Palmetto GBA adjudicates claims based on the Medicare fee schedules and guidelines set forth by the Centers for Medicare & Medicaid Services (CMS).
The durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedules contain fee schedule amounts, floors and ceilings for each procedure code subject to the DMEPOS fee schedule payment methodology.
Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees.
Medicare Part B pays for physician services based on the Medicare Physician Fee Schedule (MPFS), which include office visits, surgical procedures, anesthesia services, and a range of other diagnostic and therapeutic services.
You can verify the Medicare Physician Fee Schedule allowed amount for your state and locality using the Medicare Physician Fee Schedule Tool, which allows you to display or download fees, indicators, and indicator descriptions.
- CMS Physician Fee Schedule (PFS) Lookup
- How to Use the Searchable Medicare Physician Fee Schedule (MPFS) MLN Booklet
- CMS PFS Information
- CMS PFS Carrier Specific Files
- CMS PFS Relative Value Files
- Anesthesia Base Units and Conversion Factors