services, send pricing files to:
IHS Contract Health Services
12800 Indian School Road North East
Albuquerque, NM 87112
For releasing nonphysician pricing files to State Agencies, contact the RO to obtain the name and mailing
address of the individual to whom the file should be addressed.
For the United Mine Workers, send the pricing files to:
Government Programs Manager
UMWA Health and Retirement Funds
2121 K Street, NW
Washington, DC 20037, or
MedPricing@umwafunds.org
You may negotiate agreements with the receiving entity to use an alternate medium (e.g., paper, diskette) or
a tape file format other than that specified in §30.3.5. However, such agreements must be in writing and
signed by the affected entities (e.g., A/B MAC (A), (B), (HHH), or DME MAC, RRB S MAC, UMWA,
etc.). Furnish your RO with a copy of written agreements for using mediums other than tape or tape file
formats other than that in §30.3.5.
30.3.4 - Responsibility to Obtain and Implement Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedules
(Rev. 1, 10-01-03)
B3-4622
The A/B MACs (A), (B), (HHH), and DME MACs must download and implement the DMEPOS fee
schedules for the items and services within their jurisdiction. DME MACs must also forward the DMEPOS
fee schedule to Medicaid State Agencies. The CMS releases new fee schedules on an annual basis, with
updates being issued quarterly, if needed. The CMS issues separate instructions for downloading and
implementing fee schedule updates as appropriate. Central office (CO) will issue annual updates describing
the maintenance process for each year. These instructions provide A/B MACs (A), (B), (HHH), and DME
MACs the due dates. The instructions will also list the date the release will be made available and an
implementation date for each release.
30.3.5 - File Specifications
(Rev. 1, 10-01-03)
B3-4621

The following guidelines are used to create the pricing files.
1. Recommended Physical File Specifications-Magnetic Tape - Tape characteristics-9 track, 8 2” to 10 2”
reels with silver mylar reflector (standard reels) with write ring removed.
Parity – Odd
Recording Density - 6250 bytes per inch
Recording Code - Extended Binary Coded Decimal
File Label - IBM standard label. The tape must have an end of file mark. The first data record on the file
identifies the submitter and the receiver and serves the function of a file label.
Physical Record Length - 60 characters
Blocking Factor - 100 records per block
The external label on the reel must appear as:
From
To
Reel number HCPCS (see footnote (a) below for entry) number (the unique number by which the tape is
identified in your library).
Date (MMDDYYYY)
2. Record Specifications. The logical HCPCS record is made up of a series of 60 character physical records.
3. Blocking factor of 100 (100 records per data block).
4. Header Type Specifications
Field
No.
Field Name 	Size 	Picture 	Specification 	Field Remarks
1 	Label 	3 	X(3) 	L 	See Footnote (b)
2 	Filler 	7 	X(7) 	L
3 	A/B MAC (B) # 	5 	9(5) 	L
4 	Filler 	1 	X(1)
5 	Interm. # 	5 	9(5) 	L
6 	Filler 	1 	X(1) 	L
7 	Date Fee Updated 	8 	X(8) 	L 	MMDDYYYY
8 	Filler 	22 	X(22)
9 	Date File Created 	8 	X(8) 	L 	MMDDYYYY

5. Detail Record
Field
No. Field Name 	Size 	Picture 	Specification 	Field Remarks
1 	HCPCS 	5 	X(5) 	L
2 	Filler 	2 	XX 	L
3 	Filler 	2 	XX 	L
4 	Fee/CF/Prev. 	7 	9(5)V99 	R 	See Footnote (c) for
applicable category
5 	Fee 	7 	9(5)V99 	R 	See Footnote (d)
6 	Fee 	7 	9(5)V99 	R 	See Footnote (e)
7 	A/B MAC (B) # 	5 	X(5) 	L
8 	Locality 	2 	99 	L
9 	Filler 	23 	X(23)
(a) Identify the type of information furnished:
• 	DME fee schedule (includes supplies, inexpensive/routinely purchased, frequency service, and
capped rental);
• 	Surgical Dressings;
• 	Prevailing charges applicable to hospice physician services;
• 	Lab fee schedule;
• 	Other diagnostic service prevailing charges;
• 	Oxygen fee schedule;
• 	Prosthetic/orthotic fee schedule (includes ostomy, tracheostomy, and urologicals);
• 	Radiology conversion factors;
• 	Portable radiology fee schedule; or
• 	Certified registered nurse anesthetist conversion factors.
(b) Show the label for category as:
• 	DME - durable medical equipment;
• 	S/D - surgical dressings;
• 	HPH - prevailing charges for pricing hospice physician services;
• 	LAB - laboratory;
• 	ODX - other diagnostic services;
• 	OXY - oxygen;
• 	P/O - prosthetic/orthotic;
• 	RAD - radiology;
• 	PRF - portable radiology; or
• 	CNA - certified nurse anesthetist.

(c, d, e) 	DME
(c) 	purchase new
(d) 	purchase used
(e) 	monthly rental
NOTE: When a HCPCS code has multiple fees, list all the fees. A/B MACs (HHH) are not able to accept
procedure codes with modifiers.
HPH
(c) 	locality prevailing charge for physician services
LAB
(c) 	fee schedule amount - 60%
(d) 	fee schedule amount - 62%
ODX
(c) 	locality prevailing charge amounts
OXY
(c) 	purchase new/purchased oxygen contents
(d) 	purchase used
(e) 	monthly rental
P/O
(c) 	purchase new
RAD
(c) 	conversion factors
NOTE: HCPCS codes are not necessary for radiology.
PRF
(c) 	fee schedule amount
CNA
(c) 	conversion factor - medically directed CRNA services
(d) 	conversion factor - non-medically directed CRNA services
40 - Clinical Diagnostic Laboratory Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
The Medicare Claims Processing Manual, Chapter 16, “Laboratory Services From Independent Labs,
Physicians, and Providers,” provides background and additional information for payment of laboratory
services.
Clinical diagnostic laboratory tests - whether performed in a physician’s office, by an independent
laboratory, or by a hospital laboratory for its outpatients - are paid based on fee schedules. This section sets
out rules for use of these schedules.
The fee schedule amounts are adjusted annually to reflect changes in the Consumer Price Index (CPI) for all
Urban Consumers (U.S. city average), or as otherwise specified by legislation. Adjustments are applied and
amounts are determined by CMS and published for A/B MAC (A), (B), and (HHH) use and also on CMS
Web site. A/B MACs (A), (B), and (HHH) are notified when and where updates are published.

For a cervical or vaginal smear test (pap smear), payment is the lesser of the local fee or the national
limitation amount, but not less than the national minimum payment amount. However, in no case may
payment for these tests exceed actual charges. The Part B deductible and coinsurance do not apply.
Regardless of whether a diagnostic laboratory test is performed in a physician’s office, by an independent
laboratory, or by a hospital laboratory for its outpatients or nonpatients, it is considered a laboratory service.
When a hospital laboratory performs diagnostic laboratory tests for nonhospital patients, the laboratory is
functioning as an independent laboratory.
National minimum limitation amounts are established each year for cervical or vaginal smear clinical
laboratory tests. These payment amounts are published each year in a Recurring Update Notification issued
by CMS. The affected CPT laboratory test codes for the national minimum payment amount are also
identified in the annual Recurring Update Notification. National maximum limitation amounts may also be
established for certain services and are also published each year this Recurring Update Notification.
A/B MACs (A), (B), and (HHH) pay the lowest of the applicable current fee schedule, the actual charge, or
the NLA. This applies to all clinical diagnostic laboratory tests except:
• 	Laboratory tests furnished to a hospital inpatient whose stay is covered under Part A;
• 	Laboratory tests performed by a Skilled Nursing Facility (SNF) for its own SNF inpatients and
reimbursed under Part A or Part B and any laboratory tests furnished under arrangements to an SNF
inpatient with Part A coverage. (The only covered source for laboratory services furnished under
Part A is the SNF itself or a hospital with which the facility has a transfer agreement in effect.)
• 	Laboratory tests furnished by hospital-based or independent ESRD dialysis facilities that are
included under the ESRD composite rate payment;
• 	Laboratory tests furnished by hospitals in States or areas which have been granted demonstration
waivers of Medicare reimbursement principles for outpatient services. The State of Maryland has
been granted such demonstration waivers;
• 	Laboratory tests furnished to inpatients of a hospital with a waiver under §602(k) of the 1983
Amendments to the Act. This section of the Act provides that an outside supplier may bill under Part
B for laboratory and other nonphysician services furnished to inpatients that are otherwise paid only
though the hospital;
• 	Laboratory tests furnished to patients of rural health clinics (RHCs) under an all inclusive rate;
• 	Laboratory tests provided by a participating health maintenance organization (HMO) or health care
prepayment plan (HCPP) to an enrolled member of the plan; and
• 	Laboratory tests furnished by a hospice.
40.1 - Access to Clinical Diagnostic Lab Fee Schedule Files
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
The annual laboratory fee schedule data file should be retrieved electronically through CMS’ mainframe
telecommunications system.
For each test code, if the MAC’s system retains only the pricing amount, they should load the data from the
field named “60% Pricing Amt.” For each test code, if the MAC’s system has been developed to retain the
local fee and the NLA, they may load the data from the fields named “60% Local Fee Amt” and “60% Natl
Limit Amt” to use to determine payment. For clinical laboratory test codes for cervical or vaginal smear
tests (listed in Chapter 16, “Laboratory Services from Independent Labs, Physicians, and Providers,” §80.3)

load the data from the field named “60% Pricing Amt” to reflect the lower of the local fee or the NLA, but
not less than the national minimum payment amount. The fields named “62% Local Fee Amt,” “62% Natl
Limit Amt,” and “62% Pricing Amt” should be used by A/B MACs (A) for payment of clinical laboratory
tests performed by a sole community hospital’s qualified laboratory.
The annual laboratory fee schedule data is available via the CMS website. It is available in multiple
formats: Excel, text, and comma delimited.
40.2 - A/B MAC (B) Record Layout for Clinical Laboratory Fee Schedule
(Rev. 1, 10-01-03)
PM AB-01-162, AB-02-163
The instructions for each annual update contain the actual data set name for that year. The Data Set Name is
included with each annual update instructions.
Data Element Name 	Picture 	Location 	Comment
HCPCS Code 	X(05) 	1-5
A/B MAC (B)
Number
X(05) 	6-10
Locality 	X(02) 	11-12 	00 = Denotes Single A/B MAC (B)
State
01 = North Dakota
02 = South Dakota
20 = Puerto Rico
40 = New Hampshire
50 = Vermont
60% Local Fee 	9(05)V99 	13 - 19
62% Local Fee 	9(05)V99 	20 - 26
60% Natl Limit Amt 	9(05)V99 	27 - 33
62% Natl Limit Amt 	9(05)V99 	34 - 40
60% Pricing Amt 	9(05)V99 	41 - 47
62% Pricing Amt 	9(05)V99 	48 - 54
Gap - Fill Indicator 	X(01) 	55 - 55 	0 = No Gap-fill Required
1 = A/B MAC (B) Gap-fill
2 = Special Instructions Apply
Modifier 	X(02) 	56 - 57 	Where modifier is shown, QW
denotes a CLIA waive test.
Filler 	X(03) 	58 - 60
40.3 - Institutional Claim Record Layout for Clinical Laboratory Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)

The CMS will provide the specific file names when the prices are released. The file name will contain the
label CLAB.
Record Length = 	60
Record Format = 	FB
Block Size = 	6000
Character Code = 	EBCDIC
Sort Sequence = 	A/B MAC (B), Locality, HCPCS Code
Header Record
Data Element Name 	Picture 	Location 	Comment
1-Label 	X(03) 	1 - 3 	Value = Lab
2-Filler 	X(07) 	4 - 10
3-Filler 	X(08) 	11 - 15
4-Filler 	X(04) 	16 - 22
5-Date Fee Update 	X(08) 	23 - 30 	YYYYMMDD
6-Filler 	X(22) 	31 - 52
7-Date File Created 	X(08) 	53 - 60 	YYYYMMDD
Data Record
Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-Filler 	X(04) 	6 - 9
3-60% Fee 	9(05)V99 	10 - 16
4-62% Fee 	9(05)V99 	17 - 23
5-Filler 	X(07) 	24 - 30
6- A/B MAC (B)
Number
X(05) 	31 - 35
7- A/B MAC (B)
Locality
X(02) 	36 - 37 	00 = Single State A/B MAC (B)
01 = North Dakota
02 = South Dakota
20 = Puerto Rico

Data Element Name 	Picture 	Location 	Comment
8-State Locality 	X(02) 	38 - 39 	Separate instructions will be used
for the use of this field at a later
date.
9-Filler 	X(02) 	40 - 41
10-Effective Date 	X(08) 	42 - 49 	Update effective date
(YYYYMMDD)
11-Filler 	X(11) 	50 - 60
40.4 - Gap-Filled Fees Submitted to CMS by A/B MACs (B)
(Rev. 1, 10-01-03)
AB-01-162, AB-02-163
In accordance with §531(b) of the Benefits Improvement and Protection Act of 2000 (BIPA), CMS solicits
public comments on determining payment amounts for new laboratory tests. The CMS hosts an annual
public meeting to allow parties the opportunity to provide input to the payment determination process. The
CMS employs one of two approaches to establishing payment amounts for new laboratory test codes,
crosswalking and gap-filling. After considering public input regarding the new test codes, CMS determines
which approach is most appropriate for each new test code.
If the new test is comparable to an existing test, the new test is “crosswalked” to the existing test, and it is
assigned the local fee for the existing test and the corresponding NLA. The new test code and payment
amounts are included in the updated laboratory fee schedule annually.
If CMS determines that the laboratory fee schedule includes no sufficiently comparable test to permit
crosswalking, CMS instructs A/B MACs (B) to “gap-fill” the payment amount for the new test code. Gap-
filling is an empirical process of determining a payment amount in a locality using available information
sources. Usually the period during which gap-filled payment amounts are instructed is the year following
the introduction of a new code. During this period, A/B MACs (B) establish and use these payment
amounts; they may be revised in the course of the year. Also during this period, A/B MACs (B) must report
the gap-fill amounts to their ROs which are then forwarded to CMS CO. The CMS considers the gap-fill
amounts and uses them to establish the fees for the new test code in the next update of the laboratory fee
schedule.
In determining gap-fill amounts, the sources of information A/B MACs (B) should examine, if available,
include: charges for the test and routine discounts to charges; resources required to perform the test;
payment amounts determined by other payers; and charges, payment amounts, and resources required for
other tests that may be comparable or otherwise relevant. A/B MACs (B) may consider other sources of
information as appropriate, including clinical studies and information provided by clinicians practicing in
the area, manufacturers, or other interested parties. To assist each A/B MAC (B) in establishing a gap-fill
amount, A/B MACs (B)’ Medical Directors may meet and share information regarding the new test, though
without reaching a formal consensus.
Establishing payment amounts for new laboratory tests is inherently difficult, precisely because these tests
are new and as a result the types and extent of information available about them may be limited. Because
the circumstances of different tests may vary significantly, specifying in detail a method of using the various
information sources outlined above does not appear appropriate at this time. However, CMS designates a
new test code for gap-filling in instances where no test code seems sufficiently similar to make a crosswalk
approach appropriate. Accordingly, A/B MACs (B) should not determine a gap-fill amount by crosswalking
to the payment amount for another test code.

After determining a gap-fill amount, an A/B MAC (B) may consider if a least costly alternative to a new test
exists. If an A/B MAC (B) determines a least costly alternative test exists, the A/B MAC (B) may adopt the
payment amount of the least costly alternative test as the gap-fill amount for the new test code. The least
costly alternative amount will be considered the local fee, and CMS will use this payment amount in
establishing the NLA. However in this case, the A/B MAC (B) must report two payment amounts, the gap-
fill amount prior to determination of a least costly alternative and the payment amount that the A/B MAC
(B) has determined to be the least costly alternative.
A/B MACs (B) should also communicate the gap-fill amounts to corresponding A/B MACs (A) and (HHH).
A/B MACs (B) can seek assistance from RO staff to facilitate communication of the gap-fill amounts to A/B
MACs (A) and (HHH). The list of codes which A/B MACs (B) are required to gap-fill each year are
communicated in the annual instructions.
A/B MACs (B) provide their RO with gap-fill fees according to the date communicated by CMS (usually
May), to be used by CMS-Central for the development of subsequent or later laboratory fee schedules. A/B
MACs (B) submit the gap-fill fees in a right-justified format. These gap-fill data should be transmitted in an
ASCII file with the following file specifications to MStevenson@cms.hhs.gov with a copy to
Agreenberg@cms.hhs.gov to assist with coordinated collection of the gap-fill fees.
Data Set Name: CLXXXXX.TXT* (ASCII File)
(*Denotes A/B MAC (B) 5 - digit number)
Gap-filled Fees Record Layout
Data Element Name 	Picture 	Location 	Comment
Year 	X(4) 	1 - 4 	Set to Year (e.g., 2003)
HCPCS Code 	X(5) 	5 - 9
Modifier 	X(2) 	10 - 11
A/B MAC (B)
Number
X(5) 	12 - 16
Locality 	X(2) 	17 - 18 	00 = Denotes Single State
A/B MAC (B)
01 = North Dakota
02 = South Dakota
20 = Puerto Rico
40 = New Hampshire
50 = Vermont
Gap-fill Amount 	9(5)V99 	19 - 25 	Prior to any determination of
a least costly alternative
Least Costly
Alternative Amount
9(5)V99 	26-32
Least Costly
Alternative Code
X(5) 	33-37

40.4.1 - A/B MACs (B) Forward HCPCS Gap Fill Amounts to A/B MACs (A) and
(HHH)
(Rev. 1, 10-01-03)
CMS Memo 9-13-02 HCPCS Gap-fillR3.doc
Any A/B MAC (B) that establishes a HCPCS gap fill payment rate for its own use, or at the request of an
A/B MAC (A) or (HHH), must forward the information to the contacts at all A/B MACs (A) or (HHH) with
providers in the A/B MAC (B) service area.
A/B MACs (B) that establish HCPCS gap-fill payment rates for their own needs should forward the
information to A/B MACs (A) and (HHH) as soon as practicable. A/B MACs (A) and (HHH) are to contact
the appropriate A/B MAC (B) to request a gap fill payment rate with 5 working days of the suspension of
claims containing HCPCS codes(s) for which payment rate is needed and has not been forwarded. A/B
MACs (B) must provide the payment rate to the requesting A/B MAC (A) or (HHH) (and all other A/B
MACs (A) or (HHH) with providers in that common jurisdiction) within 10 working days of receipt of the
request.
Requests for policy clarification in A/B MAC (B) establishing the HCPCS gap fill payment rates or A/B
MAC (A) or (HHH) procedures for the use thereof should be directed to the respective Regional Office
HCPCS business function experts (BFE). Examples of the need for A/B MAC (A) or (HHH) consultation
with the BFE are coverage questions and receipt of unresolved significant inconsistencies in fee amounts
from different A/B MACs (B) for the same HCPCS. The A/B MAC (A) or (HHH) should consult the A/B
MACs (B) with disparate fees before contacting the BFE.
An A/B MAC (A) or (HHH) experiencing delay in replies or nonresponses from an A/B MAC (B) should
alert it respective Consortium Contractor Management Staff (CCMS) Contract Manager (CM). The CM
will coordinate with his/her counterpart assigned to the A/B MAC (B) to achieve more timely action by the
A/B MAC (B).
It is the A/B MAC (A)’s or (HHH)’s responsibility to ascertain the amount or consult with the A/B MAC
(B), CCMS-CM, or BFE timely. A/B MAC (A or (HHH) requests to apply CC 15 to claims which are paid
untimely solely because of a delay in ascertaining a HCPCS gap fill amount from the A/B MAC (B) should
be addressed to the respective CM. The CM will contact the HCPCS BFE for a decision. Requests for
application of CC 15 to claims for which the A/B MAC (A) or (HHH) did not request the gap fill payment
rate within 5 working days of the claim suspension and/or did not seek timely advice from the RO BFE
concerning application of gap fill amount will not be honored. Additionally, if the A/B MAC (B) replied at
least five days before the expiration of the payment floor, CC 15 requests will not be honored.
50 - Fee Schedules Used by Medicare A/B MACs (A) and (HHH) Processing
Institutional Claims
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
A/B MACs (A) and (HHH) processing institutional claims retrieve multiple files from the CMS mainframe
telecommunications system. The HCPCS data files include deleted codes for the upcoming year. A/B
MACs (A) and (HHH) need to identify deleted codes using the HCPCS files because they are not
identifiable solely from the fee schedules. HCPCS files are also obtained from CMS annually. New fee
schedules are effective for dates of service on and after January 1 of each year. Quarterly and emergency
updates to the fee schedules are also sometimes released. In that case, A/B MACs (A) and (HHH)
implement them according to the instructions accompanying the release.
Two HCPCS files are furnished by CMS. They are:
• 	The annual HCPCS file update including procedure and modifier codes and deleted codes; and

