Why it exists Copy link
Section 5102(b) of the Deficit Reduction Act of 2005 capped PFS payment for the technical component of certain diagnostic imaging services, including the technical portion of a global imaging service, at the OPPS amount. The cap keeps an imaging study in a physician office from paying more than the same study in a hospital outpatient department. Without it, the office practice expense RVU for some studies would produce more than the OPPS amount.
How it is applied Copy link
CMS publishes a locality-specific capped price for each affected code and modifier, for both facility and non-facility settings. That figure is already a final dollar amount, not an RVU adjustment. Medicare pays the lower of that figure and the standard PFS amount, so the cap works as a ceiling. Contractor prices for carrier-priced codes on the list cannot exceed the cap either.
Not every code has one Copy link
Only the imaging codes CMS designates have a capped price on file. A code with no OPPS cap entry is priced entirely by the standard PFS formula.
Does the OPPS cap lower this code here? Copy link
Enter an imaging code and the service-location ZIP to compare the PFS amount with CMS’s capped price for that locality.
Try , , ,
70496 · Chicago (IL) · Q4 2026 release
The OPPS cap lowers 70496 in Chicago (IL) to $266.11, from $280.54 under the PFS formula.
| Line | PFS formula | OPPS cap | Paid on |
|---|---|---|---|
| 70496 · Office (non-facility) | $280.54 | $266.11 | $266.11 |
| 70496 · Facility | $280.54 | $266.11 | $266.11 |
| 70496-TC · Office (non-facility) | $195.99 | $181.55 | $181.55 |
| 70496-TC · Facility | $195.99 | $181.55 | $181.55 |
Locality-adjusted allowed amounts before sequestration. The capped price is CMS’s OPPSCAP figure for this locality; Medicare pays the lower of it and the PFS amount.
Frequently asked Copy link
Does the OPPS cap change a code's RVUs?
No. The RVUs and GPCIs are unchanged. The cap only limits the final amount for eligible codes when the OPPS-based price is lower.
Does the cap apply to facility rates too?
CMS publishes separate capped prices for facility and non-facility settings, and a rate lookup applies the one matching the requested setting.
Sources Copy link
- CMS Medicare Physician Fee Schedule Relative Value Files
- CMS Physician Fee Schedule overview (cms.gov)
Written from primary CMS sources—see how we source, compute, and verify everything on this site.
- Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap, based on the OPPS payment, on the technical component of certain diagnostic imaging procedures and the technical portions of global diagnostic imaging services; the lower of the fee schedule amount and the OPPS amount is paid. —CMS Medicare Physician Fee Schedule Relative Value Files
- For contractor-priced codes, the OPPSCAP file carries only the OPPS-based payment caps, and contractor prices cannot exceed them. —CMS Medicare Physician Fee Schedule Relative Value Files
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