Contractor pricing (status C) Copy link
Status C codes are priced by the MAC that processes the claim, generally case by case after reviewing documentation such as an operative report. The relative value file leaves their RVUs blank, so there is nothing to put through the PFS formula. Because each MAC prices its own claims, the amount depends on which contractor’s jurisdiction the service was performed in.
MAC-published fee schedules Copy link
Some MACs publish fee schedules for contractor-priced codes. Where Localis has a MAC-published fee schedule on file for a code, its code page shows the contractor’s amount next to the status, labelled with the contractor and the file it came from. Where none is on file, the page says so rather than estimating one.
Other reasons there is no national amount Copy link
Contractor pricing is one of several outcomes. Each status letter points somewhere different:
| Status | Where the amount comes from |
|---|---|
| C | The MAC prices the claim |
| R (zero RVUs) | Special coverage instructions apply; if covered, the MAC prices it |
| J | The anesthesia formula: base units plus time units, times the locality’s anesthesia conversion factor |
| X | Another fee schedule, such as the Clinical Laboratory Fee Schedule for lab tests |
| E | Excluded from the PFS by regulation; paid under other rules when covered |
| B or P | Bundled into payment for another service |
| I | Medicare uses a different code for the service |
| M | A measurement code, used only for reporting |
| N | Not covered by Medicare |
Zero RVUs are not a zero allowance Copy link
Blank or zero RVUs mean the amount cannot be calculated from the PFS, not that Medicare allows $0. A lookup that turns a blank into $0.00 gives a wrong answer for contractor-priced, anesthesia and lab codes alike. Our code pages name the outcome instead; see status indicators for every letter, anesthesia payment for status J, and the lab fee schedule for lab tests.
Frequently asked Copy link
What does contractor-priced mean in Medicare?
The Medicare Administrative Contractor that processes the claim sets the amount, generally case by case from the documentation. CMS publishes no national Physician Fee Schedule amount for the code.
Is a code with no national Medicare rate not covered?
Not necessarily. Only status N means Medicare does not cover the service. Contractor-priced, anesthesia and lab codes are paid; the amount just comes from somewhere other than the national PFS formula.
Why does a Medicare fee schedule show $0 for a code?
Usually because the code has blank RVUs and a tool turned the blank into zero. Check the status indicator: it says whether the amount is contractor-priced, set by another fee schedule, bundled or not covered.
Sources Copy link
- CMS Medicare Physician Fee Schedule Relative Value Files (status indicator field)
- CMS Medicare Physician Fee Schedule Relative Value Files
- CMS Medicare Claims Processing Manual (Pub. 100-04)
Written from primary CMS sources—see how we source, compute, and verify everything on this site.
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