• 	A print file of the new year HCPCS codes.
The following fee schedules are furnished by CMS for use in processing institutional claims:
• 	Fees for hospice claims for Part B services provided by the hospice beneficiary’s attending
physician;
• 	Medicare Physician Fee Schedule;
• 	Clinical Laboratory Fee Schedule discussed in §40.3 above;
• 	Durable Medical Equipment, Prosthetics/Orthotics and Supplies (DMEPOS) Fee Schedule. A/B
MACs (HHH) with home health workloads retrieve data from all categories on this file. All MACs
retrieve data from categories prosthetic/orthotics and surgical dressings;
• 	Outpatient Rehabilitation (Therapy) and CORF Services Fee Schedule Payment Amounts
(Therapy/CORF Abstract File);
• 	CORF, outpatient Critical Access Hospital (CAH and Indian Health Services not part of the
Outpatient Rehabilitation (therapy) file; and
• 	Skilled Nursing Facility (SNF) extract file for radiology, other diagnostic and other SNF services.
50.1 - Institutional Claim Record Layout for Hospice, Radiology and Other Diagnostic
Prices and Local HCPCS Codes
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
This file contains hospice fee schedule prices extracted from the Physician Fee schedule. This file contains
pricing data for A/B MAC (B)-priced and local HCPCS codes for radiology, other diagnostic services, and
hospice services paid under the physician fee schedule. This file contains some high volume services such
as portable x-rays. The file is also used to pay claims for Critical Access Hospitals that have elected the
optional method. The CMS will provide the specific file names when the prices are released. The file name
will contain the label HHH.
Record Length 	- 	60
Record Format 	- 	FB
Block Size 	- 	6000
Character Code 	- 	EBCDIC
Sort Sequence 	- 	A/B MAC (B), Locality, HCPCS Code, Modifier
Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-Modifier 	X(02) 	6 - 7
3-Non-Facility Fee 	9(05)V99 	8 - 14

Data Element Name 	Picture 	Location 	Comment
4-PCTC Indicator 	X(01) 	15 - 15 	This field is only applicable when
pricing Critical Access Hospitals
(CAHs) that have elected the optional
method (Method 2) of payment.
5-Facility Fee 	9(05)V99 	16 - 22
6-Effective Date
7- A/B MAC (B)
Number
X(08)
X(05)
23 - 30
31 - 35
8-Locality 	X(02) 	36 - 37
9-**Label** 	X(03) 	38 - 40 	HPH = Hospice Physician Services
ODX = Other Diagnostic Services
PRF = Portable Radiology
RAD = Radiology
10-Filler 	X(2) 	41 - 42
11-Status Code 	X(1) 	43 - 43 	Separate instructions will be used for
the use of this field at a later date. This
field indicates whether the code is in
the physician fee schedule and whether
it is separately payable if the service is
covered.
12-Multiple Surgery 	X(01) 	44 - 44 	Indicator indicates which payment
adjustment rule for multiple procedures
apply to the service.
13-Non Facility PE 	9(05)V99 	45 - 51 	Non-facility practice expense RVU
14-Filler 	X(01) 	52 - 52
15- A/B MAC (A) or
(HHH) Therapy
Reduction
9(05)V99 	53 - 59 	Reduces payment amount for multiple
surgery
16-Filler 	X(01) 	60 - 60
50.2 - Institutional Claim Record Layout for the Durable Medical Equipment,
Prosthetic, Orthotic and Supply Fee Schedule
(Rev. 3350, Issued: 09-11-15, Effective: 01-01-16, Implementation: 01-04-16)
This file contains services subject to national Floors and Ceilings under the DMEPOS Fee Schedules
including Surgical Dressings. The CMS will provide the specific file names when the prices are released.
The file name will contain the label DMEPOS.
Record Length 	- 	60
Record Format 	- 	FB

Block Size 	- 	6000
Character Code 	- 	EBCDIC
Sort Sequence 	- 	Label, HCPCS Code, MOD, State
Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-MOD 	X(02) 	6 – 7
3-MOD 2 	X(02) 	8 – 9
4-Fee Schedule Amt 	9(05)V99 	10 – 16
5-Filler 	X(01) 	17
6-Rural Fee Amt 	9(05)v99 	18 – 24
7-Filler 	X(01) 	25
8-Rural Fee indicator 	X(01) 	26- 	R = Rural Fee is present
9-Filler 	X(04) 	27-30
10-State 	X(02) 	31 - 32
11-Filler 	X(05) 	33 - 37
12-*Label* 	X(3) 	38 - 40 	DME = Durable Medical Equipment
(other than oxygen)
OXY = Oxygen
P/O = Prosthetic/Orthotic
S/D = Surgical Dressings
13-Filler 	X(4) 	41 - 44
14-*Pricing Change
Indicator
X(1) 	45 - 45 	0 = No change to Update Fee Schedule
Amount since previous release
1 = A change has occurred to the
Update Fee Schedule Amount since the
previous release.
NOTE: In the initial release of the
annual update, this field is initialized to
>0’
15-Filler 	X(02) 	46 – 47
16-Effective Date 	X(08) 	48 – 55 	Update effective date (YYYYMMDD)
17-Filler 	X(05) 	56 – 60
50.3 - Institutional Claim Record Layout for the Outpatient Rehabilitation and CORF
Services Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
This is a physician fee schedule abstract file for outpatient rehabilitation and CORF services payment. The
CMS will provide the specific file names when the prices are released. The file name will contain the label
ABSTR.
Record Length 	- 	60
Record Format 	- 	FB
Block Size 	- 	6000
Character Code 	- 	EBCDIC
Sort Sequence 	- 	A/B MAC (B), Locality HCPCS Code, Modifier

Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-Modifier 	X(02) 	6 - 7
3-Non-Facility Fee 	9(05)V99 	8 - 14
4-PCTC Indicator 	X(01) 	15 - 15 	This field is only applicable when
pricing Critical Access Hospitals
(CAHs) that have elected the optional
method (Method 2) of payment.
5-Facility Fee 	9(05)V99 	12 - 22
6-Effective Date 	X(08) 	23 - 30 	Update effective date
7- A/B MAC (B)
Number
X(05) 	31 - 35
8-Locality 	X(02) 	36 - 37
9-Filler 	X(03) 	38 - 40
10-Fee Indicator 	X(1) 	41 - 41 	R = Rehab/Audiology function
test/CORF services
11-Outpatient
Hospital
X(1) 	42 - 42 	0 = Fee applicable in hospital
outpatient setting
1 = Fee not applicable in hospital
outpatient setting
12-Status Code 	X(1) 	43 - 43 	Separate instructions will be used for
the use of this field at a later date. This
field indicates whether the code is in
the physician fee schedule and whether
it is separately payable if the service is
covered.
13-Multiple Surgery 	X(01) 	44 - 44 	Indicator indicates which payment
adjustment rule for multiple procedures
apply to the service.
14-Non Facility PE 	9(05)V99 	45 - 51 	Non-facility practice expense RVU
15-Filler 	X(01) 	52 - 52
16- A/B MAC (A) or
(HHH) Therapy
Reduction
9(05)V99 	53 - 59 	Reduces payment amount for multiple
surgery
17-Filler 	X(01) 	60 - 60
50.4 - Institutional Claim Record Layout for the Skilled Nursing Facility Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)

This section contains the record layout for the SNF extract for radiology Services, other diagnostic services,
and other SNF services priced on the MPFS. The CMS will provide the specific file names when the prices
are released. 	The file name will contain the label SNF.
Record Length 	- 	60
Record Format 	- 	FB
Block Size 	- 	6000
Character Code 	- 	EBCDIC
Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-Modifier 	X(02) 	6 - 7
3-Non-Facility Fee 	9(05)V99 	8 - 14 	The SNF fee schedule amount is based
on the “non-facility rate” which is the
fee that physicians may receive if
performing the service in the
physician’s office.
4-PCTC Indicator 	X(01) 	15 - 15
5-Facility Fee 	9(05)V99 	16 - 22
6-Effective Date
7- A/B MAC (B)
Number
X(08)
X(05)
23 - 30
31 - 35
Update effective date
8-Locality 	X(02) 	36 - 37
9-Filler 	X(05) 	38 - 42
10-Status Code 	X(1) 	43 - 43 	Separate instructions will be used for
the use of this field at a later date. This
field indicates whether the code is in
the physician fee schedule and whether
it is separately payable if the service is
covered.
11-Multiple Surgery 	X(01) 	44 - 44 	Indicator indicates which payment
adjustment rule for multiple procedures
apply to the service.
12-Non Facility PE 	9(05)V99 	45 - 51 	Non-facility practice expense RVU
13-Filler 	X(01) 	52 - 52
14- A/B MAC (A) or
(HHH) Therapy
Reduction
9(05)V99 	53 - 59 	Reduces payment amount for multiple
surgery

Data Element Name 	Picture 	Location 	Comment
15-Filler 	X(01) 	60 - 60
50.5 - RESERVED
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
50.6– Physician Fee Schedule Payment Policy Indicator File Record Layout
(Rev.12326; Issued:10-26-23; Effective: 01-29-24; Implementation:01-29-24)
When a Medicare beneficiary elects hospice services, hospices must complete the data elements
identified below for the Uniform (Institutional Provider) Bill (Form CMS-1450) or its electronic
equivalent, which is a Notice of Election (NOE).
The information on the Physician Fee Schedule Payment Policy Indicator file record layout is used for
processing Method II CAH professional services with revenue codes 96X, 97X or 98X.

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
File Year
This field displays the effective year of
the file.
4 Pic x(4) 	1-4
HCPCS Code
This field represents the procedure
code. Each Current Procedural
Terminology (CPT) code and alpha-
numeric HCPCS codes that are currently
returned on the MPFS supplemental file
will be included when the MPFS Status
Indicator is A, C, T, and some with
R. The standard sort for this field is
blanks, alpha, and numeric in ascending
order.
5 Pic x(5) 	5-9
Modifier
For diagnostic tests, a blank in this field
denotes the global service and the
following modifiers identify the
components:
26 = Professional component; and
TC = Technical component.
For services other than those with a
professional and/or technical component,
a blank will appear in this field with one
exception: the presence of CPT modifier -
53 which indicates that separate Relative
Value Units (RVUs) and a fee schedule
amount have been established for
procedures which the physician
terminated before completion. This
modifier is used only with colonoscopy
code 45378 and screening colonoscopy
codes G0105 and G0121. Any other
codes billed with modifier -53 are subject
to medical review and priced by
individual consideration.
Modifier-53 = Discontinued Procedure -
Under certain circumstances, the
physician may elect to terminate a
surgical or diagnostic procedure. Due to
extenuating circumstances, or those that
2 Pic x(2) 	10-11

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
threaten the well being of the patient, it
may be necessary to indicate that a
surgical or diagnostic procedure was
started but discontinued.
Code Status
This 1 position field provides the status of
each code under the full fee schedule.
Each status code is explained in Pub. 100-
04, Chapter 23, §30.2.2.
1 Pic x(1) 	12
Global Surgery
This field provides the postoperative time
frames that apply to payment for each
surgical procedure or another indicator
that describes the applicability of the
global concept to the service.
000 = Endoscopic or minor procedure
with related preoperative and
postoperative relative values on the day
of the procedure only included in the fee
schedule payment amount; evaluation and
management services on the day of the
procedure generally not payable.
010 = Minor procedure with preoperative
relative values on the day of the
procedure and postoperative relative
values during a 10-day postoperative
period included in the fee schedule
amount; evaluation and management
services on the day of the procedure and
during this 10-day postoperative period
generally not payable.
090 = Major surgery with a 1-day
preoperative period and 90-day
postoperative period included in the fee
schedule payment amount.
MMM = Maternity codes; usual global
period does not apply.
3 Pic x(3) 	13-15

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
XXX = Global concept does not apply.
YYY = A/B MAC (A) determines
whether global concept applies and
establishes postoperative period, if
appropriate, at time of pricing.
ZZZ = Code related to another service
and is always included in the global
period of the other service. (NOTE:
Physician work is associated with intra-
service time and in some instances the
post service time.)
Preoperative Percentage (Modifier 56)
This field contains the percentage (shown
in decimal format) for the preoperative
portion of the global package. For
example, 10 percent will be shown as
010000. The total of the preoperative
percentage, intraoperative percentage, and
the postoperative percentage fields will
usually equal one. Any variance is slight
and results from rounding.
6 Pic 9v9(5) 	16-21
Intraoperative Percentage (Modifier
54)
This field contains the percentage (shown
in decimal format) for the intraoperative
portion of the global package including
postoperative work in the hospital. For
example, 63 percent will be shown as
063000. The total of the preoperative
percentage, intraoperative percentage, and
the postoperative percentage fields will
usually equal one. Any variance is slight
and results from rounding.
6 Pic 9v9(5) 	22-27
Postoperative Percentage (Modifier 55)
This field contains the percentage (shown
in decimal format) for the postoperative
portion of the global package that is
provided in the office after discharge
from the hospital. For example, 17
percent will be shown as 017000. The
6 Pic 9v9(5) 	28-33

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
total of the preoperative percentage,
intraoperative percentage, and the
postoperative percentage fields will
usually equal one. Any variance is slight
and results from rounding.
Professional Component
(PC)/Technical Component (TC)
Indicator
0 = Physician service codes: This
indicator identifies codes that describe
physician services. Examples include
visits, consultations, and surgical
procedures. The concept of PC/TC does
not apply since physician services cannot
be split into professional and technical
components. Modifiers 26 & TC cannot
be used with these codes. The total
Relative Value Units (RVUs) include
values for physician work, practice
expense and malpractice expense. There
are some codes with no work RVUs.
1 = Diagnostic tests or radiology services:
This indicator identifies codes that
describe diagnostic tests, e.g., pulmonary
function tests, or therapeutic radiology
procedures, e.g., radiation therapy. These
codes generally have both a professional
and technical component. Modifiers 26
and TC can be used with these codes.
The total RVUs for codes reported with a
26 modifier include values for physician
work, practice expense, and malpractice
expense.
The total RVUs for codes reported with a
TC modifier include values for practice
expense and malpractice expense only.
The total RVUs for codes reported
without a modifier equals the sum of
RVUs for both the professional and
technical component.
2 = Professional component only codes:
1 Pic x(1) 	34

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
This indicator identifies stand alone codes
that describe the physician work portion
of selected diagnostic tests for which
there is an associated code that describes
the technical component of the diagnostic
test only and another associated code that
describes the global test.
An example of a professional component
only code is 93010, Electrocardiogram;
interpretation and report. Modifiers 26
and TC cannot be used with these codes.
The total RVUs for professional
component only codes include values for
physician work, practice expense, and
malpractice expense.
3 = Technical component only codes:
This indicator identifies stand alone codes
that describe the technical component
(i.e., staff and equipment costs) of
selected diagnostic tests for which there is
an associated code that describes the
professional component of the diagnostic
tests only.
An example of a technical component
code is 93005, Electrocardiogram, tracing
only, without interpretation and report. It
also identifies codes that are covered only
as diagnostic tests and therefore do not
have a related professional code.
Modifiers 26 and TC cannot be used with
these codes.
The total RVUs for technical component
only codes include values for practice
expense and malpractice expense only.
4 = Global test only codes: This indicator
identifies stand alone codes for which
there are associated codes that describe:
a) the professional component of the test
only and b) the technical component of
the test only. Modifiers 26 and TC
cannot be used with these codes. The
total RVUs for global procedure only
codes include values for physician work,

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
practice expense, and malpractice
expense. The total RVUs for global
procedure only codes equals the sum of
the total RVUs for the professional and
technical components only codes
combined.
5 = Incident to Codes: This indicator
identifies codes that describe services
covered incident to a physicians service
when they are provided by auxiliary
personnel employed by the physician and
working under his or her direct
supervision.
Payment may not be made by carriers for
these services when they are provided to
hospital inpatients or patients in a hospital
outpatient department. Modifiers 26 and
TC cannot be used with these codes.
6 = Laboratory physician interpretation
codes: This indicator identifies clinical
laboratory codes for which separate
payment for interpretations by laboratory
physicians may be made. Actual
performance of the tests is paid for under
the lab fee schedule. Modifier TC cannot
be used with these codes. The total
RVUs for laboratory physician
interpretation codes include values for
physician work, practice expense and
malpractice expense.
7 = Physical therapy service: Payment
may not be made if the service is
provided to either a hospital outpatient or
inpatient by an independently practicing
physical or occupational therapist.
8 = Physician interpretation codes: This
indicator identifies the professional
component of clinical laboratory codes
for which separate payment may be made
only if the physician interprets an
abnormal smear for hospital inpatient.
This applies only to code 85060. No TC
billing is recognized because payment for

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
the underlying clinical laboratory test is
made to the hospital, generally through
the PPS rate.
No payment is recognized for code 85060
furnished to hospital outpatients or non-
hospital patients. The physician
interpretation is paid through the clinical
laboratory fee schedule payment for the
clinical laboratory test.
9 = Concept of a professional/technical
component does not apply
Multiple Procedure (Modifier 51)
Indicator indicates which payment
adjustment rule for multiple procedures
applies to the service.
0 = No payment adjustment rules for
multiple procedures apply. If the
procedure is reported on the same day as
another procedure, base payment on the
lower of: (a) the actual charge or (b) the
fee schedule amount for the procedure.
1 = Standard payment adjustment rules in
effect before January 1, 1996, for
multiple procedures apply. In the 1996
MPFSDB, this indicator only applies to
codes with procedure status of “D.” If a
procedure is reported on the same day as
another procedure with an indicator of
1,2, or 3, rank the procedures by fee
schedule amount and apply the
appropriate reduction to this code (100
percent, 50 percent, 25 percent, 25
percent, 25 percent, and by report). Base
payment on the lower of: (a) the actual
charge or (b) the fee schedule amount
reduced by the appropriate percentage.
2 = Standard payment adjustment rules
for multiple procedures apply. If the
procedure is reported on the same day as
another procedure with an indicator of 1,
2, or 3, rank the procedures by fee
schedule amount and apply the
appropriate reduction to this code (100
1 Pic (x)1 	35

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
percent, 50 percent, 50 percent, 50
percent, 50 percent, and by report). Base
payment on the lower of: (a) the actual
charge or (b) the fee schedule amount
reduced by the appropriate percentage.
3 = Special rules for multiple endoscopic
procedures apply if procedure is billed
with another endoscopy in the same
family (i.e., another endoscopy that has
the same base procedure). The base
procedure for each code with this
indicator is identified in the endoscopic
base code field.
Apply the multiple endoscopy rules to a
family before ranking the family with
other procedures performed on the same
day (for example, if multiple endoscopies
in the same family are reported on the
same day as endoscopies in another
family or on the same day as a non-
endoscopic procedure).
If an endoscopic procedure is reported
with only its base procedure, do not pay
separately for the base procedure.
Payment for the base procedure is
included in the payment for the other
endoscopy.
4 = Subject to 25% reduction of the TC
diagnostic imaging (effective for services
January 1, 2006 through June 30, 2010).
Subject to 50% reduction of the TC
diagnostic imaging (effective for services
July 1, 2010 and after). Subject to 25%
reduction of the PC of diagnostic imaging
(effective for services January 1, 2012
through December 31, 2016). Subject to
5% reduction of the PC of diagnostic
imaging (effective for services January 1,
2017 and after).
5 = Subject to 20% reduction of the
practice expense component for certain
therapy services furnished in office and
other non-institutional settings, and 25%

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
reduction of the practice expense
component for certain therapy services
furnished in institutional settings
(effective for services January 1, 2011
and after). Subject to 50% reduction of
the practice expense component for
certain therapy services furnished in both
institutional and non-institutional settings
(effective for services April 1, 2013 and
after).
6 = Subject to 25% reduction of the TC
diagnostic cardiovascular services
(effective for services January 1, 2013
and after).
7 = Subject to 20% reduction of the TC
diagnostic ophthalmology services
(effective for services January 1, 2013
and after).
9 = Concept does not apply.
Codes with RVUs equal to zero are not
included in the payment indicator file.
These codes may have multiple procedure
indicators not shown. See note below this
table for instructions on these codes.
Bilateral Surgery Indicator (Modifier
50)
This field provides an indicator for
services subject to a payment adjustment.
0 = 150 percent payment adjustment for
bilateral procedures does not apply.
The bilateral adjustment is inappropriate
for codes in this category because of: (a)
physiology or anatomy, or (b) because the
code descriptor specifically states that it
is a unilateral procedure and there is an
existing code for the bilateral procedure.
1 Pic (x)1 	36

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
1 = 150 percent payment adjustment for
bilateral procedures applies. If code is
billed with the bilateral modifier base
payment for these codes when reported as
bilateral procedures on the lower of: (a)
the total actual charge for both sides, or
(b) 150 percent of the fee schedule
amount for a single code.
If code is reported as a bilateral procedure
and is reported with other procedure
codes on the same day, apply the bilateral
adjustment before applying any
applicable multiple procedure rules.
2 = 150 percent payment adjustment for
bilateral procedure does not apply. RVUs
are already based on the procedure being
performed as a bilateral procedure.
The RVUs are based on a bilateral
procedure because: (a) the code descriptor
specifically states that the procedure is
bilateral; (b) the code descriptor states
that the procedure may be performed
either unilaterally or bilaterally; or (c) the
procedure is usually performed as a
bilateral procedure.
3 = The usual payment adjustment for
bilateral procedures does not apply.
Services in this category are generally
radiology procedures or other diagnostic
tests which are not subject to the special
payment rules for other bilateral
procedures. If a procedure is billed with
the 50 modifier, base payment on the
lesser of the total actual charges for each
side or 100% of the fee schedule amount
for each side.
9 = Concept does not apply.
Assistant at Surgery (Modifiers AS, 80, 	1 Pic (x)1 	37

FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
81 and 82)
This field provides an indicator for
services where an assistant at surgery
may be paid:
0 = Payment restriction for assistants at
surgery applies to this procedure unless
supporting documentation is submitted to
establish medical necessity.
1 = Statutory payment restriction for
assistants at surgery applies to this
procedure. Assistant at surgery may not
be paid.
2 = Payment restriction for assistants at
surgery does not apply to this procedure.
Assistant at surgery may be paid.
9 = Concept does not apply.
Co-Surgeons (Modifier 62)
This field provides an indicator for
services for which two surgeons, each in
a different specialty, may be paid.
0 = Co-surgeons not permitted for this
procedure.
1 = Co-surgeons could be paid;
supporting documentation required to
establish medical necessity of two
surgeons for the procedure.
2 = Co-surgeons permitted; no
documentation required if two specialty
requirements are met.
9 = Concept does not apply.
1 Pic (x)1 	38
Team Surgeons (Modifier 66) 	1 Pic (x)1 	39

Multiple procedure indicator
5 is included in this file;
however, the indicator
represents the therapy
multiple procedure payment
reduction which never applies
to professional service
revenue codes on CAH
outpatient claims. Multiple
procedure indicators 6 and 7
are included in this file,
however, since in these cases
the reduction only applies to
technical component services,
they will not affect the cost-
based payment on CAH
claims. On CAH claims,
technical components are
paid on a cost basis and so are
not subject to the reductions.
There may be cases when
A/B MACs (A) must
manually load a HCPCS code
that is contractor priced
which has a multiple
procedure indicator that is not
on the payment indicator file.
In these cases, the MAC
enters a multiple procedure
indicator of 0.
50.7 - Institutional
Claim Record Layout for the Mammography Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)
This is a physician fee schedule abstract file for mammography services payment. The CMS will provide
the specific file names when the prices are released. The file name will contain the label MAMMO.
Record Length 	- 	60
FIELD NAME & DESCRIPTION 	LENGTH &
PIC
Position
This field provides an indicator for
services for which team surgeons may be
paid.
0 = Team surgeons not permitted for this
procedure.
1 = Team surgeons could be paid;
supporting documentation required to
establish medical necessity of a team; pay
by report.
2 = Team surgeons permitted; pay by
report.
9 = Concept does not apply.
Endoscopic Base Codes
This field identifies an endoscopic base
code for each code with a multiple
surgery indicator of 3.
5 Pic (x) 5 	40-44
Performance Payment Indicator
(For future use)
1 Pic x (1) 	45
Diagnostic Imaging Family Indicator
88 = Subject to the reduction for
diagnostic imaging (effective for services
January 1, 2011, and after).
99 = Concept Does Not Apply
2 Pic x (2) 	46-47
Effective Date
This field displays the effective date of
the file in YYYYMMDD format.
8 Pic x(8) 	48 - 55
Filler 	30 Pic x(30) 	56 -75

Record Format 	- 	FB
Block Size 	- 	6000
Character Code 	- 	EBCDIC
Sort Sequence 	- 	A/B MAC (B), Locality HCPCS Code, Modifier
Data Element Name 	Picture 	Location 	Comment
1-HCPCS 	X(05) 	1 - 5
2-Modifier 	X(02) 	6 - 7
3-Non-Facility Fee 	9(05)V99 	8 - 14
4-PCTC Indicator 	X(01) 	15 - 15 	This field is only applicable when
pricing Critical Access Hospitals
(CAHs) that have elected the optional
method (Method 2) of payment.
5-Facility Fee 	9(05)V99 	16 - 22
6-Effective Date
7- A/B MAC (B)
Number
X(08)
X(05)
23 - 30
31 - 35
Update effective date
8-Locality 	X(02) 	36- 37
9-Filler 	X(05) 	38- 42
10-Status Code 	X(1) 	43- 43 	Separate instructions will be used for
the use of this field at a later date. This
field indicates whether the code is in
the physician fee schedule and whether
it is separately payable if the service is
covered.
11-Multiple Surgery 	X(01) 	44 - 44 	Indicator indicates which payment
adjustment rule for multiple procedures
apply to the service.
12-Non Facility PE 	9(05)V99 	45 - 51 	Non-facility practice expense RVU
13-Filler 	X(01) 	52 - 52
14- A/B MAC (A) or
(HHH) Therapy
Reduction
9(05)V99 	53 - 59 	Reduces payment amount for multiple
surgery
15-Filler 	X(01) 	60 - 60
50.8 - Institutional Claim Record Layout for the Ambulance Fee Schedule
(Rev. 2643, Issued: 01-31-13, Effective: 07-01-13, Implementation: 07-01-13)

This is a physician fee schedule abstract file for ambulance services payment. The CMS will provide the
specific file names when the prices are released. 	The file name will contain the label AMBFS.
Record Length 	- 	80
Record Format 	- 	FB
Block Size 	- 	27920
Character Code 	- 	EBCDIC
Sort Sequence 	- 	HCPCS, A/B MAC (B), Locality
Field Name 	Format 	Position 	Description
1-HCPCS 	X(05) 	1 - 5 	HCFA Common Procedure Coding
System
2- A/B MAC (B)
Number
X(05) 	6 - 10
3-Locality Code 	X(02) 	11-12
4-Base RVU 	9(4)v99 	13 - 18 	Relative Value Unit
5-Non-Facility PE
GPCI
9v9(3) 	19 - 22 	Geographic Adjustment Factor
6-Conversion Factor 	9(5)v99 	23 - 29 	Conversion Factor
7-Urban Mileage 	9(5)v99 	30 - 36 	Urban payment rate or base rate
mileage rate (determined by HCPCS)
8-Rural Mileage 	9(5)v99 	37 - 43 	Rural payment rate or base rate mileage
rate (determined by HCPCS)
9-Current Year 	9(04) 	44- 47 	YYYY
10-Current Quarter 	9(01) 	48 	Calendar Quarter-value 1-4
11-Effective Date 	9(8) 	49- 56 	Effective date of fee schedule file
12-Filler 	X(24) 	57 - 80 	Future Use
60 - Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Fee
Schedule
(Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03-23)
The CMS issues instructions for implementing and/or updating the DMEPOS fee schedule payment amounts
on an annual basis (January), with quarterly updates as necessary (April, July and October). In addition,
special instructions may be issued at any time if necessary for implementation of changes in the statute,
regulations, or for other reasons. The DMEPOS fee schedule is provided to DME MACs, the Pricing, Data
Analysis and Coding Contractor (PDAC), and A/B MACs (B) via CMS’ mainframe telecommunication
system.

Upon successful receipt of the updated file(s), MACs send notification of receipt via email to
price_file_receipt@cms.hhs.gov stating the name of the file received and the entities for which they were
received (e.g., MAC name and A/B MAC (A) or (HHH) number).
A separate DMEPOS Fee Schedule file is released to A/B MACs (A) and (HHH), Railroad Retirement
Board (RRB) and RRB’s Specialty MAC, Indian Health Service, and United Mine Workers. This fee
schedule is also available on the CMS site (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html) for other interested parties like the State
Medicaid agencies and managed care organizations. The fee schedule for parenteral and enteral nutrition
(PEN) is released to the PDAC and DME MACs in a separate file. All annual updates to fee schedules are
to be implemented on January 1 for claims with dates of service on or after January 1.
Effective February 28, 2022, national fee schedule amounts for new DMEPOS items and services that are
added to the DMEPOS or PEN fee schedule files are established by CMS using the process summarized
below and outlined in the regulations at 42 CFR 414.114 and 414.240. As explained in more detail in §60.3
below, MACs shall establish interim local fee schedule amounts for use in paying claims for new items and
services billed using codes for miscellaneous items and services and for use in paying claims on an interim
basis until the national fee schedule amounts are established.
Process for Establishing National Fee Schedule Amounts – Effective February 28, 2022
If a preliminary determination is made by CMS that a new item or service without a fee schedule pricing
history falls under a DMEPOS benefit category, CMS makes a preliminary payment determination for the
item or service and posts the preliminary payment determination on the website www.CMS.gov
approximately 2 weeks prior to a public meeting. After consideration of public consultation provided at the
public meeting on the preliminary benefit category and payment determinations for the item or service, CMS
posts final determinations on the website www.CMS.gov and implements the benefit category
determinations and payment determinations for items and services through program instructions. Some
determinations may be deferred to future cycles of the public consultation process if more time is needed to
develop preliminary or final benefit category and payment determinations.
Benefit category determinations are made using the public meeting process described above for an item or
service that is the subject of a request for a HCPCS code set modification. Benefit category determinations
are also made using the public meeting process in cases where a manufacturer for a new item or service is
not requesting a HCPCS code set modification for the item or service, but requests CMS to determine
whether the item or service falls under a DMEPOS benefit category. Benefit category determinations are
also made using the public meeting process when CMS identifies a need to address whether an item or
service falls under a DMEPOS benefit category.
60.1 - Record Layout for DMEPOS Fee Schedule
(Rev. 12991; Issued: 12-13-24; Effective: 01-01-25; Implementation: 01-06-25)
Sort Sequence: Category, HCPCS, 1st Modifier, 2nd Modifier State

Field Name 	Pic 	Position 	Comment
Year 	X(4) 	1 - 4 	Applicable Update Year
HCPCS Code 	X(5) 	5 - 9 	All current year active and deleted codes subject
to DMEPOS floors and ceilings
1st Modifier 	X(2) 	10 - 11
2nd Modifier 	X(2) 	12 - 13
Jurisdiction 	X 	14 	D = DME MAC Jurisdiction
L = Local A/B MAC (B) jurisdiction
J = Joint DME MAC/A/B MAC (B) jurisdiction
Category 	X(2) 	15 - 16 	IN = Inexpensive/Routinely Purchased
FS = Frequently Serviced
CR = Capped Rental
OX = Oxygen & Oxygen Equipment
OS = Ostomy, Tracheostomy & Urologicals
SD = Surgical Dressings
PO = Prosthetics & Orthotics
SU = Supplies
TE = TENS
TS = Therapeutic Shoes
SC = Splints and Casts
IL = Intraocular Lenses
LC = Lymphedema Compression Treatment
Items
LT = Labor Rate
HCPCS Action 	X 	17 	Indicates active/delete status in HCPCS file
A = Active Code
D = Deleted Code, price provided for grace
period processing only
Region 	X(2) 	18 - 19 	This amount is not used for pricing claims. It is
on file for informational purposes.
00 = For all non Prosthetic and Orthotic Services
01 - 10 = For Prosthetic and Orthotic Services
only. This field denotes the applicable regional
fee schedule.
State 	X(2) 	20 - 21
Original Base Fee 	9(5)V99 	22 - 28 	This amount is not used for pricing claims. It is
on file for informational purposes. For capped
rental services, this amount represents the base
fee after adjustments for rebasing and statewide
conversions. The base year for E0607 and
L8603 is 1995. Since pricing amounts for E1405
and E1406 are developed by summing pricing
amounts from source codes, they do not have a
true base fee. For these codes, this field will be
filled with zeros.
Beginning January 1, 2016, this field will
include the Competitive Bidding Rural Fee
Amount for specific HCPCS codes. A new
indicator field (RURAL FEE INDICATOR)
shall be populated with a value of “R” when the
Rural Fee is present in this field.

Ceiling 	9(5)V99 	29 - 35 	This amount is not used for pricing claims. It is
on file for informational purposes and could be
integrated into other processes (i.e., IR review,
validation, inquiries). NOTE: Since E0607 is
priced via national IR, it is not priced using
floors and ceilings. For E0607, this field will be
filled with zeros. Since pricing amounts for
E1405 and E1406 are developed by summing
pricing amounts from source codes, they are not
subject to ceilings and floors. Since non-mail
order (no-KL) codes A4233, A4234, A4235,
A4236, A4253, A4256, A4258, and A4259 are
priced using National Mail order single payment
amounts, they are not subject to ceilings and
floors. Splints, casts and intraocular lenses are
national fee schedule amounts not subject to
ceilings. For these codes, this field will be filled
with zeros. Beginning January 1, 2016, this field
will also be filled with zeros for codes whose
fees are adjusted using DMEPOS competitive
bid information. Labor rates and lymphedema
compression treatment items are not subject to
ceilings.
Floor 	9(5)V99 	36 - 42 	This amount is not used for pricing claims. It is
on file for informational purposes and could be
integrated into other processes (i.e., IR review,
validation, inquiries). NOTE: Since E0607 is
priced via national IR, it is not priced using
floors and ceilings. For E0607, this field will be
filled with zeros. Since pricing amounts for
E1405 and E1406 are developed by summing
pricing amounts from source codes, they are not
subject to ceilings and floors. Since non-mail
order (no-KL) codes A4233, A4234, A4235,
A4236, A4253, A4256, A4258, and A4259 are
priced using National Mail order single payment
amounts, they are not subject to ceilings and
floors. Splints, casts and intraocular lenses are
national fee schedule amounts not subject to
floors. For these codes, this field will be filled
with zeros. Beginning January 1, 2016, this field
will also be filled with zeros for codes whose
fees are adjusted using DMEPOS competitive
bid information. Labor rates and lymphedema
compression treatment items are not subject to
floors.
Updated Fee Schedule
Amount
9(5)V99 	43 - 49 	Amount used for pricing.
Filler 	X 	50 	Set to spaces
Pricing Change
Indicator
X 	51 	0 = No change to the updated fee schedule
amount since previous release.
1 = A change has occurred to the updated fee
schedule amount since the previous release.
Rural Fee Indicator 	X(01) 	R = Rural Fee is present in the Original Base Fee
field

Filler 	X(8) 	53 - 60 	Set to spaces
60.2 - Quarterly Update Schedule for DMEPOS Fee Schedule
(Rev. 2902, Issued: 03-11-14, Effective: 04-01-14, Implementation: 04-07-14)
Following is an approximate schedule for making additions (for new HCPCS codes) and corrections to base-
year amounts for the DMEPOS fee schedule.
• 	The DME MACs identify instances where base year fees are incorrect and forward requests for
revisions to their regional offices. The DME MACs also identify those instances where fee schedule
amounts are replaced by inherent reasonableness (IR) limits/payment amounts, should the authority
for making IR adjustments be restored. A/B MACs (B) and DME MACs must use the file layout in
§60.1 above to submit all revisions. Regional offices will review those requests and, upon
concurrence, forward them to the Division of Data Systems (DDS) and the Division of DMEPOS
Policy (DDP) in CMS Central Office. Those transmissions must occur within the timeframes
established by CMS.
• 	Requests for revisions must be accompanied by a narrative description.
• 	For inherent reasonableness (IR) changes, the effective date of the revised payment amount must be
provided. The format provides a field for those dates.
• 	DDS will recalculate the current year fee schedule amounts as appropriate.
• 	DDS will transmit the entire DMEPOS file to the DME MACs, PDAC, and A/B MACs using the file
layout described in §60.1 above. An indicator in the record field will identify those instances where
pricing amounts have changed. These transmissions must occur within the dates specified each year
by CMS. DDP must also receive a copy of the corrected fees.
• 	Concurrently, DDP issues instructions for implementing the revised fee schedule amounts.
• 	DME MACs and A/B MACs should give providers 30 days’ notice before revised payment amounts
are implemented. Dates for implementation are provided by CMS.
• 	DME MACs and A/B MACs should make adjustments on those claims that were processed
incorrectly if brought to their attention. Adjustments may be made retroactively to January 1 unless
otherwise specified.
• 	CMS will furnish the revised payment amounts to RRB, Indian Health Service and United Mine
Workers. DME MACs and A/B MACs (A), (B), and (HHH), shall provide the data to the State
Medicaid Agencies.

• 	Fee Schedule Disclaimer: Whenever the MACs publish the DMEPOS fee schedule in their
bulletins/notices, a disclaimer must be added. The disclaimer is, “Inclusion or exclusion of a fee
schedule amount for an item or service does not imply any health insurance coverage.”
• 	CMS will release specific timeframes for quarterly changes for DMEPOS Fees.
60.3 - Gap-filling DMEPOS Fees
(Rev. 13610; Issued: 01-30-26; Effective: 01-01-26; Implementation: 01-05-26)
Gap-filling is used in establishing fee schedule amounts for new DMEPOS items or
services that do not have a fee schedule pricing history. If a HCPCS code is new and
describes items and services that have a fee schedule pricing history (classified and paid for
previously under a different code, including codes for miscellaneous items, e.g., E1399,
and including fee schedule amounts established by CMS or the MACs), the fee schedule
amounts for the new code are established using the process included in section 60.3.1 of
this manual.
All DMEPOS items and services subject to payment on a fee schedule basis as mandated
by sections 1833(o)(2)(A), 1834(a), (h), and (i) of the Social Security and/or by regulations
at 42 CFR 414.102 and 414.210 must have national fee schedule amounts established by
CMS or interim local fee schedule amounts established by the MACs for use in paying
claims for the items and services. Effective February 28, 2022, interim local fee schedule
amounts established by the MACs for paying claims on an interim basis are considered a
fee schedule pricing history for continuity of pricing purposes under §60.3.1 below for the
time before national fee schedule amounts are established, but can be considered by CMS
in developing national fee schedule amounts. Once national fee schedule amounts are
established for an item or service, the national fee schedule amounts become the new fee
schedule pricing history for the item or service for continuity of pricing purposes under
§60.3.1 below. Local fee schedule amounts established by the MACs for use in paying
claims prior to February 28, 2022 are considered a fee schedule pricing history for
continuity of pricing purposes under §60.3.1 below.
The DME MACs or A/B MACs must establish fee schedule amounts for DMEPOS items
and services billed using HCPCS codes for miscellaneous items not otherwise classified
under the HCPCS (e.g., E1399, L2999, and L8699). Once the fee schedule amounts are
established for DMEPOS items and services billed using HCPCS codes for miscellaneous
items, these fee schedule amounts would only change when update factors are applied, to
correct an error in the calculation of the fee schedule amounts, for based on program
instructions.
For DME items, the DME MACs must apply the DME payment method depending on the
DME class the item falls under (e.g., the item would be paid on a capped rental basis if it is
expensive, not customized, not oxygen and oxygen equipment, and does not require
frequent and substantial servicing in order to avoid risk to the patient).

National fee schedule amounts established by CMS and interim local fee schedule amounts
established by the DME MACs and A/B MACs Part B shall be gap-filled for items for which
charge data were unavailable during the fee schedule data base year using the fee schedule
amounts for comparable equipment. Fee schedule amounts for new HCPCS codes for items
and services without a fee schedule pricing history are established using existing fee schedule
amounts for comparable items when items with existing fee schedule amounts are determined
to be comparable to the new items and services. A comparison can be based on, but not limited
to the following components: physical, mechanical, electrical, function and intended use, and
additional attributes and features. When examining whether an item is comparable to another
item, the analysis can be based on the items as a whole, its subcomponents, or a combination
of items. A new product does not need to be comparable within each category, and there is no
prioritization to the categories.
Examples of Attributes in Each Component Category
• 	Physical: Aesthetics, Design, Customized vs. Standard, Material, Portable, Size,
Temperature Range/Tolerance, Weight
• 	Mechanical: Automated vs. Manual, Brittleness, Ductility, Durability, Elasticity,
Fatigue, Flexibility, Hardness, Load Capacity, Flow-Control, Permeability, Strength
• 	Electrical: Capacitance, Conductivity, Dielectric Constant, Frequency, Generator,
Impedance, Piezo-electric, Power, Power Source, Resistance
• 	Function and Intended Use: Function, Intended Use
• 	Additional Attributes and Features: “Smart”, Alarms, Constraints, Device
Limitations, Disposable, Parts, Features, Invasive vs. Non-Invasive.
If unable to identify comparable item(s), other sources of pricing data can be used to calculate
the gap-filled fee schedule amount for the new item. These sources include using supplier or
commercial price lists with prices in effect during the fee schedule data base year. Data base
“year” refers to the time period mandated by the statute and/or regulations from which
Medicare allowed charge data is to be extracted in order to compute the fee schedule amounts
for the various DMEPOS payment categories. For example, the fee schedule base year for
inexpensive or routinely purchased durable medical equipment is the 12 month period ending
June 30, 1987. Supplier price lists include catalogues and other retail price lists (such as
internet retail prices) that provide information on commercial pricing for the item. Potential
appropriate sources for such commercial pricing information can also include payments made
by Medicare Advantage plans as well as verifiable information from supplier invoices and non-
Medicare payer data (e.g., fee schedule amounts comprised of the median of the commercial
pricing information adjusted as described below). DME MACs and A/B MACs shall gap-fill
based on current instructions released each year for implementing and updating the payment
amounts.

