The purpose of this page is to provide a description of the fields contained on the MPFSDB.
Limiting charge - The maximum amount that non-participating providers may bill their Medicare patients on non-assigned claims. The limiting charge is equal to 115 percent of the non-participating allowance.
eRx limiting charge - Maximum amount that a non-participating unsuccessful e-prescriber may bill their Medicare patients on non-assigned claims. The eRx limiting charge equals the non - participating allowance times the negative payment adjustment times 115%.
Facility setting -'#' in this field indicates when facility pricing applies.
Global period - The 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 - Carrier 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.
Source indicator - No longer applies.
Conversion factor - This is a single national number that is used by all carriers in calculating payments under the Medicare fee schedule. It transforms relative value units (RVUs) into payment amounts.
Work RVU - The physician work required for the service. These units were developed by panels of physicians and researchers at Harvard University and in some cases revised by CMS. The work component of the RVU was based on the time required to furnish the service, the intensity of the effort, and the technical skills required.
Practice RVU - The practice expenses involved such as office rent, salaries of office staff, and supplies.
Malpractice RVU - The professional malpractice liability premiums.
Site of service RVU - No longer applies.
Facility RVU - The resource-based practice expense relative units for facility settings.
Non-facility RVU - The resource-based practice expense relative value units for non - facility settings.
Work GPCI - The geographic practice cost index (GCPI) that reflects the variation in work practice costs from area to area.
Practice GPCI - The geographic practice cost index that reflects the variation in practice costs from area to area.
Malpractice GPCI - The geographic practice cost index that reflects the variation in malpractice costs from area to area.
Status - Status of each code under the full fee schedule. The definition of each status code is at the end of the field descriptions.
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;
carriers 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).
Reference: Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS) Relative Value Files
C = Carriers/MACs priced code. Carriers/MACS will establish RVUs and payment amounts for these services, generally on an individual case-by-case basis following review of documentation such as an operative report.
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 these codes, when covered continues under reasonable charge procedures.
I = Invalid code. No grace period for this status.
M = Measurement codes. Used for reporting purposes only.
N = Non-covered services. These codes are carried on the Healthcare Common Procedure Coding System (HCPCS) tape as non-covered services.
P = Bundled/excluded codes. There are no RVUs and no payment amounts for these services.
No separate payment should be 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 would
be paid under the other payment provisions of the act.
Q = Therapy functional information code. Used for required reporting purposes only. (No longer used beginning 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 ambulance services and clinical diagnostic laboratory services).
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.
0 = Full Service only (physician service codes)
-26 and -TC modifiers are not valid.
1 = Diagnostic tests or radiology services
-26 and -TC modifiers are valid.
2 = Professional component only codes
-26 and -TC modifiers are not valid.
3 = Technical component only codes
-26 and TC modifiers are not valid.
4 = Global test only codes.
-26 and -TC modifiers are not valid.
5 = "Incident to" codes (payment may not be made for in-hospital, or out-patient.)
-26 and -TC modifiers are not valid.
6 = Clinical laboratory codes (laboratory physician interpretation codes)
-26 modifier is valid, -TC modifier is not valid.
7 = Physical therapy service. (Payment may not be made for an inpatient or outpatient POS by an independently practicing physical or occupational therapist).
8 = Physician interpretation codes of clinical laboratory codes. (Indicator identifies the professional component of clinical laboratory codes for which separate payment may only be made if the physician interprets an abnormal smear for a hospital inpatient. This applies to code 85060).
-TC modifier is not valid.
9 = Concept of a professional/technical component does not apply.
-26 and -TC modifiers are not valid.
This field provides levels of physician supervision required for diagnostic tests payable under the physician fee schedule.
General supervision - the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non - physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
Direct supervision in the office setting - the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
Personal supervision - a physician must be in attendance in the room during the performance of the procedure.
01 = Procedure must be performed under the general supervision of a physician.
02 = Procedure must be performed under the direct supervision of a physician, independent psychologist or a clinical psychologist.
03 = Procedure must be performed under the personal supervision of a physician.
04 = Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist. Otherwise the procedure 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 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 the procedure must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
66 = May be personally performed by a physician or by a PT 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.
22 = May be performed by a technician with on-line real-time contact with a physician.
Indicates which payment adjustment rule for multiple procedures will apply to the service.
0 = Criteria does not apply.
1 = Standard multiple surgery criteria apply.
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".
2 = Standard multiple surgery criteria apply (January 1, 1996, and after).
3 = Endoscopic criteria applies.
4 = Subject to 25% reduction of the TC diagnostic imaging (effective for services on or after 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 professional component (26 modifier) diagnostic imaging (effective for services January 1, 2012 and after).
5 = Subject to 20% reduction of the practice expense component for certain therapy services (effective for services January 1, 2011 and after).
6 = Subject to 25% reduction of the TC of Cardiovascular services effective 1/1/13.
7 = Subject to 20% reduction of the TC of Ophthalmology services effective 1/1/13.
9 = Concept does not apply.
Indicator for services subject to a payment adjustment.
0 = Bilateral does not apply.
1 = Valid for bilateral - criteria does apply.
2 = Money is already established for bilateral.
3 = Radiological procedures or diagnostic tests. Bilateral criterion does not apply.
9 = Concept does not apply.
Indicator for services where an assistant at surgery is never paid for per the CMS Internet-only manual.
0 = Payment restriction - must have supporting documentation.
1 = Assistant at surgery cannot be paid.
2 = Assistant at surgery can be paid.
9 = Concept does not apply.
Indicator for services for which two surgeons, each in a different specialty, may be paid
Skills of two surgeons (must be of different specialties).
0 = Co surgery not payable.
1 = Can be paid with medical necessity established by documentation.
2 = Co-surgeons permitted; no documentation required if two specialty requirements met.
9 = Concept does not apply.
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 is required to establish medical necessity of a team; paid by report.
2 = Team surgeons permitted; pay by report.
9 = Team surgeon concept does not apply.
Looking for a specific fee? Please visit our Fee Schedule page (JH)(JL).
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