Medicare Physician Fee Schedules (MPFS)

Medicare Part B pays for physician services based on the Medicare Physician Fee Schedule (MPFS), which lists the more than 7,400 unique covered services and their payment rates. Physicians' services include the following:

  • Office visits;
  • Surgical procedures;
  • Anesthesia services; and
  • A range of other diagnostic and therapeutic services.

Mandatory Payment Reductions in the Medicare Fee-for-Service Program - Sequestration

View the educational CMS MPFS Fact Sheet This link will take you to an external website. which includes information on physician services, MPFS payment rates and MPFS payment rates formula.

2015

The CY 2015 MPFSDB fees posted are valid from July 1, 2015 through December 31, 2015.

State/Territory Excel PDF
Hawaii/Pacific Islands Excel PDF
Nevada Excel PDF
Northern California - Area 03 (Marin, Napa and Solano Counties) Excel PDF
Northern California – Area 05 (San Francisco County) Excel PDF
Northern California – Area 06 (San Mateo County) Excel PDF
Northern California – Area 07 (Alameda and Contra Costa Counties) Excel PDF
Northern California – Area 09 (Santa Clara County) Excel PDF
Northern California – Area 99 (All Other Counties) Excel PDF
Southern California – Area 17 (Ventura County) Excel PDF
Southern California – Area 18 (Los Angeles County) Excel PDF
Southern California – Area 26 (Orange County) Excel PDF
Southern California – Area 99 (Imperial, San Diego, Santa Barbara and San Luis Obispo Counties) Excel PDF

 

2015 Jurisdiction E MPFS updates are listed below.

For Dates of Service on/after 1/1/15 and processed on/after 7/1/15

State CMS MPFS Locality Notes Procedure Code Modifier Par Fee NonPar Fee Limiting Charge eRx Limiting Charge EHR Limiting Charge PQRS Limiting Charge EHR + PQRS Limiting Charge
CA 03   88366   289.62 275.14 316.41 n/a 313.25 311.66 308.55
CA 03   88366 TC 219.04 208.09 239.30 n/a 236.91 235.71 233.35
CA 03   93355   248.79 236.35 271.80 n/a 269.08 267.72 265.05
CA 05   88366   309.70 294.22 338.35 n/a 334.97 333.27 329.94
CA 05   88366 TC 236.39 224.57 258.26 n/a 255.68 254.39 251.84
CA 05   93355   256.97 244.12 280.74 n/a 277.93 276.53 273.76
CA 06   88366   306.66 291.33 335.03 n/a 331.68 330.00 326.70
CA 06   88366 TC 233.65 221.97 255.27 n/a 252.72 251.44 248.93
CA 06   93355   255.67 242.89 279.32 n/a 276.53 275.13 272.38
CA 07   88366   284.79 270.55 311.13 n/a 308.02 306.46 303.40
CA 07   88366 TC 214.61 203.88 234.46 n/a 232.12 230.94 228.63
CA 07   93355   247.33 234.96 270.20 n/a 267.50 266.15 263.49
CA 09   88366   302.35 287.23 330.31 n/a 327.01 325.36 322.10
CA 09   88366 TC 229.40 217.93 250.62 n/a 248.11 246.86 244.39
CA 09   93355   255.87 243.08 279.54 n/a 276.74 275.35 272.59
CA 17   88366   268.61 255.18 293.46 n/a 290.53 289.06 286.17
CA 17   88366 TC 201.13 191.07 219.73 n/a 217.53 216.43 214.27
CA 17   93355   242.33 230.21 264.74 n/a 262.09 260.77 258.16
CA 18   88366   265.83 252.54 290.42 n/a 287.52 286.06 283.20
CA 18   88366 TC 197.92 188.02 216.22 n/a 214.06 212.98 210.85
CA 18   93355   245.03 232.78 267.70 n/a 265.02 263.68 261.05
CA 26   88366   275.66 261.88 301.16 n/a 298.15 296.64 293.68
CA 26   88366 TC 207.28 196.92 226.46 n/a 224.20 223.06 220.83
CA 26   93355   245.88 233.59 268.63 n/a 265.94 264.60 261.95
CA 99   88366   250.07 237.57 273.21 n/a 270.48 269.11 266.42
CA 99   88366 TC 184.55 175.32 201.62 n/a 199.60 198.60 196.61
CA 99   93355   234.79 223.05 256.51 n/a 253.94 252.66 250.14
HI 01   88366   263.86 250.67 288.27 n/a 285.39 283.95 281.11
HI 01   88366 TC 197.98 188.08 216.29 n/a 214.13 213.05 210.92
HI 01   93355   234.43 222.71 256.12 n/a 253.56 252.28 249.76
NV 00   88366   243.30 231.14 265.81 n/a 263.15 261.82 259.20
NV 00   88366 TC 179.22 170.26 195.80 n/a 193.84 192.86 190.93
NV 00   93355   233.17 221.51 254.74 n/a 252.19 250.92 248.41