If the only available price information is from a period other than the base period, apply the
deflation factors that are included in the current year implementation instructions against
current pricing in order to approximate the base year price for gap-filling purposes.
The deflation factors for gap-filling purposes are shown below:
Year* 	OX 	CR 	PO 	SD 	PE 	SC 	IL
1987 	0.965 	0.971 	0.974 	n/a 	n/a 	n/a 	n/a
1988 	0.928 	0.934 	0.936 	n/a 	n/a 	n/a 	n/a
1989 	0.882 	0.888 	0.890 	n/a 	n/a 	n/a 	n/a
1990 	0.843 	0.848 	0.851 	n/a 	n/a 	n/a 	n/a
1991 	0.805 	0.810 	0.813 	n/a 	n/a 	n/a 	n/a
1992 	0.781 	0.786 	0.788 	n/a 	n/a 	n/a 	n/a
1993 	0.758 	0.763 	0.765 	0.971 	n/a 	n/a 	n/a
1994 	0.740 	0.745 	0.747 	0.947 	n/a 	n/a 	n/a
1995 	0.718 	0.723 	0.725 	0.919 	n/a 	n/a 	n/a
1996 	0.699 	0.703 	0.705 	0.895 	0.973 	n/a 	n/a
1997 	0.683 	0.687 	0.689 	0.875 	0.951 	n/a 	n/a
1998 	0.672 	0.676 	0.678 	0.860 	0.936 	n/a 	n/a
1999 	0.659 	0.663 	0.665 	0.844 	0.918 	n/a 	n/a
2000 	0.635 	0.639 	0.641 	0.813 	0.885 	n/a 	n/a
2001 	0.615 	0.619 	0.621 	0.788 	0.857 	n/a 	n/a
2002 	0.609 	0.613 	0.614 	0.779 	0.848 	n/a 	n/a
2003 	0.596 	0.600 	0.602 	0.763 	0.830 	n/a 	n/a
2004 	0.577 	0.581 	0.582 	0.739 	0.804 	n/a 	n/a
2005 	0.563 	0.567 	0.568 	0.721 	0.784 	n/a 	n/a
2006 	0.540 	0.543 	0.545 	0.691 	0.752 	n/a 	n/a
2007 	0.525 	0.529 	0.530 	0.673 	0.732 	n/a 	n/a
2008 	0.500 	0.504 	0.505 	0.641 	0.697 	n/a 	n/a
2009 	0.508 	0.511 	0.512 	0.650 	0.707 	n/a 	n/a
2010 	0.502 	0.506 	0.507 	0.643 	0.700 	n/a 	n/a
2011 	0.485 	0.488 	0.490 	0.621 	0.676 	n/a 	n/a
2012 	0.477 	0.480 	0.482 	0.611 	0.665 	n/a 	n/a
2013 	0.469 	0.472 	0.473 	0.600 	0.653 	n/a 	0.983
2014 	0.459 	0.462 	0.464 	0.588 	0.640 	0.980 	0.963
2015 	0.459 	0.462 	0.463 	0.588 	0.639 	0.978 	0.962
2016 	0.454 	0.457 	0.458 	0.582 	0.633 	0.969 	0.952
2017 	0.447 	0.450 	0.451 	0.572 	0.623 	0.953 	0.937
2018 	0.435 	0.437 	0.439 	0.556 	0.605 	0.927 	0.911
2019 	0.427 	0.430 	0.431 	0.547 	0.595 	0.912 	0.896
2020 	0.425 	0.427 	0.429 	0.544 	0.592 	0.906 	0.891
2021 	0.403 	0.406 	0.407 	0.516 	0.561 	0.859 	0.845
2022 	0.370 	0.372 	0.373 	0.473 	0.515 	0.788 	0.774
2023 	0.359 	0.361 	0.362 	0.460 	0.500 	0.765 	0.752
2024 	0.349 	0.351 	0.352 	0.446 	0.485 	0.743 	0.730
2025 	0.339 	0.342 	0.343 	0.435 	0.473 	0.724 	0.711

* Year price in effect
Payment Category Key:
OX Oxygen & oxygen equipment (DME) CR
Capped rental (DME)
IN Inexpensive/routinely purchased (DME) FS
Frequently serviced (DME)
SU DME supplies
PO Prosthetics & orthotics SD
Surgical dressings
OS Ostomy, tracheostomy, and urological supplies PE
Parental and enteral nutrition
TS Therapeutic Shoes SC
Splints and Casts
IL 	Intraocular Lenses inserted in a physician’s office
IN, FS, OS and SU category deflation factors=PO deflation factors
After deflation, the result must be increased by 1.7 percent and by the annual update factors
shown below.

DMEPOS Fee Schedule Update Factors for Gap-Filling Purposes (Updates applied to
1986/87 base year amounts unless otherwise noted)
Update factors mandated by sections 1834(a)(14), 1834(h)(1)(E), 1834(h)(4)(A), 1834(i)(1)(B), and
1842(s)(1)(B) of the Social Security Act
Year
Class III
DME
Other DME,
Ostomy,
Tracheostomy, and
Urological Supplies
Parenteral and
Enteral
Nutrition¹
Surgical
Dressings²
Prosthetics,
Orthotics, and
Other Prosthetic
Devices³
1989 1.7% 	1.7% 	n/a 	n/a 	1.7%
1990 0.0% 	0.0% 	n/a 	n/a 	0.0%
1991 3.7% 	3.7% 	n/a 	n/a 	0.0%
1992 3.7% 	3.7% 	n/a 	n/a 	4.7%
1993 3.1% 	3.1% 	n/a 	3.1% 	3.1%
1994 3.0% 	3.0% 	n/a 	3.0% 	0.0%
1995 2.5% 	2.5% 	n/a 	2.5% 	0.0%
1996 3.0% 	3.0% 	n/a 	3.0% 	3.0%
1997 2.8% 	2.8% 	n/a 	2.8% 	2.8%
1998 0.0% 	0.0% 	n/a 	0.0% 	1.0%
1999 0.0% 	0.0% 	n/a 	0.0% 	1.0%
2000 0.0% 	0.0% 	n/a 	0.0% 	1.0%
2001 3.7% 	3.7% 	n/a 	3.7% 	3.7%
2002 0.0% 	0.0% 	0.0% 	0.0% 	1.0%
2003 1.1% 	1.1% 	1.1% 	1.1% 	1.1%
2004 2.1% 	0.0% 	2.1% 	0.0% 	0.0%
2005 3.3% 	0.0% 	3.3% 	0.0% 	0.0%
2006 2.5% 	0.0% 	2.5% 	0.0% 	0.0%
2007 0.0% 	0.0% 	4.3% 	0.0% 	4.3%
2008 2.7% 	0.0% 	2.7% 	0.0% 	2.7%
2009 5.0% 	5.0% 	5.0% 	5.0% 	5.0%
2010 0.0% 	0.0% 	0.0% 	0.0% 	0.0%
2011 -0.1% 	-0.1% 	-0.1% 	-0.1% 	-0.1%
2012 2.4% 	2.4% 	2.4% 	2.4% 	2.4%
2013 0.8% 	0.8% 	0.8% 	0.8% 	0.8%
2014 1.0% 	1.0% 	1.0% 	1.0% 	1.0%
2015 1.5% 	1.5% 	1.5% 	1.5% 	1.5%
2016 -0.4% 	-0.4% 	-0.4% 	-0.4% 	-0.4%

2017 0.7% 	0.7% 	0.7% 	0.7% 	0.7%
2018 1.1% 	1.1% 	1.1% 	1.1% 	1.1%
2019 2.3% 	2.3% 	2.3% 	2.3% 	2.3%
2020 0.9% 	0.9% 	0.9% 	0.9% 	0.9%
2021 0.2% 	0.2% 	0.2% 	0.2% 	0.2%
2022 5.1% 	5.1% 	5.1% 	5.1% 	5.1%
2023 8.7% 	8.7% 	8.7% 	8.7% 	8.7%
2024 2.6% 	2.6% 	2.6% 	2.6% 	2.6%
2025 2.4% 	2.4% 	2.4% 	2.4% 	2.4%
2026 2.0% 	2.0% 	2.0% 	2.0% 	2.0%
¹ Base Year is 1995 ²
Base Year is 1992
³ Artificial legs, arms, and eyes (prosthetics); leg, arm, back, and neck braces (orthotics); and all other prosthetic
devices other than ostomy, tracheostomy, and urological supplies, parenteral and enteral nutrition, and
intraocular lenses inserted in a physician's office
Note that when gap-filling for capped rental items, it is necessary to first gap-fill the purchase
price and then compute the base period fee schedule at 10 percent of the base period purchase
price.
For used equipment, establish fee schedule amounts at 75 percent of the fee schedule amount
for new equipment.

Gap-filling is not used in establishing fee schedule amounts for new lymphedema compression
treatment items that do not have a fee schedule pricing history. Additional information on
payment for lymphedema compression treatment items is available at Pub. 100-04 Medicare
Claims Processing Manual, Chapter 20, Section 181.1 Payment Policy for Lymphedema
Compression Treatment Items.
If within 5 years of establishing fee schedule amounts using supplier or commercial prices, the
supplier or commercial prices decrease by less than 15 percent, CMS can make a one- time
adjustment to the fee schedule amounts using the new prices. The new supplier or commercial
prices would be used to establish the new fee schedule amounts in the same way that the older
prices were used, including application of the deflation formula of this section.

60.3.1 - Payment Concerns While Updating Codes
(Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03-23)
The following instructions apply in situations where the CMS CO does NOT provide
pricing guidance related to implementation of fee schedule for DMEPOS items and
services.
Because a HCPCS code is new does not necessarily mean that Medicare payment on a fee
schedule basis has never been made for the item and service described by the new code. In
accordance with regulations at 42 CFR 414.110 and 414.236, if a new HCPCS code is
added, CMS and/or MACs make efforts to determine whether the item and service has a
fee schedule pricing history. If there is a fee schedule pricing history, the previous fee
schedule amounts for the previous code(s) are mapped to the new code(s) to ensure
continuity of pricing.
When the code for an item is divided into several codes for the components of that item,
the total of the separate fee schedule amounts established for the components must not be
higher than the fee schedule amount for the original item. When there is a single code that
describes two or more distinct complete items (for example, two different but related or
similar items), and separate codes are subsequently established for each item, the fee
schedule amounts that applied to the single code continue to apply to each of the items
described by the new codes. When the codes for the components of a single item are
combined in a single global code, the fee schedule amounts for the new code are
established by totaling the fee schedule amounts used for the components (that is, use the
total of the fee schedule amounts for the components as the fee schedule amount for the
global code). When the codes for several different items are combined into a single code,
the fee schedule amounts for the new code are established using the average (arithmetic
mean), weighted by allowed services, of the fee schedule amounts for the formerly separate
codes.
60.4 - Process for Submitting Revisions to DMEPOS Fee Schedule to
CMS
(Rev. 12068; Issued: 06-02-23; Effective: 07-01-23; Implementation: 07-03-23)
The DME MACs identify instances where revisions to DMEPOS fees are needed and
forward requests to CMS via email to the Division of Data Systems. The information must
be contained in an ASCII file. The requests must include a narrative description.
The following file specifications are 2003 examples, the actual file names may change each
year:
Data Set Name 	DMEREV1A.TXT 	First Quarter Submission
DMEREV1B.TXT 	Second Quarter Submission

DMEREV1C.TXT 	Third Quarter Submission
DMEREV1D.TXT 	Fourth Quarter Submission
Record Format
Field Name 	PIC 	Position 	Comment
HCPCS Code 	X(5) 	1 - 5
Filler 	X(1) 	6 - 6 	Set to Spaces
First Modifier 	X(2) 	7 - 8
Filler 	X(1) 	9 	Set to Spaces
Second Modifier 	X(2) 	10 - 11
Filler 	X(2) 	12 - 13 	Set to Spaces
State 	X(3) 	14 - 16
Filler 	X(1) 	17 	Set to Spaces
Revised Base Fee 	S9(5)V99 	18 - 26 	1992 level for surgical dressings;
1995 level for PEN;
2013 level for Splints & Casts;
2012 level for certain IOLs;
1989 for all other categories
Filler 	X(1) 	27 	Set to Spaces
Capped Rental
Rebasing Indicator
X(1) 	28 	For Capped Rental Services Only:
0 - IR not applied to original base
fee and base fee in effect prior to
1991, base fee is subject to
rebasing adjustment
1 - IR applied to original base fee
or base fee not in effect prior to
1991, base fee is exempted from
rebasing adjustment
Filler 	X(1) 	29 	Set to Spaces

Field Name 	PIC 	Position 	Comment
Nature of Fee
Revision
X(1) 	30 	0 = Correction
1 = IR Revision
2 = Other - Please submit
supporting documentation.
Filler 	X(1) 	31 	Set to Spaces
IR - Effective Date 	9(8) 	32 - 39 	Field is applicable only to those
records where the fee has
changed due to an inherent
reasonableness decision and the
previous field contains a value of
“1.” Format is YYYYMMDD
The CMS will recalculate current year fee schedule amounts as appropriate and release the
entire file in the record layout described in §60.1. An indicator in the record field (Pricing
Change Indicator) will identify those instances where pricing amounts have changed. The
CMS will also issue instructions for implementing the revised fee schedule amounts with
the fee schedule.
60.5 – Rural ZIP Code Claim Record Layout for Medicare Contractors
Processing Rural DMEPOS Fee Schedule Claims
(Rev. 3350, Issued: 09-11-15, Effective: 01-01-16, Implementation: 01-04-16)
This file contains rural area, as defined in 42 CFR §414.202, ZIP codes within the
contiguous United States for use processing claims subject to the adjusted fee schedule
methodology required by Section1834(a)(1)(F) of the Social Security Act. The CMS will
provide the specific file names when the rural ZIP code files are released.
Field Name 	Pic 	Position 	Comment
Effective Date 	9(8) 	1 - 8 	Effective date that ZIP code considered rural
(CCYYMMDD).
Expiration Date 	9(8) 	9 - 16 	Final date for considering a ZIP code rural. Field
will be filled with 99999999s if an end-date has
not been established. Discontinued rural ZIP
codes will be end dated as of the end of the
quarter it was last an active rural ZIP. File
Format is CCYYMMDD.
ZIP Code 	X(5) 	17 - 21 	5-digit ZIP code considered rural
State 	X(2) 	22 - 23
Filler 	X(17) 	24 -40 	Set to spaces
70 - Parenteral and Enteral Nutrition (PEN) Fee Schedule

(Rev. 1, 10-01-03)
PM B-01-54, AB-02-152
The Balanced Budget Act of 1997 §4315 authorized the Secretary to implement a fee
schedule for parenteral and enteral nutrition (PEN) items and services. These items were
previously paid on a reasonable charge basis. The DME MACs will make payment based
on the new PEN fee schedule effective for claims with dates of service on or after January
1, 2002.
The file layout for the PEN fee schedule is consistent with that of the DMEPOS fee
schedule in §60.1 above except that “Region,” “Ceiling,” and “Floor” fields are not
applicable and will be zero filled.
The CMS issues instructions for implementing an annual PEN fee schedule along with the
DMEPOS fee schedule instructions. The PEN fee schedule is provided to DME MACs and
the Pricing, Data Analysis, and Coding Contractor (PDAC) via CMS’ mainframe
telecommunication system.
70.1 - Record Layout for PEN Fee Schedule
(Rev. 3350, Issued: 09-11-15, Effective: 01-01-16, Implementation: 01-04-16)
Field Name 	Pic 	Position 	Comment
Year 	X(4) 	1 - 4 	Applicable Update Year
HCPCS Code 	X(5) 	5 - 9 	All current year active and deleted codes
1st Modifier 	XX 	10 - 11
2nd Modifier 	XX 	12 - 13
Jurisdiction 	X 	14 	D = DME MAC Jurisdiction
Category 	XX 	15 - 16 	PE = Parenteral and Enteral Nutrition.
HCPCS Action 	X 	17 	Indicates active/delete status in HCPCS
file
A = Active Code
D = Deleted Code, price provided for
grace period processing only
Filler 	XX 	18 - 19 	Value = 00
State 	XX 	20 - 21
Original Base Fee 	9(5)V99 	22 - 28 	This amount is not used for pricing
claims. It is on file for informational
purposes.
Beginning January 1, 2016, this field
will include the Competitive Bidding
Rural Fee Amount for specific HCPCS
codes. A new indicator field (RURAL
FEE INDICATOR) shall be populated
with a value of “R” when the Rural Fee
is present in this field.
Filler 	9(5)V99 	29 - 35 	This field is zero filled.

Field Name 	Pic 	Position 	Comment
Filler 	9(5)V99 	36 - 42 	This field is zero filled.
Updated Fee Schedule
Amount
9(5)V99 	43 - 49 	Amount used for pricing.
Gap-Fill Indicator 	X 	50 	0 = No Gap-filling required.
1 = A/B MAC (B) Needs to Gap-fill
Original Base Year Amount.
Pricing Change
Indicator
X 	51 	0 = No change to the updated fee
schedule amount since previous release.
1 = A change has occurred to the
updated fee schedule amount since the
previous release.
Rural Fee Indicator 	X(01) 	52 	R = Rural Fee is present in the Original
Base Fee field
Filler 	X(8) 	53 - 60
80 - Reasonable Charges as Basis for A/B MAC (B)/DME MAC Payments
(Rev. 1, 10-01-03)
B3-5000, AB-01-118, AB-02-136, B-02-089
Effective with services furnished on or after January 1, 1992, A/B MACs (B) pay for
physicians’ services based on a fee schedule. Nonphysician services are also paid based on
a percentage of fee schedule amounts depending on the type of nonphysician and service
rendered. Other services and supplies (e.g., DMEPOS) are paid under the fee schedule
designed specifically for those services. Beginning in 1992, only the services listed below
are paid under the reasonable charge methodology.
Where payment continues to be made on a reasonable charge basis for items and services,
other than ambulance and laboratory services, A/B MACs (B) compute customary and
prevailing charge updates at the beginning of each fee screen year (the 12-month period
beginning January), using available statistics on charges for services from claims processed
or services rendered during the 12 month period ending June 30 immediately preceding the
start of the fee screen year. For example, the customary and prevailing charge rates
established for fee screen year 2003 (January 1, 2003, through December 31, 2003) are
based on the charges made from July 1, 2001, through June 30, 2002.
Instructions regarding payment for ambulance and for laboratory services still subject to
reasonable charges are found in Medicare Claims Processing Manual, Chapter 15,
“Ambulance,” and Chapter 16, “Laboratory Services from Independent Labs, Physicians,
and Providers.” Additional instructions regarding payment for dialysis supplies and
equipment are provided in the Medicare Claims Processing Manual, Chapter 8, “Outpatient
ESRD Hospital, Independent Facility, and Physician/Supplier Claims.”
See specific year Program Memorandum instructions for a list of codes that are subject to
the inflation-indexed charge (IIC) each year. A/B MACs (B) compute each year’s IIC
screen, by increasing the appropriate previous year’s screen by the percentage amount

specified in annual Program Memorandum instructions. A/B MACs (B) must not compute
IIC screens for items paid using gap-filled payment amounts in the previous year. See
specific year Program Memorandum instructions for any variances to these rules and for
each year’s specific increase percentage.
Services paid on a reasonable charge basis continue to be paid for under the rules in this
section. A/B MACs (B)/DME MACs have the primary responsibility for determining
reasonable charges. The following guidelines are intended to assure overall consistency
among A/B MACs (B)/DME MACs with respect to the concepts applied in making
reasonable charge determinations.
80.1 - Criteria for Determining Reasonable Charge
(Rev. 1, 10-01-03)
B3-5002, B-03-007
There are two criteria in §1842 of the Act that must be considered in determining the
reasonable charge for a service. They are:
• 	The customary charges for similar services generally made by the physician or
other person furnishing such services; and
• 	The prevailing charges in the locality for similar services.
Therefore, the reasonable charge for a specific service in the absence of unusual medical
complications or circumstances, may not exceed the lowest of:
• 	The customary charge for that service;
• 	The prevailing charge made for similar services in the locality; or
• 	The actual charge for the service. (See §80.8.)
The law also provides that the reasonable charge for a service not exceed the charge
applicable for a comparable service under comparable circumstances to the contractor’s
policyholders or subscribers. (See §80.7.) The A/B MAC (B) or DME MAC also
determines if the charge for the specific item or service is inherently reasonable.
The income of an individual patient may not be considered in determining the amount of
the reasonable charge.
Public Law 96-499 requires that reasonable charge payments be based on customary and
prevailing charge screens in effect on the date the service is rendered. However, if the
service was rendered at any time prior to the current fee year, payment is based on the
screens in effect during the preceding fee screen year.
To implement this provision, the A/B MAC (B) must complete the following activities:

• 	Retain the prior year’s pricing files in the system so that reasonable charge pricing
data is available for two years. As of July 1, 2003, all A/B MACs (B) operating the
MCS system must retain at least five pricing files (current period plus four prior
periods); and
• 	Price the service based on the date of service on the claim using pricing files in
effect for the same year as the date of service.
80.2 - Updating Customary and Prevailing Charges
(Rev. 1, 10-01-03)
B3-5003
A/B MACs (B)/DME MACs update customary and prevailing charge limits at the
beginning of each fee screen year (the 12-month period beginning January), using available
statistics on charges for services from claims processed or services rendered during the 12-
month period ending June 30 immediately preceding the start of the fee screen year. For
example, the limits used during fee screen year 2003 (January 1, 2003, through December
31, 2003) were based on the charges made from July 1, 2001, through June 30, 2002.
Customary and prevailing charge screens for a fee screen year are not changed except for
the following reasons:
• 	In individually identified and highly unusual situations where equity clearly
indicates that the increases are warranted and requested by the entity furnishing the
service;
• 	To correct erroneous calculations; or
• 	To establish screens for new services.
A/B MACs (B)/DME MACs must ensure that all data on the frequency of services, all data
files and customary and prevailing charge files used to establish reasonable charge screens
are retained and are available for use.
80.3 - The Customary Charge
(Rev. 1, 10-01-03)
B3-5010, B3-5205
The customary charge is the amount that best represents the actual charges made for a
given medical service or by other persons who supply other medical and health services to
the general public. Therefore, obtain information on the customary charges from the
following sources:
• 	Physicians and other persons not only from the Medicare program;
• 	Any other available sources;
• 	Other contractor programs;
• 	Other insurance programs;

