Sequestration
Sequestration is an across-the-board cut to Medicare payments, usually about 2%, taken after the fee schedule amount is calculated. It comes off the payment rat...
Facility vs non-facility
Medicare pays a different amount for the same code depending on where the service is performed. The non-facility rate applies in settings like a physician’s off...
Medicare fee schedule
A fee schedule is the complete list of amounts a payer will pay for covered services—one allowed amount per billing code. Medicare's version, the Physician Fee...
PFS payment formula
Medicare’s Physician Fee Schedule turns a code into a payment with one formula: multiply each RVU component by its geographic index, add them, and multiply by t...
Percent of Medicare
Most commercial payer contracts price physician services as a percentage of the Medicare Physician Fee Schedule amount rather than negotiating a dollar figure c...
2026 conversion factor
Starting with CY2026, the Physician Fee Schedule no longer has a single national conversion factor. CMS publishes two: a higher rate for clinicians who qualify...
HCPCS vs CPT
CPT and HCPCS are not competing code sets. CPT is Level I of HCPCS. When people contrast "HCPCS vs CPT" they usually mean the alphanumeric Level II codes (like...
Checking a medical bill
Every practice sets its own charges, so there is no master price list to compare a bill against. What you can do is run three checks that catch most billing pro...
2027 conversion factor
For CY2027, CMS has proposed two Physician Fee Schedule conversion factors: $33.17 for qualifying APM participants (QPs) and $32.84 for everyone else. Both are...
Medicare underpayment check
To check a Medicare payment, work out the allowed amount you expected for the exact claim line, then compare it with the allowed amount on the remittance before...
Historical Medicare rate
The Medicare amount for a service is the one in the fee schedule release in effect on its date of service, not the one current when the claim is filed or review...
Practice fee schedule
A practice’s charge for a code is its own number, separate from any payer’s allowed amount. Many practices set charges as a multiple of their local Medicare amo...
Medicare fee schedule spreadsheet
You can calculate Medicare Physician Fee Schedule amounts in a spreadsheet from CMS’s relative value file, its GPCI file and one formula. The formula is the eas...
No national PFS rate
A code shows no national Physician Fee Schedule amount when its status indicator says the amount is set somewhere else: by the local Medicare Administrative Con...
Clinical Laboratory Fee Schedule
Medicare pays most clinical diagnostic lab tests from the Clinical Laboratory Fee Schedule (CLFS), not the Physician Fee Schedule. Since 2018 each CLFS rate is...
Facility fee
When a service is performed in a hospital outpatient department or an ambulatory surgical center, Medicare makes two payments: one to the physician under the Ph...
Medicaid vs Medicare rates
Each state Medicaid program sets its own fee schedule, and for physician services most pay well below Medicare. The useful comparison is code by code: a state’s...
For plain-language definitions of individual terms, browse the glossary—or see a rate computed end-to-end in the expected-payment calculator.