 

The CY 2015 MPFSDB fees posted are valid from January 1, 2015 through June 30, 2015. These fees were updated by the "Protecting Access to Medicare Act of 2014," which the President signed on April 1, 2014.

State/Territory Excel PDF
Hawaii/Pacific Islands Excel PDF
Nevada Excel PDF
Northern California - Area 03 (Marin, Napa and Solano Counties) Excel¿¿ PDF
Northern California – Area 05 (San Francisco County) Excel PDF
Northern California – Area 06 (San Mateo County) Excel PDF
Northern California – Area 07 (Alameda and Contra Costa Counties) Excel PDF
Northern California – Area 09 (Santa Clara County) Excel PDF
Northern California – Area 99 (All Other Counties) Excel PDF
Southern California – Area 17 (Ventura County) Excel PDF
Southern California – Area 18 (Los Angeles County) Excel PDF
Southern California – Area 26 (Orange County) Excel PDF
Southern California – Area 99 (Imperial, San Diego, Santa Barbara and San Luis Obispo Counties) Excel PDF

 

2014

In order to reflect appropriate payment policy as included in the CY 2014 MPFS Final Rule, the MPFSDB has been updated with April changes, and those necessitated by "Protecting Access to Medicare Act of 2014," which the President signed on April 1, 2014. This law extends the 0.5% update through December 31, 2014. Since the Act extends the MPFSDB policies to all of CY 2014, the April update payment files that were previously created to be effective from January 1, 2014 to March 31, 2014, can now be used by MACs to be effective from January 1, 2014 to December 31, 2014.

State/Territory Excel PDF
Hawaii/Pacific Islands Excel PDF
Nevada Excel PDF
Northern California - Area 03 (Marin, Napa and Solano Counties) Excel PDF
Northern California – Area 05 (San Francisco County) Excel PDF
Northern California – Area 06 (San Mateo County) Excel PDF
Northern California – Area 07 (Alameda and Contra Costa Counties) Excel PDF
Northern California – Area 09 (Santa Clara County) Excel PDF
Northern California – Area 99 (All Other Counties) Excel PDF
Southern California – Area 17 (Ventura County) Excel PDF
Southern California – Area 18 (Los Angeles County) Excel PDF
Southern California – Area 26 (Orange County) Excel PDF
Southern California – Area 99 (Imperial, San Diego, Santa Barbara and San Luis Obispo Counties) Excel PDF

 

Updates and Announcements

2013

The revised Medicare Phyisician Fee Schedules, in xls format, are available and effective for services performed on or after January 1, 2013.