• 	Federal Employee Health Benefit Program;
• 	TriCare;
• 	Any studies conducted by State or local medical societies;
• 	From public agencies;
• 	Any data volunteered from other sources.
Where circumstances warrant, MACs may also ask physicians or other persons for their
charges for services rendered to the public in general. MACs should validate any
information on charges obtained from sources against claims.
A. Charges for Rare or Unusual Procedures
A/B MACs (B) may incur situations where a new or rare procedure is performed and
information on customary and prevailing charges is difficult to obtain. In such situations,
in order to make the reasonable charge determination:
a. 	Obtain data, if possible, on the charges made for the unusual or rare procedure in
other areas similar to the locality in which the service was rendered; or
b. 	Consult with the local medical society regarding the appropriate charge to be made
for this procedure.
A relative value scale may be used together with available information about the
physician’s customary charges and about the prevailing charges for more frequently
performed services in the locality in order to fill gaps in the data available. Where there is
insufficient information, consult with any medical authority that would be helpful, such as
the medical personnel within the A/B MAC (B), the local or State medical society, or
hospital medical personnel. In assessing the value of the procedure, the medical personnel
should take into consideration:
a. 	Its complexity;
b. 	The time needed to perform the procedure; and
c. 	The prevailing charges in the locality for other procedures of comparable
complexity.
A/B MACs (B) then determine reasonable charge for a given service on the best available
medical opinion and information on customary and prevailing charges.
80.3.1 - Calculating Customary Charge
(Rev. 1, 10-01-03)
B3-5010.1, B3-5213
A/B MACs (B) and DME MACs use to the extent possible, the actual charges for services
rendered during the year ending June 30 immediately preceding the start of the fee screen

year. Use data either from claims processed or from claims for services rendered during
that 12-month period.
The A/B MAC (B) or DME MAC arrays each charge the physician, supplier, or another
entity made for a service in ascending order. The lowest actual charge which is high
enough to include the median of the arrayed charge data is then selected as the physician’s
or other person’s customary charge for the service. Include charges made to a class of
patients (such as members of a Preferred Provider Organization) in the array of charges
used to compute the customary charge.
Customary charges may be established using price lists when there is inadequate charge
data. In this case, use only the fees charged and the price lists in effect as of December 31
of the data base year. The intent is to use a price list which reasonably replicates the
median of the prices charged by the supplier for his items and services during the data base
year.
Where the MAC permitted an increase in a customary charge under the equity provision
(see §80.3.1.1 below), the increased amount is recognized as the customary charge for the
next fee screen year if it exceeds the median of charges made by the physician or other
person for the service during the 12 months ending June 30 immediately preceding the start
of that fee screen year. The increased amount is the correct customary charge for use in the
appropriate prevailing charge calculation(s).
A. Inclusion of Sales Taxes in Reasonable Charges
Sales taxes where appropriate were included in the calculation of reasonable charges
computed. They were also accounted for in the calculation of the base fee schedules for
DME and orthotic/prosthetic devices. The Consumer Price Index used to update fee
schedules also accounts for sales tax. Therefore, MACs do not make any additional
payment for sales taxes and do not make adjustments in fees to reflect local changes in tax
rates.
80.3.1.1 - Equity Adjustments in Customary Charge Screens
(Rev. 1, 10-01-03)
B3-5010.2
Once the MAC establishes the customary charge screens for a fee screen year, further
increases (other than to correct errors) are permitted only in individually identified and
highly unusual situations where equity clearly indicates that the increases are warranted.
Requests for revisions in customary charge profiles are initiated only by physicians or other
persons furnishing covered services. Such requests are neither encouraged nor
discouraged, and each request is handled on the basis of its own merits.
All of the following considerations are taken into account, as applicable, in determining
whether unusual circumstances warrant a revision in a customary profile in a particular
situation.

• 	Time elapsed since last change was made in customary charge
o 	Identify if the last change made in a customary charge for the service was in
the past two or three years. Generally, the more time that has elapsed since
the last change the stronger the case is for recognizing the current charge.
o 	Take into consideration that a physician or other entity did not increase fees
charged for a service because of the government’s request for restraint and
this can be verified. This should be taken into account in determining
whether unusual circumstances are present in a particular case.
• 	Consider the amount of the requested increase and the relationship of the new
and old charges to the customary charges of other physicians or other persons in the
locality for the service.
• 	Increases in Operating Expenses Used to Justify an Increase in Charges
o 	The entity must specifically prove that increases in operating expenses are
substantially above those resulting from general economic factors and the
situation is unique.
80.3.2 - Customary Charge Profile
(Rev. 1, 10-01-03)
B3-5010.3
A/B MACs (B)/DME MACs establish and maintain adequate data on the customary
charges for specific services and procedures made by individual physicians and other
persons and organizations which render covered services. This data must be readily
available. The customary charge record for each entity rendering covered services must
include a minimum of the following data:
• 	Entity name, address, identification code, locality and specialty status;
• 	A continuing history of the entity’s charges for specific services, supplies, etc;
• 	A customary charge for each specific service or item derived from the entity’s
history of charges for that service or item (and which is to be used as the basis for
the determination of reasonable charges in conjunction with the prevailing charge
criterion); and
• 	For a charge made under unusual circumstances, include a description of the
circumstances.
A/B MACs (B)/DME MACs develop and include in the entity’s profile a customary charge
conversion factor for use with a relative value scale when there is insufficient data to

establish the actual customary charge or when an infrequently performed service or item is
involved.
80.4 - Prevailing Charge
(Rev. 1, 10-01-03)
B3-5020
Prevailing charges are those charges that fall within the range of charges most frequently
and widely used in a locality for a particular procedure or service. The top of this range
establishes an overall limitation on the charges that the A/B MAC (B) accepts as
reasonable for a given procedure or service, except where unusual circumstances or
medical complications warrant an additional charge.
For any fee screen year, the prevailing charge limit in a locality for a service must be
calculated as the 75th percentile of the customary charges determined for that service.
Array each customary charge for the service in ascending order and weight by how often
the physician or other person rendered the service (as reflected by the charge data used to
calculate the customary charge. The lowest customary charge which is high enough to
include the customary charges of the physicians or other persons who rendered 75 percent
of the cumulative services is then determined as the prevailing charge for the service. The
proper procedure for establishing revised prevailing charge screens based on the 75th
percentile is illustrated by the following example:
Customary Charge 	Number of the item/
service rendered
Cumulative Services
$5 	1402 	1402
$6 	1115 	2517
$7 	1680 	4197
$8 	803 	5000
Total 5000
In the above example, 75 percent of the total of 5,000 services equals 3,750 services. The
prevailing charge is, therefore, $7. (A total of 2,517 services were rendered with $5 and $6
customary charges, and an additional 1,680 services were rendered with $7 customary
charges. The 3,750th service was thus rendered with a $7 customary charge.)
A/B MACs (B)/DME MACs establish four customary charges as the minimum number of
customary charges for the same service needed to calculate the prevailing charge for a
particular service in a locality or in an A/B MAC (B) service area.
If it is necessary to establish customary charges using price lists, A/B MACs (B)/DME
MACs use these customary charges to also establish the required prevailing charges. (See
§80.3.1.) If the A/B MAC (B)/DME MAC cannot derive precise data on the frequency of
services from their records, they may use any information they have about the volume of
business done by various suppliers in their area in order to weight the customary charges
used to calculate the prevailing charges.

If the A/B MAC (B)/DME MAC has not established a locality prevailing charge for the
service by specialty or group of specialties, they select the locality prevailing charge from
the remaining sources of data (items 2 through 5 below inclusive). That sequence must be
followed in strict order except as otherwise permitted by item 6. The first charge available
in the sequence of sources of data is selected as the locality prevailing charge. Payments
must be based on the fully adjusted locality prevailing charges.
Approved Sources of Data in the Required Sequence
1 	Prevailing charge by locality and by specialty or group of specialties;
2 	Prevailing charge by A/B MAC (B) service area and by specialty or group of
specialties;
3 	Prevailing charge by locality without regard to specialty;
4 	Prevailing charge by A/B MAC (B) service area without regard to specialty; and
5 	Array of actual charges - Where items 1 through 4 have not produced an acceptable
prevailing charge and where at least four physicians or other persons in your service
area (without regard to locality or specialty) have submitted charges for a service
(but four “qualified customary charges” are not available), array all the available
actual charges for that service. Set the prevailing charge for that service at the 75th
percentile of that array.
6 	Item 4 may be omitted with RO approval from the sources of data listed above, e.g.,
because this simplifies claims processes and reduces the related expenses. Also,
when there is insufficient charge data to establish valid prevailing charges for
substantial numbers of services or items, request RO assistance in working out
mergers of charge data with that from other A/B MACs (B). Use another A/B
MAC (B)’s data that has a similar service area with regards to medical prices, and
other economic and demographic characteristics. Such data mergers must receive
prior approval from CMS.
The steps described above may not always achieve a perfect result. However,
beneficiaries, physicians, and suppliers have the right to question the determination in a
given case. In such instances, A/B MACs (B) should use their best judgment based on the
available data to resolve the issue.
The CMS publishes A/B MAC (B) and DME MAC localities. These designations should
be used in making reasonable charge determinations. Where appropriate, multiple
localities may be used with respect to different types and levels of services. This may
occur where there are not enough members of a specialty group in any one locality to
establish a valid basis for deriving the prevailing charges for their services. Prior CO
approval must be obtained when deviating from the established CMS localities.

80.4.1 - Rounding of Reasonable Charge Calculation
(Rev. 1, 10-01-03)
B3-5021
A/B MAC (B) screens should include both dollars and cents. Rounding of customary and
prevailing charges should not normally take place with one exception.
Rounding is permitted in situations where the A/B MAC (B)’s customary charge
calculation is clearly erroneous and results in a peculiar or odd cent amount, e.g., $8.33. In
such an instance, rounding to the nearest l0 cents is permissible, pending the required
correction of the calculation, where the data result in a customary charge that is not in 25-
cent or 75-cent units. For other than the 25-cent or 75-cent amounts, fractional amounts
ending in 5-cent increments should be rounded up to the nearest l0 cents. However, where
the A/B MAC (B) knows the odd cents in a customary charge calculation are correct, e.g.,
because a sales tax is involved in the charges made by a physician, then no rounding of the
odd cents should take place.
The above exception applies only to customary charge calculations, and not to prevailing
charges. The exception is permissible only as an interim measure to deal with an
immediate problem. The A/B MAC (B) should promptly identify the cause of the error and
take appropriate corrective action.
There should be no need for rounding initial prevailing charge calculations since actual
customary charges are used to establish these screens.
80.5 - Filling Gaps in A/B MAC (B) Reasonable Charge Screens
(Rev. 1, 10-01-03)
B3-5022, AB-02-136, B-02-089
Where there is insufficient actual charge data for determining the customary charge and/or
the prevailing charge in the locality for a particular medical procedure or service, A/B
MACs (B)/DME MACs must use one of the following gap-filling methods to establish the
needed screen.
A. Gaps in Customary Charge Screens
A/B MACs (B)/DME MACs fill a gap in a customary charge screen:
1. 	By applying a conversion factor derived from the physician’s (or supplier’s) known
customary charges for other services in the same category of service (medicine,
surgery, etc.) to a relative value scale in the manner suggested in §§80.3, or
2. 	By using the 50th percentile in the array of customary charges (weighted by
frequency) that was used to establish the prevailing charges for similar services for
the physicians in the same specialty and locality.

A/B MACs (B)/DME MACs must ensure that, where a 50th percentile charge is used as a
customary charge for payment purposes, the reasonable charge does not exceed either that
amount or the locality prevailing charge. Also, all A/B MACs (B)/DME MACs that use
50th percentile charges to fill gaps in their customary charge data must retain the capacity
to calculate and use conversion factors with relative value scales when this is appropriate.
B. Gaps in Prevailing Charge Screens
Where the A/B MAC (B) has not been able to establish a prevailing charge for a service
based on the prevailing charge screen procedures, then A/B MACs (B) must gap-fill the
payment amounts using a prevailing charge conversion factor (§80.5.1) and a relative value
scale, manually if necessary. (See §80.3 regarding charges for rare or unusual procedures.
This is to be used as a last resort.
80.5.1 - Use of Relative Value Scale and Conversion Factors for
Reasonable Charge Gap-Filling
(Rev. 1, 10-01-03)
B3-5022.1
The relative value scales used to fill gaps in charge data for the Medicare program should,
to the extent possible, be those that contractors use in their own programs. Relative value
scales developed by contractors or by medical societies for States other than those in which
your Medicare service area is located should be carefully reviewed and validated before
they are used. Ensure that a relative value scale, which is used to estimate customary
charges or prevailing charges, accurately reflects charge patterns in the area you service.
Similarly, the conversion factor used with the relative value scale should reflect the known
customary charges of the physician or other person for whom a customary charge is being
estimated, or the known prevailing charges for services in the locality, as appropriate.
As a result of consent agreements with the Federal Trade Commission (FTC), relative
value scales formerly published by the American Academy of Orthopedic Surgeons, the
American College of Obstetricians and Gynecologists, the American College of Radiology,
and the California Medical Association have been withdrawn from circulation. The FTC
consent agreements did not bar the use of the related procedural terminology and coding
systems. However, do not use these four relative value scales to fill gaps in customary and
prevailing charge data.
This does not mean that you must discontinue using relative value scales to fill gaps in
customary charges or in determining prevailing charges. Instead use a system of relative
value units that has not been the subject of a consent agreement, or develop your own
system. A potential source of information in this regard is the relative value scale that has
been included with the CMS HCPCS. This relative value scale is included with HCPCS as
an informational item only. You may use it, revise it, or use some other relative value scale
if you deem it more appropriate.

You may, if necessary develop a relative value scale for gap-filling purposes by dividing
the unadjusted prevailing charges in a locality by a common denominator and filling the
gaps in the resulting “relative value scale” by relying on medical staff judgment or on other
persons with knowledge of the charging patterns and practices in your service area.
Alternatively, you may use a service area wide approach and/or the unweighted average of
the customary charges that have been made for a service, divided by a common
denominator.
For radiology codes (codes beginning with 7, local radiology codes, and R-codes in
HCPCS), you may use the national and local relative values used to make payment under
the radiology fee schedule.
Customary and/or prevailing charge conversion factors used with relative value scales to
fill gaps in reasonable charge screens should be calculated as outlined in A and B below.
(Develop separate customary charge conversion factors for each physician or supplier from
his known customary charges in the same category of services, e.g., medicine, surgery,
radiology, etc. Similarly, separate prevailing charge conversion factors, by locality (and by
specialty or groups of specialties as applicable), should be calculated based on the known
prevailing charges, by locality and specialty, or groups of specialties within the same
category of service. Customary charge conversion factors may only be calculated for a
physician for a category of service if the physician has at least seven customary charges for
services in that category of service upon which to base the conversion factor calculation. If
a physician does not have sufficient customary charges to calculate a conversion factor in
one category of service, this does not preclude the calculation of his customary charge
conversion factors for other categories of service for which he does have sufficient
customary charges).
A. Customary Charge
Use the following formula for the calculation of a customary charge conversion factor:
C/F = Customary charge conversion factor
CHG = The physician’s customary charge for a procedure
SVC = Number of times the physician performed the procedure
l-n = The different procedures the physician performed within a category of service
RVU = The relative value unit assigned to a procedure
SIGMA = Sum of
C/F = CHG1
RVUl x SVC l + CHG2
RVU2 x SVC 2 .CHGn
RVUn x SVC n
_________________________________________________

SIGMA SVC1-n
EXAMPLE: 	Compute a customary charge conversion factor for a physician with the
following charge history: (May be for medicine, surgery, radiology, pathology.)
Procedure 	Frequency 	Customary Charge 	Relative Value
1 	$ 3 	5.00 	1
2 	7 	12.00 	2
3 	5 	35.00 	4
4 	4 	20.00 	3
5 	6 	8.00 	1.5
25
Method
l. For each procedure, divide the customary charge by the relative value and multiply the
result by the frequency of that procedure in the physician’s charge history.
2. Add all the results of these computations.
3. Divide the result by the sum of all the frequencies.
Solution
(5x3)
1 + (12x7)
2 + (35x5)
4 + (20x4)
3 + (8x6
1.5 divided by 25=
(5 x 3) + (6 x 7) + (8.75 x 5) + (6.67 x 4) + (5.33 x 6) = 25
15 + 42 + 43.75 + 26.68 + 3l.98 = 25
159.41 = $6.40 (i.e., $6.38 rounded to the 25 nearest 10 cents)
To determine a physician’s customary charge for a particular procedure where there is no
reliable statistical basis, multiply the relative value of the procedure by the physician’s
customary charge conversion factor for the appropriate category of service (e.g., radiology,
medicine, surgery).
B. Prevailing Charges
The prevailing charge conversion factors used with the appropriate relative value scale are
developed from the same formula used for customary charge conversion factors, except
that:
CHG = The fully adjusted locality prevailing charge for a procedure by locality and
by specialty or group of specialties (regardless of the source of data from which the
locality prevailing charge was developed).
SVC = The number of times the procedure was performed by all physicians in the
same specialty or group of specialties and locality.

l-n = The different procedures within a category of service for which prevailing
charges have been established by specialty or group of specialties and locality.
The conversion factors calculated for any fee screen year reflect customary and prevailing
charges calculated on the basis of charge data for the year ending June 30 immediately
preceding the start of the fee screen year. Also, reasonable charge screens established
through the use of a relative value scale and conversion factors consist of two components.
Consequently, the conversion factors must be recalculated when there is any change in the
relative value units assigned to procedures (as may occur if you use a different or updated
relative value scale) in order to assure that the change(s) in unit values do not violate the
integrity of the reasonable charge screens. The economic index limitation, the no rollback
provision, and the Administrative Savings Clause are not applied directly to prevailing
charge conversion factors calculated in accordance with this section.
80.6 - Inflation Indexed Charge (IIC) for Nonphysician Services
(Rev. 2837, Issued: 12-13-13, Effective: 01-01-14 - payment reasonable charge
basis/04-01-14 - payment national fee schedule basis, Implementation: 01-06-14 -
payment reasonable charge basis/04-07-14 - payment national fee schedule basis)
A General
Effective for services rendered on or after October 1, 1985, an additional factor - the
inflation indexed charge (IIC), is added to the factors taken into consideration in
determining reasonable charges for non-physician services. Non-physician services are
defined as those Part B medical services, supplies, and equipment reimbursed on a
reasonable charge basis and not subject to the application of the Medicare Economic Index
(MEI).
Examples of items affected by the IIC are:
• 	Prosthetic and orthotic devices not subject to the fee schedules [Therapeutic Shoes
(2005 and prior), Intraocular Lenses (2014 and prior)];
• 	Blood products and transfusion medicine;
• 	Certain medical supplies used in connection with home dialysis (2011 and prior);
and
• 	Ambulance services (2001 and prior)
80.7 - Determination of Comparable Circumstances
(Rev. 1, 10-01-03)
B3-5026
A/B MACs (B) do not make a reasonable charge determination that would be higher than
the charge upon which they would base payment to their own policyholders for a

comparable service under comparable circumstances. The charge upon which payment is
based does not mean the amount the A/B MAC (B) would be obligated to pay. Under
certain circumstances, some A/B MACs (B) pay amounts on behalf of their policyholders,
which are below the customary and prevailing charges physicians or other persons usually
make to the general public. Payments under the medical insurance program are not limited
to these lower amounts.
“Comparable circumstances” refers to the circumstances under which services are rendered
to individuals and the nature of your health insurance programs, and the method used to
determine the amounts of payment under these programs. Generally, comparability exists
where:
• 	Payment is made under the contractor’s own program on the customary charges of
physicians or other persons, and on current prevailing charges in a locality, and
• 	The determination does not preclude recognition of factors such as specialty status
and unusual circumstances that affect the amount charged for a service.
However, even where there is comparability, coverage limitations applicable under the
contractor’s own programs do not necessarily apply to reasonable charge determinations
for Medicare purposes.
The “current” customary and/or prevailing charges of an A/B MAC (B)’s private health
plan refer to the payment screens that are presently in effect, e.g., payment levels actually
being used in the A/B MAC (B)’s private business for settling claims submitted by its
policy holders or subscribers. A/B MACs (B) must, therefore, continue to apply the
comparability limitation based upon their payment screens that are presently in effect, even
where an update under their private insurance plans has been deferred. If an A/B MAC
(B)’s private health plan allowances are later revised, it will be necessary for the A/B MAC
(B) to reexamine the relationship of these new payment levels to those under the Medicare
program an initiate the necessary changes through their routine maintenance operations.
Responsibility for determining whether an A/B MAC (B)’s program has comparability will
fall upon the A/B MAC (B) in reporting pertinent information about its programs to CMS.
When the pertinent information has been reported, CMS will advise the A/B MAC (B)
whether any of its programs have comparability.
80.8 - Applying Criteria for Reasonable Charge Determinations
(Rev. 1, 10-01-03)
B3-5030, B3-5030.2
The reasonable charge determination for a covered service should be based on the actual
charge for the service when that charge is no higher than the applicable customary and
prevailing charges. The A/B MAC (B) should exercise judgment so that its reasonable
charge determinations are realistic and equitable. A/B MACs (B) should take into account
special factors in individual cases that might affect the reasonableness of charges. The

special factors could involve travel, medical complications, or other unusual circumstances
such as prolonged time and attention required by a patient’s condition.
Different services and supplies for which charges are made under Part B, may not be
grouped together for the purpose of making one overall reasonable charge determination.
Thus, in processing a claim for payment a separate reasonable charge determination must
be made with respect to each item for which a charge is made.
80.8.1 - Waiver of Deductible and Coinsurance
(Rev. 1, 10-01-03)
B3-5220
Physicians or suppliers who routinely waive the collection of deductible or coinsurance
from a beneficiary constitute a violation of the law pertaining to false claims and
kickbacks. These situations should be referred to Program Integrity area for additional
investigation according to the procedures in the Medicare Program Integrity Manual.
Deductible and coinsurance amounts are taken into account (included) in determining the
reasonable charge for a service or item. In this regard, a billed amount that is not
reasonably related to an expectation of payment is not considered the “actual” charge for
the purpose of processing a claim or for the purpose of determining customary charges.
Where a physician/supplier makes a reasonable collection effort for the payment of
coinsurance/deductibles, failure to collect payment is not considered a reduction in the
physician’s/supplier’s charge. To be considered a reasonable collection effort, the effort to
collect Medicare coinsurance/deductible amounts must be similar to the effort made to
collect comparable amounts from non-Medicare patients. It must also involve the issuance
of a bill to the beneficiary or to the party responsible for the patient’s personal financial
obligations. In addition, it may include other actions, such as subsequent billings,
collection letters and telephone calls or personal contacts which constitute a genuine, rather
than token, collection effort.
90 - Inherent Reasonableness Used for Payment of Nonphysician Services
(Rev. 1, 10-01-03)
B3-5246, AB-98-9 (Obsolete instructions)
Placeholder for instruction when current regulation is finalized.
100 - Competitive Bidding Durable Medical Equipment Prosthetics,
Orthotics and Supplies (DMEPOS) Single Payment Amounts
(Rev. 2682, Issued: 04-05-13, Effective: 07-01-13, Implementation: 07-01-13)
Section 1847 (b)(5) of the Social Security Act mandates that a single payment amount be
established for each item in each competitive bid area based on the bids submitted and
accepted for that item. Section 1847(a)(6) of the Act requires that this payment basis be
substituted for the fee schedule payment basis otherwise applied under section 1834(a) of

the Act for DME, section 1834(h) of the Act for off-the-shelf orthotics, or section 1842(s)
of the Act for enteral nutrients, equipment and supplies, as appropriate.
For the Round One Rebid, the DME MACs will make payment based on the new
competitive bidding single payment amounts effective for claims with dates of service on
or after January 1, 2011. The CMS issues instructions for implementing the single
payment amounts and/or updating the payment amounts quarterly for competitive bidding
items. The following files will be provided to the DME MACs and the Pricing, Data
Analysis and Coding (PDAC) Contractor via CMS’ mainframe telecommunication system
in order to implement a competitive bidding round: a Healthcare Common Procedure
Coding System (HCPCS) category file, a bid pricing file, a ZIP Code file, and a contract
supplier file. All four files will contain data only for the current competitive bidding round.
The DME MACs will make manual updates to the competitive bidding files, as instructed
through Recurring Update Notifications. The following files will be provided on a
quarterly basis to the DME MACs and the Pricing, Data Analysis and Coding (PDAC)
Contractor via CMS’ mainframe telecommunication system: HCPCS category file, bid
pricing file, and ZIP Code file. These files will only contain the changes for that quarter.
Upon successful receipt of the mainframe files, DME MACs will send notification of
receipt via e-mail to price_file_receipt@cms.hhs.gov, stating the name of the files received
and the entities for which they were received (e.g., DME MAC name).
Following program implementation and on an as needed basis, updates to the contract
supplier file will be accomplished via an Excel file emailed directly from the Competitive
Bidding Implementation Contractor (CBIC) to the DME MACs. Upon successful receipt
of the files, the DME MACs will send notification of receipt via email stating the name of
the file received and the entities for which they were received (e.g., DME MAC name) to
the CBIC. E-mails should be sent to cbic.dmemac@palmettoGBA.com at the CBIC. The
DME MACs shall manually update the contract supplier file with the changes by adding
and/or end dating each supplier record.
Public use files containing the competitive bidding HCPCS categories, single payment
amounts and ZIP Codes are available on the CBIC Website at
http://www.dmecompetitivebid.com/palmetto/cbic.nsf.
100.1 - Record Layout for Competitive Bidding HCPCS Category File
(Rev. 2088, Issued: 11-05-10, Effective: 01-01-11, Implementation: 01-03-11)
Field Name 	Pic 	Position 	Comment
CBA Bid Category
Effective Date
X(8) 	1 - 8
Bid Product Category
Effective Date- CC
9(2) 	1 - 2

Field Name 	Pic 	Position 	Comment
Bid Product Category
Effective Date-Year
9(2) 	3 - 4
Bid Product Category
Effective Date -Month
9(2) 	5 - 6
Bid Product Category
Effective-Day
9(2) 	7 - 8
Bid Category
Expiration Date
X(8) 	9 - 16
Bid Product Category
Expiration Date -CC
9(2) 	9 - 10
Bid Product Category
Expiration Date -
Year
9(2) 	11 - 12
Bid Product Category
Expiration Date-
Month
9(2) 	13 - 14
Bid Product Category
Expiration Date - Day
9(2) 	15 - 16
HCPCS Procedure
Codes
X(13)_ 	17 - 29
HCPCS Procedure
Code
X(5) 	17 - 21 	All Competitive Bidding Active Codes.
Modifier 1 	X(2) 	22 - 23
Modifier 2 	X(2) 	24 - 25
Modifier 3 	X(2) 	26 - 27
Modifier 4 	X(2) 	28 - 29

Field Name 	Pic 	Position 	Comment
CBA Area 	X(5) 	30 - 34 	16740 = Charlotte NC-SC
16741 = Charlotte NC-SC Mail Order
17140 = Cincinnati OH
17141 = Cincinnati OH Mail Order
17460 = Cleveland OH
17461 = Cleveland OH Mail Order
19100 = Dallas TX
19101 = Dallas TX Mail Order
28140 = Kansas MO-KS
28141 = Kansas MO- KS Mail Order
33100 = Miami FL
33101 = Miami FL Mail Order
36740 = Orlando FL
36741 = Orlando FL Mail Order
38300 = Pittsburgh PA
38301 = Pittsburgh PA Mail Order
40140 = Riverside CA
40141 = Riverside CA Mail Order
Bid Product Category
Number
X(3) 	35 - 37 	001 = Oxygen Supplies & Equipment
002 = Standard Power Wheelchairs
003 = Complex Rehab Power
Wheelchairs
004 = Mail Order Diabetic Supplies
005 = Enteral Nutrients, Equipment
006 = CPAPs, RADs and Related
Supplies
007 = Hospital Beds & Related Supplies
009 = Walkers & Related Supplies
010 = Support Surfaces

Field Name 	Pic 	Position 	Comment
Bid Business Rule 1 	X(1) 	38 - 38 	When field contains “S”, permits non-
contract physicians to bill selected CB
items or “H”, permits Hospitals to bill
selected CB items
Bid Business Rule 2 	X(1) 	39 - 39 	When field contains “S”, permits non-
contract physicians to bill selected CB
items or “H”, permits Hospitals to bill
selected CB items.
Bid Business Rule 3 	X(1) 	40 - 40 	For future use
Bid Business Rule 4 	X(1) 	41- 41 	For future use
Bid Business Rule 5 	X(1) 	42 - 42 	For future use
Filler 	X(8) 	43 - 50
100.2 - Record Layout for Competitive Bidding Pricing File
(Rev. 2088, Issued: 11-05-10, Effective: 01-01-11, Implementation: 01-03-11)
Field Name 	Pic 	Position 	Comment
CBA Bid Round
Effective Date
X(8) 	1-8
Bid Round Effective
Date - CC
9(2) 	1 -2
Bid Round Effective
Date -Year
9(2) 	3-4
Bid Round Effective
Date - Month
9(2) 	5 - 6
Bid Round Effective
Date - Day
9(2) 	7 - 8

Field Name 	Pic 	Position 	Comment
Bid Round Expiration 	X(8) 	9-16
Bid Round Expiration
Date -CC
9(2) 	9 - 10
Bid Round Expiration
Date - Year
9(2) 	11 - 12
Bid Round Expiration
Date- Month
9(2) 	13 - 14
Bid Round Expiration
Date - Day
9(2) 	15 - 16
HCPCS Procedure
Code
X(5) 	17 - 21
Modifier 1 	X(2) 	22 - 23
Modifier 2 	X(2) 	24 - 25
Modifier 3 	X(2) 	26 - 27
Modifier 4 	X(2) 	28 - 29
DMEPOS Category 	X(2) 	30 - 31 	IN = Inexpensive/Routinely Purchased
FS = Frequently Serviced
CR = Capped Rental
OX = Oxygen & Oxygen Equipment
OS = Ostomy, Tracheostomy &
Urologicals
SD = Surgical Dressings
PO = Prosthetics & Orthotics
SU = Supplies
TE = TENS

Field Name 	Pic 	Position 	Comment
CBA Area 	X(5) 	32 - 36 	16740 = Charlotte NC-SC
16741 = Charlotte NC-SC Mail Order
17140 = Cincinnati OH
17141 = Cincinnati OH Mail Order
17460 = Cleveland OH
17461 = Cleveland OH Mail Order
19100 = Dallas TX
19101 = Dallas TX Mail Order
28140 = Kansas MO-KS
28141 = Kansas MO- KS Mail Order
33100 = Miami FL
33101 = Miami FL Mail Order
36740 = Orlando FL
36741 = Orlando FL Mail Order
38300 = Pittsburgh PA
38301 = Pittsburgh PA Mail Order
40140 = Riverside CA
40141 = Riverside CA Mail Order
Bid Price 	9(6)V99. 	37 - 44 	Competitive Bidding Single Payment
Amount for HCPCS code
Bid Price Effective
Date
X(8) 	45 - 52
Bid Price Effective
Date - CC
9(2) 	45 - 46
Bid Price Effective
Date -Year
9(2) 	47 - 48
Bid Price Effective
Date - Month
9(2) 	49 - 50
Bid Price Effective
Date - Day
9(2) 	51 - 52

Field Name 	Pic 	Position 	Comment
Bid Price Expiration
Date
X(8) 	53 - 60
Bid Price Expiration
Date -CC
9(2) 	53 - 54
Bid Price Expiration
Date - Year
9(2) 	55 - 56
Bid Price Expiration
Date- Month
9(2) 	57 - 58
Bid Price Expiration
Date - Day
9(2) 	59 - 60
Price Change
Indicator
X(1) 	61 - 61
Bid Product Category 	X(3) 	62 - 64 	001 = Oxygen Supplies & Equipment
002 = Standard Power Wheelchairs
003 = Complex Rehab Power
Wheelchairs
004 = Mail Order Diabetic Supplies
005 = Enteral Nutrients, Equipment
006 = CPAPs, RADs and Related
Supplies
007 = Hospital Beds & Related Supplies
009 = Walkers & Related Supplies
010 = Support Surfaces
Filler 	X(12) 	65 - 76
100.3 - Record Layout for Competitive Bidding ZIP Code File
(Rev. 2088, Issued: 11-05-10, Effective: 01-01-11, Implementation: 01-03-11)
Field Name 	Pic 	Position 	Comment
CBA ZIP Code
Effective Date
X(8) 	1- 8

Field Name 	Pic 	Position 	Comment
Bid ZIP Code
Effective Date- CC
9(2) 	1 - 2
Bid ZIP Code
Effective Date-Year
9(2) 	3-4
Bid ZIP Code
Effective Date -Month
9(2) 	5 - 6
Bid ZIP Code
Effective Date - Day
9(2) 	7- 8
Bid ZIP Code
Expiration Date
X(8) 	9-16
Bid ZIP Code
Expiration Date -CC
9(2) 	9 - 10
Bid ZIP Code
Expiration Date -
Year
9(2) 	11 - 12
Bid ZIP Code
Expiration Date-
Month
9(2) 	13 - 14
Bid ZIP Code
Expiration Date - Day
9(2) 	15 - 16
CBA ZIP Code 	X(5) 	17 - 21 	ZIP Code for the CBA
CBA State 	X(2) 	22 - 23

Field Name 	Pic 	Position 	Comment
CBA Area 	X(5) 	24- 28 	16740 = Charlotte NC-SC
16741 = Charlotte NC-SC Mail Order
17140 = Cincinnati OH
17141 = Cincinnati OH Mail Order
17460 = Cleveland OH
17461 = Cleveland OH Mail Order
19100 = Dallas TX
19101 = Dallas TX Mail Order
28140 = Kansas MO-KS
28141 = Kansas MO- KS Mail Order
33100 = Miami FL
33101 = Miami FL Mail Order
36740 = Orlando FL
36741 = Orlando FL Mail Order
38300 = Pittsburgh PA
38301 = Pittsburgh PA Mail Order
40140 = Riverside CA
40141 = Riverside CA Mail Order
Filler 	X(12) 	29 - 40
100.4 - Record Layout for Competitive Bidding Contract Supplier File
(Rev. 2088, Issued: 11-05-10, Effective: 01-01-11, Implementation: 01-03-11)
Field Name 	Pic 	Position 	Comment
Supplier NSC
Number
X(10) 	1 - 10
Supplier NPI Number 	X(10) 	11 - 20

Field Name 	Pic 	Position 	Comment
CBA Area 	X(5) 	21 - 25 	16740 = Charlotte NC-SC
16741 = Charlotte NC-SC Mail Order
17140 = Cincinnati OH
17141 = Cincinnati OH Mail Order
17460 = Cleveland OH
17461 = Cleveland OH Mail Order
19100 = Dallas TX
19101 = Dallas TX Mail Order
28140 = Kansas MO-KS
28141 = Kansas MO- KS Mail Order
33100 = Miami FL
33101 = Miami FL Mail Order
36740 = Orlando FL
36741 = Orlando FL Mail Order
38300 = Pittsburgh PA
38301 = Pittsburgh PA Mail Order
40140 = Riverside CA
40141 = Riverside CA Mail Order
Bid Effective Date 	X(8) 	26 - 33
Bid Effective Date-
CC
9(2) 	26 - 27
Bid Effective Date-
Year
9(2) 	28 - 29
Bid Effective Date -
Month
9(2) 	30 - 31
Bid Effective Date-
Day
9(2) 	32 - 33
Bid Expiration Date 	X(8) 	34 - 41
Bid Expiration Date -
CC
9(2) 	34 - 35

Field Name 	Pic 	Position 	Comment
Bid Expiration Date -
Year
9(2) 	36 - 37
Bid Expiration Date-
Month
9(2) 	38 - 39
Bid Expiration Date -
Day
9(2) 	40 - 41
Bid Switches Occurs
500 Times
X(500) 	42-541 	The switch occurrence equates to the
500 Times Bid category; i.e., Bid
Switch (1) denotes the supplier contract
for category 001
Bid Switch (1) 	X(1) 	42 - 42
Bid Switch (2) 	X(1) 	43 - 43
Filler 	X(59) 	542 - 600
100.5 - Adjustments to the Single Payment Amounts to Reflect Changes
in HCPCS Codes
(Rev. 1535, Issued: 06-13-08, Effective: 07-01-08, Implementation: 07-07-08)
If new HCPCS codes are established following the start of a competitive bidding contract
period that describe new technology items that did not previously fall under HCPCS codes
for competitive bidding items, they will not be added to the competitive bidding HCPCS,
CBA pricing and public use files.
If a HCPCS code descriptor for a competitive bidding item is revised to clarify the item
described by that code after the competitive bidding contract period begins, a
corresponding code descriptor change will be made in the competitive bidding HCPCS,
CBA pricing and public use files.
Should a HCPCS code be deleted from the HCPCS after the competitive bidding contract
period begins, the deleted code will be considered invalid for claims submission under the
competitive bidding program and will be removed from the competitive bidding HCPCS,
CBA pricing and public use files. Although the code is discontinued, as explained below,
the items that previously fell under the code may continue to be subject to the competitive
bidding program.
If a HCPCS code for a competitive bidding item is revised after the contract period for a
competitive bidding program begins, CMS will adjust the single payment amount(s) for the
item(s) on the CBA pricing file for that Round using one of the following methods:

a. 	If a single HCPCS code for an item is divided into two or more HCPCS codes for
the components of that item, the sum of the single payment amounts for the new
HCPCS codes will equal the single payment amount for the original item. In
accordance with instructions provided in future recurring update notifications, the
payment amounts for the HCPCS codes for the components will be established
based on the corresponding fee schedule amounts for these codes that are
established in accordance with section 60.3 of chapter 23 of the Claims Processing
Manual. These amounts for the components of the item will then be adjusted by the
same percentage to the level where the sum of the payment amounts for the HCPCS
codes for the components equals the single payment amount for the item.
b. 	If a single HCPCS code is divided into two or more separate HCPCS codes for
different but similar items, the single payment amount for each of the new separate
HCPCS codes is equal to the single payment amount applied to the original, single
HCPCS code.
c. 	If the HCPCS codes for components of an item are merged into a single HCPCS
code for the item, the single payment amount for the new HCPCS code is equal to
the total of the separate single payment amounts for the components.
d. 	If multiple HCPCS codes for different but similar items are merged into a single
HCPCS code, the items to which the new HCPCS codes apply may be furnished by
any supplier that has a valid Medicare billing number. Payment for the new code
will be based on the fee schedule methodology, even if single payment amounts
were established for the discontinued multiple HCPCS codes. The old codes will
be considered invalid and no longer included in the competitive bidding program
for the remainder of the contract term.
Contract suppliers must furnish the item(s) described by the new HCPCS code(s) in
scenarios (a) through (c) above and submit claims using the new codes. Notification of a
competitive bidding HCPCS code change will occur through program instruction.
Addendum - MPFSDB File Record Layout and Field Descriptions
(Rev. 12823, Issued:09-05- 24, Effective: 10-08-24, Implementation Date:10-08-24)
The CMS MPFSDB includes the total fee schedule amount, related component parts, and
payment policy indicators. The record layout is provided below. Beginning with the 2019
MPFSDB, and thereafter, the MPFSDB File Record Layout will no longer be revised
annually in this section for the sole purpose of changing the calendar year, but will only be
revised when there is a change to a field. Previous MPFSDB file layouts (for 2018 and
prior) can be found on the CMS web site on the Physician Fee Schedule web page at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/index.html.