State/Territory Excel
Hawaii/Pacific Islands Excel
Nevada Excel
Northern California - Area 03 (Marin, Napa and Solano Counties) Excel
Northern California – Area 05 (San Francisco County) Excel
Northern California – Area 06 (San Mateo County) Excel
Northern California – Area 07 (Alameda and Contra Costa Counties) Excel
Northern California – Area 09 (Santa Clara County) Excel
Northern California – Area 99 (All Other Counties) Excel
Southern California – Area 17 (Ventura County) Excel
Southern California – Area 18 (Los Angeles County) Excel
Southern California – Area 26 (Orange County) Excel
Southern California – Area 99 (Imperial, San Diego, Santa Barbara and San Luis Obispo Counties) Excel

 

If you have elected to be a participant during 2013, the limiting charges indicated on the report will not pertain to your practice. The non-participating fee schedule amounts and limiting charges do not apply to services or supplies unless they are paid under the physician fee schedule. Limiting charge applies to unassigned claims by non-participating providers. All services provided to Medicare beneficiaries are subject to audit and documentation requirements.

Clinical Social Workers

Reimbursements for all clinical social worker (CSW - specialty 80) services reimbursement amounts remain, as set by law, at 75 % of the clinical psychologist reimbursement level.

Facility Setting Payment Differential

As part of the resource-based practice expense initiative, CMS has replaced the previous policy that systematically reduced the practice expense relative value units (RVUs) by 50%for certain procedures performed in facilities with a policy that would generally identify two different levels (facility and non-facility) of practice expense RVUs for each procedure code depending on the location of the service.

Some services, by the nature of their codes, are performed only in certain settings and will have only one level of practice expense RVU per code. Many of these are evaluation and management codes with code descriptions specific as to the location of the service. Other services, such as most major surgical services with a 90-day global period, are performed entirely or almost entirely in the hospital, and those services generally are provided with a practice expense RVU only for the out-of-office or facility setting.

The higher non-facility practice expense RVUs are generally used to calculate payments for services performed in a physician's office and for services furnished to a patient in the patient's home; facility; or institution other than a hospital, skilled nursing facility (SNF), or ambulatory surgical center (ASC). For these services, the physician typically bears the cost of resources, such as labor, medical supplies and medical equipment associated with the physician's service.

The lower facility practice expense RVUs generally are used to calculate payments for physicians' services furnished to hospital, SNF and ASC patients. The cost for non-physicians' services and other items, including medical equipment and supplies, are typically borne by the hospital, SNF or ASC.

The facility-based fees are linked to their own separate RVUs independent of the non-facility fee RVUs. This differs from the former site-of-service fee reductions, which were based simply on a percentage reduction of the full fee rather than a separate RVU.

2013 Non-physician Practitioner Fee Schedule

Sections 4511 and 4512 of the Balanced Budget Act of 1997 (BBA) provide that payment for the professional services of these non-physician practitioners will be linked to the physician fee schedule.

Payment may be made for services furnished by nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNs) in all settings permitted by state law, but only if no facility or other provider charges are paid in connection with the service. Payment would be equal to 80 percent of the lesser of the actual charge or 85 percent of the physician fee schedule. Payment for a PA's services may only be made to the PA's employer. Under certain circumstances, a PA as an independent contractor qualifies as an employment relationship where payment is made to the employer.

Practitioners Subject to Mandatory Assignment

Some practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed charge amount as payment in full for their practitioner services. The beneficiary's liability is limited to any applicable deductible plus the 20 percent coinsurance. The following practitioners must accept assignment for all Medicare covered services they furnish, and carriers do not send a participation enrollment package to these practitioners. The non-participating fee schedule amounts and limiting charges do not apply to services rendered by:

  • Specialty 32 - Anesthesiologist assistants (AAs)
  • Specialty 42 - Certified nurse midwives
  • Specialty 43 - Certified registered nurse anesthetists (CRNAs)
  • Specialty 50 - NPs
  • Specialty 68 - Clinical psychologists
  • Specialty 71 - Registered dietitians/nutritionists
  • Specialty 73 - Mass immunization roster billers
  • Specialty 80 - Clinical social workers
  • Specialty 89 - CNs
  • Specialty 97 - Physician assistants

Note: The provider type 'mass immunization biller' (specialty 73) can bill only for influenza and pneumococcal vaccinations and administrations. These services are not subject to the deductible or the 20 percent coinsurance.

Last Updated Jul 21, 2015