MPFSDB File Layout
HEADER RECORD
FIELD # 	DATA ELEMENT NAME 	LOCATION 	PIC
1 	Header ID 	1-4 	x(4) Value “Head"
2 	Header Number 	5 	x(1)
3 	Data Set Name 	6-50 	x(45)
4 	Record Length 	51-53 	x(3)
5 	Filler 	54-54 	x(1)
6 	Block size 	55-58 	x(4)
7 	Filler 	59-59 	x(1)
8 	Number of Records
Number does not include this header
record.
60-69 	9(10)
9 	Date Created 	70-77 	x(8) YYYYMMDD
10 	Blanks 	78-345 	x(268)
DATA RECORD
FIELD # & ITEM 	LENGTH & PIC
1
File Year
This field displays the effective year of the file.
4 Pic x(4)
2
A/B MAC (B) Number
This field represents the 5-digit number assigned to the A/B MAC
(B).
5 Pic x(5)
3
Locality
This 2-digit code identifies the pricing locality used.
2 Pic x(2)
4
HCPCS Code
This field represents the procedure code. Each A/B MAC (B)
Current Procedural Terminology (CPT) code (other than codes for
Multianalyte Assays with Algorithmic Analyses (MAAA) and
Proprietary Laboratory Analyses (PLA)) and alpha-numeric HCPCS
codes other than B, C, E, K, L and U codes will be included. The
standard sort for this field is blanks, alpha, and numeric in ascending
order. Note: MAAA and PLA are alpha-numeric CPT codes.
5 Pic x(5)
5
Modifier
2 Pic x(2)

FIELD # & ITEM 	LENGTH & PIC
For diagnostic tests, a blank in this field denotes the global service
and the following modifiers identify the components:
26 = Professional component
TC = Technical component
For services other than those with a professional and/or technical
component, a blank will appear in this field with one exception: the
presence of CPT modifier -53 which indicates that separate Relative
Value Units (RVUs) and a fee schedule amount have been
established for procedures which the physician terminated before
completion. This modifier is used only with colonoscopy through
stoma code 44388, colonoscopy code 45378 and screening
colonoscopy codes G0105 and G0121. Any other codes billed with
modifier -53 are subject to medical review and priced by individual
consideration.
Modifier-53 = Discontinued Procedure - Under certain
circumstances, the physician may elect to terminate a surgical or
diagnostic procedure. Due to extenuating circumstances, or those
that threaten the well being of the patient, it may be necessary to
indicate that a surgical or diagnostic procedure was started but
discontinued.
6
Descriptor
This field will include a brief description of each procedure code.
50 Pic x(50)
7
Code Status
This 1 position field provides the status of each code under the full
fee schedule. Each status code is explained in §30.2.2.
1 Pic x(1)
8
Conversion Factor
This field displays the multiplier which transforms relative values
into payment amounts. The file will contain the conversion factor
for the File Year which will reflect all adjustments.
8 Pic 9(4)v9999
9
Update Factor
This update factor has been included in the conversion factor in
Field 8.
6 Pic 9(2)v9999
10
Work Relative Value Unit
This field displays the unit value for the physician work RVU.
9 Pic 9(7)v99

FIELD # & ITEM 	LENGTH & PIC
11
Filler
9 Pic 9(7)v99
12
Malpractice Relative Value Unit
This field displays the unit value for the malpractice expense RVU.
9 Pic 9(7)v99
13
Work Geographic Practice Cost Indices (GPCIs)
This field displays a work geographic adjustment factor used in
computing the fee schedule amount.
5 Pic 99v999
14
Practice Expense GPCI
This field displays a practice expense geographic adjustment factor
used in computing the fee schedule amount.
5 Pic 99v999
15
Malpractice GPCI
This field displays a malpractice expense geographic adjustment
factor used in computing the fee schedule amount.
5 Pic 99v999
16
Global Surgery
This field provides the postoperative time frames that apply to
payment for each surgical procedure or another indicator that
describes the applicability of the global concept to the service.
000 = Endoscopic or minor procedure with related preoperative and
postoperative relative values on the day of the procedure only
included in the fee schedule payment amount; evaluation and
management services on the day of the procedure generally not
payable.
010 = Minor procedure with preoperative relative values on the day
of the procedure and postoperative relative values during a 10-day
postoperative period included in the fee schedule amount; evaluation
and management services on the day of the procedure and during
this 10-day postoperative period generally not payable.
090 = Major surgery with a 1-day preoperative period and 90-day
postoperative period included in the fee schedule payment amount.
MMM = Maternity codes; usual global period does not apply.
XXX = Global concept does not apply.
YYY = A/B MAC (B) determines whether global concept applies
and establishes postoperative period, if appropriate, at time of
pricing.
3 Pic x(3)

FIELD # & ITEM 	LENGTH & PIC
ZZZ = Code related to another service and is always included in the
global period of the other service. (Note: Physician work is
associated with intra-service time and in some instances the post
service time.)
17
Preoperative Percentage (Modifier 56)
This field contains the percentage (shown in decimal format) for the
preoperative portion of the global package. For example, 10 percent
will be shown as 010000. The total of fields 17, 18, and 19 will
usually equal one. Any variance is slight and results from rounding.
6 Pic 9v9(5)
18
Intraoperative Percentage (Modifier 54)
This field contains the percentage (shown in decimal format) for the
intraoperative portion of the global package including postoperative
work in the hospital. For example, 63 percent will be shown as
063000. The total of fields 17, 18, and 19 will usually equal one.
Any variance is slight and results from rounding.
6 Pic 9v9(5)
19
Postoperative Percentage (Modifier 55)
This field contains the percentage (shown in decimal format) for the
postoperative portion of the global package that is provided in the
office after discharge from the hospital. For example, 17 percent
will be shown as 017000. The total of fields 17, 18, and 19 will
usually equal one. Any variance is slight and results from rounding.
6 Pic 9v9(5)
20
Professional Component (PC)/Technical Component (TC) Indicator
0 = Physician service codes: This indicator identifies codes that
describe physician services. Examples include visits, consultations,
and surgical procedures. The concept of PC/TC does not apply since
physician services cannot be split into professional and technical
components. Modifiers 26 & TC cannot be used with these codes.
The total Relative Value Units (RVUs) include values for physician
work, practice expense and malpractice expense. There are some
codes with no work RVUs.
1 = Diagnostic tests or radiology services: This indicator identifies
codes that describe diagnostic tests, e.g., pulmonary function tests,
or therapeutic radiology procedures, e.g., radiation therapy. These
codes generally have both a professional and technical component.
Modifiers 26 and TC can be used with these codes.
The total RVUs for codes reported with a 26 modifier include values
for physician work, practice expense, and malpractice expense.
1 Pic x(1)

FIELD # & ITEM 	LENGTH & PIC
The total RVUs for codes reported with a TC modifier include
values for practice expense and malpractice expense only. The total
RVUs for codes reported without a modifier equals the sum of
RVUs for both the professional and technical component.
2 = Professional component only codes: This indicator identifies
stand alone codes that describe the physician work portion of
selected diagnostic tests for which there is an associated code that
describes the technical component of the diagnostic test only and
another associated code that describes the global test.
An example of a professional component only code is 93010,
Electrocardiogram; interpretation and report. Modifiers 26 and TC
cannot be used with these codes. The total RVUs for professional
component only codes include values for physician work, practice
expense, and malpractice expense.
3 = Technical component only codes: This indicator identifies stand
alone codes that describe the technical component (i.e., staff and
equipment costs) of selected diagnostic tests for which there is an
associated code that describes the professional component of the
diagnostic tests only.
An example of a technical component code is 93005,
Electrocardiogram, tracing only, without interpretation and report. It
also identifies codes that are covered only as diagnostic tests and
therefore do not have a related professional code. Modifiers 26 and
TC cannot be used with these codes.
The total RVUs for technical component only codes include values
for practice expense and malpractice expense only.
4 = Global test only codes: This indicator identifies stand alone
codes for which there are associated codes that describe: a) the
professional component of the test only and b) the technical
component of the test only. Modifiers 26 and TC cannot be used
with these codes. The total RVUs for global procedure only codes
include values for physician work, practice expense, and malpractice
expense. The total RVUs for global procedure only codes equals the
sum of the total RVUs for the professional and technical components
only codes combined.
5 = Incident to codes: This indicator identifies codes that describe
services covered incident to a physicians service when they are
provided by auxiliary personnel employed by the physician and
working under his or her direct supervision.
Payment may not be made by A/B MACs (B) for these services
when they are provided to hospital inpatients or patients in a hospital
outpatient department. Modifiers 26 and TC cannot be used with
these codes.

FIELD # & ITEM 	LENGTH & PIC
6 = Laboratory physician interpretation codes: This indicator
identifies clinical laboratory codes for which separate payment for
interpretations by laboratory physicians may be made. Actual
performance of the tests is paid for under the lab fee schedule.
Modifier TC cannot be used with these codes. The total RVUs for
laboratory physician interpretation codes include values for
physician work, practice expense and malpractice expense.
7 = Private practice therapist’s service: Payment may not be made if
the service is provided to either a hospital outpatient or a hospital
inpatient by a physical therapist, occupational therapist, or speech-
language pathologist in private practice.
8 = Physician interpretation codes: This indicator identifies the
professional component of clinical laboratory codes for which
separate payment may be made only if the physician interprets an
abnormal smear for hospital inpatient. This applies only to code
85060. No TC billing is recognized because payment for the
underlying clinical laboratory test is made to the hospital, generally
through the PPS rate.
No payment is recognized for code 85060 furnished to hospital
outpatients or non-hospital patients. The physician interpretation is
paid through the clinical laboratory fee schedule payment for the
clinical laboratory test.
9 = Concept of a professional/technical component does not apply.
21
Multiple Procedure (Modifier 51)
Indicator indicates which payment adjustment rule for multiple
procedures applies to the service.
0 = No payment adjustment rules for multiple procedures apply. If
procedure is reported on the same day as another procedure, base
payment on the lower of: (a) the actual charge or (b) the fee schedule
amount for the procedure.
1 = Standard payment adjustment rules in effect before January 1,
1996, for multiple procedures apply. In the 1996 MPFSDB, this
indicator only applies to codes with procedure status of “D.” If a
procedure is reported on the same day as another procedure with an
indicator of 1,2, or 3, rank the procedures by fee schedule amount
and apply the appropriate reduction to this code (100 percent, 50
percent, 25 percent, 25 percent, 25 percent, and by report). Base
payment on the lower of: (a) the actual charge or (b) the fee schedule
amount reduced by the appropriate percentage.
2 = Standard payment adjustment rules for multiple procedures
apply. If procedure is reported on the same day as another
procedure with an indicator of 1, 2, or 3, rank the procedures by fee
1 Pic (x)1

FIELD # & ITEM 	LENGTH & PIC
schedule amount and apply the appropriate reduction to this code
(100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by
report). Base payment on the lower of: (a) the actual charge or (b)
the fee schedule amount reduced by the appropriate percentage.
3 = Special rules for multiple endoscopic procedures apply if
procedure is billed with another endoscopy in the same family (i.e.,
another endoscopy that has the same base procedure). The base
procedure for each code with this indicator is identified in field 31G.
Apply the multiple endoscopy rules to a family before ranking the
family with other procedures performed on the same day (for
example, if multiple endoscopies in the same family are reported on
the same day as endoscopies in another family or on the same day as
a non-endoscopic procedure).
If an endoscopic procedure is reported with only its base procedure,
do not pay separately for the base procedure. Payment for the base
procedure is included in the payment for the other endoscopy.
4 = Subject to 25% reduction of the TC diagnostic imaging
(effective for services January 1, 2006 through June 30, 2010).
Subject to 50% reduction of the TC diagnostic imaging (effective for
services July 1, 2010 and after). Subject to 25% reduction of the PC
of diagnostic imaging (effective for services January 1, 2012 through
December 31, 2016). Subject to 5% reduction of the PC of
diagnostic imaging (effective for services January 1, 2017 and after).
5 = Subject to 20% reduction of the practice expense component for
certain therapy services furnished in office and other non-
institutional settings, and 25% reduction of the practice expense
component for certain therapy services furnished in institutional
settings (effective for services January 1, 2011 and after). Subject to
50% reduction of the practice expense component for certain therapy
services furnished in both institutional and non-institutional settings
(effective for services April 1, 2013 and after).
6 = Subject to 25% reduction of the TC diagnostic cardiovascular
services (effective for services January 1, 2013 and after).
7 = Subject to 20% reduction of the TC diagnostic ophthalmology
services (effective for services January 1, 2013 and after).
9 = Concept does not apply.
22
Bilateral Surgery Indicator (Modifier 50)
This field provides an indicator for services subject to a payment
adjustment.
0 = 150 percent payment adjustment for bilateral procedures does
not apply. If procedure is reported with modifier -50 or with
1 Pic (x)1

FIELD # & ITEM 	LENGTH & PIC
modifiers RT and LT, base payment for the two sides on the lower
of: (a) the total actual charge for both sides or (b) 100 percent of the
fee schedule amount for a single code. Example: The fee schedule
amount for code XXXXX is $125. The physician reports code
XXXXX-LT with an actual charge of $100 and XXXXX-RT with an
actual charge of $100.
Payment would be based on the fee schedule amount ($125) since it
is lower than the total actual charges for the left and right sides
($200).
The bilateral adjustment is inappropriate for codes in this category
because of (a) physiology or anatomy or (b) because the code
descriptor specifically states that it is a unilateral procedure and
there is an existing code for the bilateral procedure.
1 = 150 percent payment adjustment for bilateral procedures applies.
If code is billed with the bilateral modifier or is reported twice on
the same day by any other means (e.g., with RT and LT modifiers or
with a 2 in the units field), base payment for these codes when
reported as bilateral procedures on the lower of: (a) the total actual
charge for both sides or (b) 150 percent of the fee schedule amount
for a single code.
If code is reported as a bilateral procedure and is reported with other
procedure codes on the same day, apply the bilateral adjustment
before applying any applicable multiple procedure rules.
2 = 150 percent payment adjustment for bilateral procedure does not
apply. RVUs are already based on the procedure being performed as
a bilateral procedure. If procedure is reported with modifier -50 or
is reported twice on the same day by any other means (e.g., with RT
and LT modifiers with a 2 in the units field), base payment for both
sides on the lower of (a) the total actual charges by the physician for
both sides or (b) 100 percent of the fee schedule amount for a single
code.
Example: The fee schedule amount for code YYYYY is $125. The
physician reports code YYYYY-LT with an actual charge of $100
and YYYYY-RT with an actual charge of $100. Payment would be
based on the fee schedule amount ($125) since it is lower than the
total actual charges for the left and right sides ($200).
The RVUs are based on a bilateral procedure because: (a) the code
descriptor specifically states that the procedure is bilateral; (b) the
code descriptor states that the procedure may be performed either
unilaterally or bilaterally; or (c) the procedure is usually performed
as a bilateral procedure.
3 = The usual payment adjustment for bilateral procedures does not
apply. If procedure is reported with modifier -50 or is reported for
both sides on the same day by any other means (e.g., with RT and

FIELD # & ITEM 	LENGTH & PIC
LT modifiers or with a 2 in the units field), base payment for each
side or organ or site of a paired organ on the lower of: (a) the actual
charge for each side or (b) 100% of the fee schedule amount for each
side. If procedure is reported as a bilateral procedure and with other
procedure codes on the same day, determine the fee schedule
amount for a bilateral procedure before applying any applicable
multiple procedure rules.
Services in this category are generally radiology procedures or other
diagnostic tests which are not subject to the special payment rules
for other bilateral procedures.
9 = Concept does not apply.
23
Assistant at Surgery
This field provides an indicator for services where an assistant at
surgery is never paid for per IOM.
0 = Payment restriction for assistants at surgery applies to this
procedure unless supporting documentation is submitted to establish
medical necessity.
1 = Statutory payment restriction for assistants at surgery applies to
this procedure. Assistant at surgery may not be paid.
2 = Payment restriction for assistants at surgery does not apply to
this procedure. Assistant at surgery may be paid.
9 = Concept does not apply.
1 Pic (x)1
24
Co-Surgeons (Modifier 62)
This field provides an indicator for services for which two surgeons,
each in a different specialty, may be paid.
0 = Co-surgeons not permitted for this procedure.
1 = Co-surgeons could be paid; supporting documentation required
to establish medical necessity of two surgeons for the procedure.
2 = Co-surgeons permitted; no documentation required if two
specialty requirements are met.
9 = Concept does not apply.
1 Pic (x)1
25
Team Surgeons (Modifier 66)
This field provides an indicator for services for which team surgeons
may be paid.
0 = Team surgeons not permitted for this procedure.
1 = Team surgeons could be paid; supporting documentation
required to establish medical necessity of a team; pay by report.
1 Pic (x)1

FIELD # & ITEM 	LENGTH & PIC
2 = Team surgeons permitted; pay by report.
9 = Concept does not apply.
26
Filler
1 Pic (x)1
27
Site of Service Differential
For 1999 and beyond, the site of service differential no longer
applies. The following definitions will apply for all years after
1998:
0 = Facility pricing does not apply.
1 = Facility pricing applies.
9 = Concept does not apply.
1 Pic (x)1
28
Non-Facility Fee Schedule Amount
This field shows the fee schedule amount for the non-facility setting.
This amount equals Field 34.
Note: Field 33 D indicates if an additional adjustment should be
applied to this formula.
Non-Facility Pricing Amount for the File Year
[(Work RVU * Work GPCI) +
( Non-Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor
9 Pic 9(7)v99
29
Facility Fee Schedule Amount
This field shows the fee schedule amount for the facility setting.
This amount equals Field 35.
Note: Field 33D indicates if an additional adjustment should be
applied to this formula.
Facility Pricing Amount for the File Year
[(Work RVU * Work GPCI) +
( Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor
Place of service codes to be used to identify facilities.
02 – Telehealth-Provided Other than in Patient’s Home.
19 – Off Campus-Outpatient Hospital
21 - Inpatient Hospital
22 – On Campus-Outpatient Hospital
9 Pic 9(7)v99

FIELD # & ITEM 	LENGTH & PIC
23 - Emergency Room - Hospital
24 - Ambulatory Surgical Center – In a Medicare approved ASC, for
an approved procedure on the ASC list, Medicare pays the lower
facility fee to physicians. Beginning with dates of service January 1,
2008, in a Medicare approved ASC, for procedures NOT on the
ASC list of approved procedures, contractors will also pay the lower
facility fee to physicians.
26 - Military Treatment Facility
31 - Skilled Nursing Facility
34 - Hospice
41 - Ambulance - Land
42 - Ambulance Air or Water
51 - Inpatient Psychiatric Facility
52 - Psychiatric Facility Partial Hospitalization
53 - Community Mental Health Center
56 - Psychiatric Residential Treatment Facility
61 - Comprehensive Inpatient Rehabilitation Facility
29A
Anti-markup Test Indicator
This field providers an indicator for Anti-markup Test HCPCS
codes:
‘1’ = Anti-markup Test HCPCS.
‘9’ = Concept does not apply.
1 Pic x
30
Record Effective Date
This field identifies the effective date for the MPFSDB record for
each HCPCS. The field is in YYYYMMDD format.
NOTE: This is not the date the HCPCS code was created. It is the
date the code was updated or added to the MPFSDB file for the
current file year. This field is set to January 1 for all codes during
the annual update process.
8 Pic x(8)
31
Filler
28 Pic x(28)
31EE
Reduced therapy fee schedule amount
9Pic(7)v99
31DD
Filler
1Pic x(2)

FIELD # & ITEM 	LENGTH & PIC
31CC
Imaging Cap Indicator
A value of “1” means subject to OPPS payment cap determination.
A value of “9” means not subject to OPPS payment cap
determination.
1Pic x(1)
31BB
Non-Facility Imaging Payment Amount
9Pic(7)v99
31AA
Facility Imaging Payment Amount
9Pic(7)v99
31A
Physician Supervision of Diagnostic Procedures
This field is for use in post payment review.
01 = Procedure must be performed under the general supervision of
a physician.
02 = Procedure must be performed under the direct supervision of a
physician.
03 = Procedure must be performed under the personal supervision of
a physician.
(Diagnostic imaging procedures performed by a Registered
Radiologist Assistant (RRA) who is certified and registered by The
American Registry of Radiologic Technologists (ARRT) or a
Radiology Practitioner Assistant (RPA) who is certified by the
Certification Board for Radiology Practitioner Assistants (CBRPA),
and is authorized to furnish the procedure under state law, may be
performed under direct supervision.)
04 = Physician supervision policy does not apply when procedure is
furnished by a qualified, independent psychologist or a clinical
psychologist; otherwise must be performed under the general
supervision of a physician.
05 = Not subject to supervision when furnished personally by a
qualified audiologist, physician or non physician practitioner. Direct
supervision by a physician is required for those parts of the test that
may be furnished by a qualified technician when appropriate to the
circumstances of the test.
06 = Procedure must be personally performed by a physician or a
physical therapist (PT) who is certified by the American Board of
Physical Therapy Specialties (ABPTS) as a qualified
electrophysiological clinical specialist and is permitted to provide
2 Pic x(2)

FIELD # & ITEM 	LENGTH & PIC
the procedure under State law. Procedure may also be performed by
a PT with ABPTS certification without physician supervision.
21 = Procedure may be performed by a technician with certification
under general supervision of a physician; otherwise must be
performed under direct supervision of a physician. Procedure may
also be performed by a PT with ABPTS certification without
physician supervision.
22 = May be performed by a technician with on-line real-time
contact with physician.
66 = May be personally performed by a physician or by a physical
therapist with ABPTS certification and certification in this specific
procedure.
6A = Supervision standards for level 66 apply; in addition, the PT
with ABPTS certification may personally supervise another PT, but
only the PT with ABPTS certification may bill.
77 = Procedure must be performed by a PT with ABPTS
certification (TC & PC) or by a PT without certification under direct
supervision of a physician (TC & PC), or by a technician with
certification under general supervision of a physician (TC only; PC
always physician).
7A = Supervision standards for level 77 apply; in addition, the PT
with ABPTS certification may personally supervise another PT, but
only the PT with ABPTS certification may bill.
09 = Concept does not apply.
31B
This field has been deleted to allow for the expansion of field 31A.
31C
Facility Setting Practice Expense Relative Value Units
9 Pic(7)v99
31D
Non-Facility Setting Practice Expense Relative Value Units
9 Pic(7)v99
31E
Filler
9 Pic(7)v99
31F
Filler
Reserved for future use.
1 Pic x(1)
31G
Endoscopic Base Codes
This field identifies an endoscopic base code for each code with a
multiple surgery indicator of 3.
5 Pic x(5)

FIELD # & ITEM 	LENGTH & PIC
32A
1996 Transition/Fee Schedule Amount
This field is no longer applicable since transitioning ended in 1996.
This field will contain a zero.
9 Pic 9(7)v99
32B
1996 Transition/Fee Schedule
This field is no longer applicable since transitioning ended in 1996.
This field will contain spaces.
1 Pic x(1)
32C
1996 Transition/Fee Schedule Amount When Site or Service
Differential Applies
This field is no longer applicable since transitioning ended in 1996.
This field will contain a zero.
9 Pic 9(7)v99
33A
Units Payment Rule Indicator
Reserved for future use.
9 = Concept does not apply.
1 Pic x(1)
33B
Mapping Indicator
This field is no longer applicable since transitioning ended in 1996.
This field will contain spaces.
1 Pic x(1)
33C
Anti-markup Locality—Informational Use—Locality used for
reporting utilization of anti-markup services.
NOT FOR A/B MAC (B) USE: These Medicare Advantage
encounter pricing localities are for Shared System Maintainer
purposes only. The locality values were developed to facilitate
centralized processing of encounter data by the Medicare Advantage
organizations.
2 Pic x(2)
33D
Calculation Flag
This field is informational only; the SSMs do not need to add this
field. The intent is to assist A/B MACs (B) to understand how the
fee schedule amount in fields 28 and 29 are calculated. The MMA
mandates an additional adjustment to selected HCPCS codes. A
value of “1” indicates an additional fee schedule adjustment of 1.32
in 2004 and 1.03 in 2005. A value of “0” indicates no additional
adjustment needed. A value of “2” indicates an additional fee
schedule adjustment of 1.05 effective 7/1/2008.
1 Pic x(1)

FIELD # & ITEM 	LENGTH & PIC
33 E
Diagnostic Imaging Family Indicator
For services effective January 1, 2011, and after, family indicators
01 - 11 will not be populated.
01 = Family 1 Ultrasound (Chest/Abdomen/Pelvis – Non Obstetrical
02 = Family 2 CT and CTA (Chest/Thorax/Abd/Pelvis)
03 = Family 3 CT and CTA (Head/Brain/Orbit/Maxillofacial/Neck)
04 = Family 4 MRI and MRA (Chest/Abd/Pelvis)
05 = Family 5 MRI and MRA (Head/Brain/Neck)
06 = Family 6 MRI and MRA (spine)
07 = Family 7 CT (spine)
08 = Family 8 MRI and MRA (lower extremities)
09 = Family 9 CT and CTA (lower extremities)
10 = Family 10 Mr and MRI (upper extremities and joints)
11 = Family 11 CT and CTA (upper extremities)
88 = Subject to the reduction of the TC diagnostic imaging (effective
for services January 1, 2011, and after). Subject to the reduction of
the PC diagnostic imaging (effective for services January 1, 2012
and after).
99 = Concept Does Not Apply
2Pic x(2)
33F
Performance Payment Indicator
(For future use)
1 Pic x (1)
33G
National Level Future Expansion
3 Pic x (3)
34
Non-Facility Fee Schedule Amount
This field replicates field 28.
9 Pic 9(7)v99
35
Facility Fee Schedule Amount
This field replicates field 29.
9 Pic 9(7)v99
36
Filler
1 Pic x(1)
37 	7 Pic x(7)

FIELD # & ITEM 	LENGTH & PIC
Future Local Level Expansion**
The Updated 1992 Transition Amount was previously stored in this
field. A/B MACs (B) can continue to maintain the updated
transition amount in this field.
38A
Future Local Level Expansion**
The adjusted historical payment basis (AHPB) was previously stored
in this field. A/B MACs (B) can continue to maintain the AHPB in
this field.
7 Pic x(7)
38 B
Filler
This field was originally established for 15 spaces. Since AHPB
data will only use 7 of the 15 spaces, A/B MACs (B) have 8
remaining spaces for their purposes.
** These fields will be appended by each A/B MAC (B) at the local
level.
8 Pix x(8)

Transmittals Issued for this Chapter
Rev # 	Issue Date Subject 	Impl Date 	CR#
R13701CP 06/16/2026 Update to Several Sections of the Internet-
Only Manual (IOM) Publication (Pub.)
100-04, Medicare Claims Processing
Manual, Chapter 23 - Fee Schedule
Administration and Coding Requirements
07/16/2026 	14428
R13610CP 01/30/2026 Calendar Year 2026 Update for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule
01/05/2026 	14326
R13519CP 12/19/2025 Calendar Year 2026 Update for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule-
Rescinded and replaced by Transmittal
10233
01/05/2026 	14326
R13216CP 05/09/2025 Update to Several Sections of the Internet-
Only Manual (IOM) Publication (Pub.)
100-04, Medicare Claims Processing
Manual, Chapter 23 - Fee Schedule
Administration and Coding Requirements
06/06/2025 	14048
R13150CP 04/11/2025 Internet Only Manual (IOM) Update to
100-04 Chapter 13, Section 90.3 -
Transportation Component (HCPCS
Codes R0070 - R0075) and Chapter 23,
Section 30.5 - Payment Amounts for
Portable X-Ray Transportation Services
05/12/2025 	13909
R12991CP 12/13/2024 Calendar Year 2025 Update for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule
01/06/2025 	13888
R12823CP 09/05/2024 Update to Internet-Only Manual
Publication (Pub.) 100-04, Chapters 12
and 23, to Update Place of Service (POS)
Code Descriptions to Match the POS
Descriptions Found in Pub. 100-04,
Chapter 26
10/08/2024 	13744
R12645CP 05/16/2024 Update to Pub. 100-04 Medicare Claims
Processing Manual, Chapter 23, Section
60.3 Gap-filling Durable Medical
Equipment Prosthetics Orthotics Supplies
(DMEPOS) Fees
06/17/2024 	13617

Rev # 	Issue Date Subject 	Impl Date 	CR#
R12601CP 05/02/2024 Update to Several Sections of the Internet-
only Manual (IOM) Publication (Pub.)
100-04, Medicare Claims Processing
Manual, Chapter 23 - Fee Schedule
Administration and Coding Requirements
06/04/2024 	13599
R12573CP 04/09/2024 Manual Update to Section 20.7 in Chapter
23 of Publication (Pub) 100-04
08/10/2020 	11833
R12398CP 12/07/2023 Calendar Year 2024 Update for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule
01/02/2024 	13463
R12326CP 10/26/2023 Internet-Only Manual Update, Pub. 100-
04, Chapter 23 (Fee Schedule
Administration and Coding
Requirements), Section 50.6
01/29/2024 	13410
R12068CP 06/02/2023 July Quarterly Update for 2023 Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule
07/03/2023 	13235
R11630CP 10/06/2022 Instructions to the Fiscal Intermediary
Shared System [FISS] to Add Additional
Multiple Procedure Indicators 6 and 7 Into
the Physician Fee Schedule Payment
Policy Indicator File Record Layout
04/03/2023 	12871
R11137CP 12/02/2021 Calendar Year 2022 Update for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies (DMEPOS) Fee Schedule
01/03/2022 	12521
R10878CP 07/15/2021 Update to the Internet-only Manual (IOM)
Publication (Pub.) 100-04, Medicare
Claims Processing Manual, Chapter 23 -
Fee Schedule Administration and Coding
Requirements, Section 20.9 - Fee
Schedule Administration and Coding
Requirements
08/16/2021 	12311

Rev # 	Issue Date Subject 	Impl Date 	CR#
R10504CP 12/04/2020 CY 2021 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/04/2021 	12063
R10320CP 08/28/2020 Updates to Chapter 23 - Fee Schedule
Administration and Coding Requirements
12/01/2020 	11941
R10356CP 09/18/2020 Update to the Medicare Claims Processing
Manual
10/19/2020 	11958
R10233CP 07/24/2020 Update to the (IOM) Publication 100-04,
Medicare Claims Processing Manual,
Chapter 23 - Fee Schedule Administration
and Coding Requirements, Section 20.9 -
Fee Schedule Administration and Coding
Requirements
06/16/2020 	11782
R10211CP 07/10/2020 Manual Update to Section 20.7 in Chapter
23 of Publication (Pub) 100-04 08/10/2020 	11833
R10136CP 05/15/2020 Update to the (IOM) Publication 100-04,
Medicare Claims Processing Manual,
Chapter 23 - Fee Schedule Administration
and Coding Requirements, Section 20.9 -
Fee Schedule Administration and Coding
Requirements– Rescinded and replaced by
Transmittal 10233
06/16/2020 	11782
R4465CP 	11/15/2019 Medicare Claims Processing Manual
Chapter 23 - Fee Schedule Administration
and Coding Requirements
01/30/2019 	10868
R4418CP 	10/18/2019 Medicare Physician Fee Schedule
Database (MPFSDB) Update to Status
Indicators
11/19/2019 	11453
R4298CP 	05/03/2019 Medicare Physician Fee Schedule
Database (MPFSDB) File Record Layout
10/07/2019 	11191
R4188CP 	12/28/2018 Medicare Claims Processing Manual
Chapter 23 - Fee Schedule Administration
01/30/2019 	10868

Rev # 	Issue Date Subject 	Impl Date 	CR#
and Coding Requirements- Rescinded and
replaced by Transmittal 4465
R4131CP 	09/14/2018 Updates to Chapter 23 Fee File
Instructions
12/17/2018 	10926
R4130CP 	09/14/2018 Update to the Medicare Claims Processing
Manual, Chapter 23, Section 60.3
10/15/2018 	10924
R3931CP 	12/01/2017 CY 2018 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/02/2018 	10395
R3903CP 	11/03/2017 Annual Medicare Physician Fee Schedule
(MPFS) Files Delivery and
Implementation and Medicare Physician
Fee Schedule Database (MPFSDB) 2018
File Layout Manual
01/02/2018 	10218
R3876CP 	10/06/2017 Decommission the MCS Maintained
HBCRB081 Report (“Correct Coding
Quarterly Savings Report”)
04/02/2018 	10284
R3721CP 	02/24/2017 Updates to Pub. 100-04, Chapters 12, 17
and 23 to Correct Remittance Advice
Messages
05/25/2017 	9906
R3693CP 	01/13/2017 Medicare Physician Fee Schedule
Database (MPFSDB) 2017 File Layout
Manual
01/03/2017 	9784
R3671CP 	12/05/2016 CY 2017 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/03/2016 	9854
R3613CP 	09/16/2016 Medicare Physician Fee Schedule
Database (MPFSDB) 2017 File Layout
Manual – Rescinded and replaced by
Transmittal 3693.
01/03/2017 	9784

Rev # 	Issue Date Subject 	Impl Date 	CR#
R3416CP 	11/23/2015 CY 2016 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/04/2016 	9431
R3371CP 	10/09/2015 Medicare Physician Fee Schedule
Database (MPFSDB) 2016 File Layout
Manual
01/04/2016 	9346
R3350CP 	09/11/2015 Implementation of Adjusted Durable
Medical Equipment Prosthetics, Orthotics,
and Supplies (DMEPOS) Fee Schedule
Amounts Using Information from the
National Competitive Bidding Program
(CBP)
01/04/2016 	9239
R3316CP 	08/07/2015 Implementation of Adjusted Durable
Medical Equipment Prosthetics, Orthotics,
and Supplies (DMEPOS) Fee Schedule
Amounts Using Information from the
National Competitive Bidding Program
(CBP) – Rescinded and replaced by
Transmittal 3350
01/04/2016 	9239
R3190CP 	02/06/2015 CY 2015 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/05/2015 	8999
R3144CP 	12/05/2014 Medicare Physician Fee Schedule
Database (MPFSDB) 2015 File Layout
Manual
01/05/2015 	8958
R3129CP 	11/21/2014 CY 2015 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule –
Rescinded and replaced by Transmittal
3190
01/05/2015 	8999
R3124CP 	11/13/2014 2015 Healthcare Common Procedure
Coding System (HCPCS) Annual Update
Reminder
01/05/2014 	8975

Rev # 	Issue Date Subject 	Impl Date 	CR#
R3100CP 	10/24/2014 2015 Healthcare Common Procedure
Coding System (HCPCS) Annual Update
Reminder – Rescinded and replaced by
Transmittal 3124
01/05/2014 	8975
R3093CP 	10/10/2014 Medicare Physician Fee Schedule
Database (MPFSDB) 2015 File Layout
Manual – Rescinded and replaced by
Transmittal 3144
01/05/2015 	8958
R3081CP 	09/26/2014 Update to Pub. 100-04, Chapter 23 to
Provide Language-Only Changes for
Conversion to ICD-10
Upon
Implementation
of ICD-10
8692
R3020CP 	08/08/2014 Update to Pub. 100-04, Chapter 23 to
Provide Language-Only Changes for
Conversion to ICD-10 – Rescinded and
replaced by Transmittal 3081
Upon
Implementation
of ICD-10
8692
R2902CP 	03/11/2014 April Quarterly Update for 2014 Durable
Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee
Schedule
04/07/2014 	8645
R2893CP 	02/28/2014 April Quarterly Update for 2014 Durable
Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee
Schedule
04/07/2014 	8645
R2837CP 	12/13/2013 Change to the Reasonable Charge Update
for 2014 for Splints, Casts and Certain
Intraocular Lenses
01/06/2014 	8523
R2836CP 	01/06/2013 CY 2014 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/06/2014 	8531
R2790CP 	09/20/2013 Medicare Physician Fee Schedule
Database (MPFSDB) 2014 File Layout
Manual
01/06/2014 	8455

Rev # 	Issue Date Subject 	Impl Date 	CR#
R2783CP 	09/10/2013 Corrections to the Medicare Claims
Processing Manual
09/17/2013 	8343
R2725CP 	06/14/2013 Corrections to the Medicare Claims
Processing Manual – Rescinded and
replaced by Transmittal 2783
09/17/2013 	8343
R2709CP 	05/17/2013 July Quarterly Update for 2013 Durable
Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee
Schedule
07/01/2013 	8325
R2682CP 	04/05/2013 Quarterly Update for the Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Competitive Bidding
Program (CBP) - July 2013
07012013 	8232
R2643CP 	01/31/2013 Streamlining the Process for Updating the
Abstract Files Used to Price Institutional
Claims
07/01/2013 	8128
R2632CP 	01/11/2013 CY 2013 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule
01/07/2013 	8133
R2608CP 	12/07/2012 CY 2013 Update for Durable Medical
Equipment, Prosthetics, Orthotics and
Supplies (DMEPOS) Fee Schedule –
Rescinded and replaced by Transmittal
2632
01/07/2013 	8133
R2566CP 	10/12/2012 Medicare Physician Fee Schedule
Database (MPFSDB) 2013 File Layout
Manual
01/07/2013 	8064
R2549CP 	09/21/2012 Medicare Physician Fee Schedule
Database (MPFSDB) 2013 File Layout
Manual – Rescinded and replaced by
Transmittal 2566
01/07/2013 	8064

Rev # 	Issue Date Subject 	Impl Date 	CR#
R2340CP 	11/04/2011 CY 2012 Update for Durable Medical
Equipment, Prosthetics. Orthotics and
Supplies (DMEPOS) Fee Schedule
01/03/2012 	7635
R2288CP 	08/26/2011 Establishing a Quarterly Recurring Update
Notification Process for Temporary “K”
and “Q” Codes
01/03/2012 	7493
R2287CP 	08/26/2011 Medicare Physician Fee Schedule
Database (MPFSDB) 2012 File Layout
Manual
01/03/2012 	7554
R2236CP 	06/03/2011 July Quarterly Update for 2011 Durable
Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee
Schedule
07/05/2011 	7416
R2148CP 	02/04/2011 Auto Denial of Claim Line(s) Items
Submitted With a GZ Modifier
07/05/2011 	7228
R2119CP 	12/14/2010 Medicare Physician Fee Schedule
Database (MPFSDB) 2011 File Layout
Manual
01/03/2011 	7243
R2101CP 	11/19/2010 Medicare Physician Fee Schedule
Database (MPFSDB) 2011 File Layout
Manual – Rescinded and replaced by
Transmittal 2119
01/03/2011 	7243
R2088CP 	1105/2010 	January 2011 Quarterly Update for the
DMEPOS Competitive Bidding Program
01/03/2011 	7181
R2006CP 	07/23/2010 October Quarterly Update for 2010
Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS) Fee
Schedule
10/04/2010 	7070
R1853CP 	11/13/2009 CY 2010 Fee Schedule Update for
Durable Medical Equipment, Prosthetics.
Orthotics and Supplies (DMEPOS) Fee
Schedule
01/04/2010 	6720

Rev # 	Issue Date Subject 	Impl Date 	CR#
R1825CP 	10/08/2009 Medicare Physician Fee Schedule
Database (MPFSDB) 2010 File Layout
01/04/2010 	6648
R1822CP 	10/02/2009 Medicare Physician Fee Schedule
Database (MPFSDB) 2010 File Layout –
Rescinded and replaced by Transmittal
1825
01/04/2010 	6648
R1717CP 	04/24/2009 Speech-Language Pathology Practice
Payment Policy
07/06/2009 	6381
R1709CP 	04/03/2009 Manualization of the Medicare Physician
Fee Schedule (MPFS) Record Layouts for
Contractors Processing Institutional
Claims
07/06/2009 	6443
R1644CP 	12/05/2008 2008 Jurisdiction List for Durable Medical
Equipment Prosthetics, Orthotics, and
Supply Healthcare Common Procedure
Coding System (HCPCS) Codes
10/27/2008 and
12/12/2008
6062
R1632CP 	11/07/2008 Medicare Physician Fee Schedule
Database (MPFSDB) 2009 File Layout
01/05/2009 	6227
R1630CP 	11/07/2008 Fee Schedule Update for 2009 for Durable
Medical Equipment, Prosthetics, Orthotics
and Supplies
01/05/2009 	6270
R1605CP 	09/26/2008 2008 Jurisdiction List for Durable Medical
Equipment Prosthetics, Orthotics, and
Supply Healthcare Common Procedure
Coding System (HCPCS) Codes –
Rescinded and replaced by Transmittal
1644
10/27/2008 	6062
R1535CP 	06/13/2008 July 2008 Quarterly Update for the
DMEPOS Competitive Bidding Program
07/07/2008 	6101
R1472CP 	03/06/2008 Update of Institutional Claims References 	04/07/2008 	5893

Rev # 	Issue Date Subject 	Impl Date 	CR#
R1421CP 	01/25/2008 Update of Institutional Claims References
- Rescinded and Replaced by Transmittal
1472
04/07/2008 	5893
R1358CP 	10/26/2007 Medicare Physician Fee Schedule
Database (MPFSDB) 2008 File
01/07/2008 	5774
R1005CP 	07/21/2006 Medicare Physician Fee Schedule
Database (MPFSDB) 2007 File Layout
01/02/2007 	5206
R823CP 	02/01/2006 New Temporary Code for Battery for
Power Mobility Devices
07/03/2006 	4253
R614CP 	07/22/2005 Medicare Physician Fee Schedule
Database (MPFSDB) 2006 File Layout
01/03/2006 	3889
R341CP 	10/29/2004 Implementation of the Medicare Physician
Fee Schedule (MPFS) National Abstract
File for Purchased Diagnostic Tests and
Interpretations
04/04/2005 	3481
R323CP 	10/22/2004 Update Regarding the Use of American
Dental Association's (ADA) Current
Dental Terminology (CDT) Codes on
Medicare Contractors Web Sites and
Other Electronic Media
11/22/2004 	3499
R286CP 	08/27/2004 Medicare Physician Fee Schedule
Database (MPFSDB) 2005 File Layout
01/03/2005 	3421
R283CP 	08/27/2004 2005 Healthcare Common Procedure
Coding System (HCPCS) Annual Update
Reminder
01/03/2005 	3422
R236CP 	07/23/2004 2005 DMEPOS Pricing File Record
Layout Expansion and New Pricing
Procedures for Certain DMEPOS Items
Based on Modifiers
01/03/2005 	3300

Rev # 	Issue Date Subject 	Impl Date 	CR#
R210CP 	06/18/2004 CMS Annual Reminder to Contractors of
The ICD-9-CM Update for October 1,
2004
10/04/2004 	3303
R127CP 	03/26/2004 Annual Spreadsheet Containing an
Updated List of HCPCS Codes for
Durable Medical Equipment Regional
Carrier (DMERC) and Part B Local
Carrier Jurisdictions to Reflect Codes That
Have Been Added or Discontinued
(Deleted) During Each Year
05/26/2004 	3139
R126CP 	03/26/2004 ICD-9 Coding for Beneficiary Claims 	N/A 	2857
R095CP 	02/06/2004 Eliminate The 90-Day Grace Period for
Billing Discontinued ICD-9-CM Codes
10/01/2004 	3094
R089CP 	02/06/2004 Eliminating The 90-Day Grace Period for
Billing Discontinued HCPCS Codes
07/06/2004 	3093
R066CP 	01/16/2004 Quarterly Update to Correct Coding
Initiative (CCI) Edits, Version 10 1,
Effective April 1, 2004
04/05/2004 	2997
R050CP 	12/19/2003 Clarification That Medicare Contractors
Will Be Receiving Quarterly Updates for
Temporary HCPCS Codes
04/05/2004 	2967
R043CP 	12/19/2003 Using the American Dental Association's
(ADA's) Current Dental Terminology-
Fourth Edition (CDT-4) Codes of
Contractors Web Sites and Other
Electronic Media.
01/20/2004 	3003
R037CP 	12/08/2003 Adding place of service (POS) code 42 to
Field 29 of MFSDB; and 38B, and adding
the year 2004 to field 8 Conversion Factor
01/05/2004 	2970
R001CP 	10/01/2003 Initial Publication of Manual 	NA 	NA
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