How we source, compute, and verify everything on this site

Amount = (work RVU × work GPCI + practice-expense RVU × PE GPCI + malpractice RVU × MP GPCI) × conversion factor, with the practice-expense RVU matched to the requested setting: facility or office (non-facility).

Whether a code pays is decided by its status indicator, never by its dollar value: A, R, and T pay; B, I, N, P, M, X, and E are not separately payable; C is carrier-priced with no national amount.

A blank RVU (carrier-priced and similar rows) returns payable = false with a reason. No surface ever converts a blank into $0.

When the request sets the qpp flag, the qualifying-participant conversion factor for that release prices the line instead of the standard one.

Status-J codes price as (base units + time units) × the locality's anesthesia conversion factor. Base units come from the ingested CMS file; time comes from the request.

Limit: Without a locality and time_minutes on the request, only the anesthesia conversion factor is surfaced—a full amount is never estimated from missing inputs.

ZIPs resolve through the CMS ZIP-to-carrier/locality crosswalk in force for the requested period. A ZIP that spans localities or is missing from the crosswalk is reported as such, not guessed.

When CMS publishes an OPPS cap for the code, modifier, and locality, the computed amount is capped at CMS's precomputed price for the requested setting, before sequestration.

The sequestration reduction is an explicit request flag applied after the formula and any cap—never baked into a rate. The payment calculator applies it to the Medicare 80% share, the way it lands on a remittance.

For codes whose PC/TC indicator is 1, the -26 and -TC amounts come from CMS's own modifier-specific RVU rows—looked up, not computed as a percentage.

Limit: Component-only indicator values (2, 3, 6) are simplified: those codes price from their base rows, and the split validation only opens the -26/-TC combination for indicator 1.

Indicator 1 pays 150% of the base amount; indicator 2 pays 100% because the RVUs already assume a bilateral procedure; indicator 3 pays both sides in full.

Limit: Indicator 0 currently reports no bilateral payment, where CMS still pays the single-side amount—a documented simplification.

Paid at the configured assistant percentages (physician and non-physician) when the assistant-surgery indicator permits payment. Indicator 0 prices at the same percentage and carries the documentation condition in the result, since CMS gates it on documented medical necessity rather than barring it. Indicator 1's statutory bar is honored with a reason and no amount.

Each co-surgeon prices at the configured co-surgery percentage when the indicator permits it; the documentation-required case carries that condition in the result.

CMS prices team surgery by individual report, so no fixed amount exists. Permitted lines return no amount with that reason—a refusal to guess, applied deliberately.

Payment modifiers that carry no fixed fee-schedule percentage (reduced, discontinued, or unusual services, among others) are not priced. The line keeps its base amount and the response says the modifier was not applied.

Indicator-2 lines on a claim are ranked by fee-schedule amount: 100% for the first, 50% for the second through fifth. CMS suspends the sixth and later for by-report review, so those lines carry no invented amount—only the documented floor.

Indicator 1 selects a different, older reduction schedule than the standard one. It appears on zero rows in every release we have ingested, so those lines bill at full amount with a reason rather than under the wrong schedule.

Endoscopy families sharing a base code (the ENDO BASE field) collapse into one service—the highest-paid member pays in full, each subsequent member pays its own amount minus the base code's amount—and the combined family total then joins the standard indicator-2 ranking. The base code's own fee-schedule amount is resolved even when it wasn't separately billed.

Limit: Requires the claim's indicator-3 lines to carry a resolvable ENDO BASE code; a line whose base amount can't be resolved bills at full amount with a reason instead of guessing.

The technical (TC) and professional (PC) components rank and reduce independently, each in its own pool, per the date-of-service percentage in MpprPolicy: TC 50% off since 2010-07-01 (25% off before), PC 5% off since 2017-01-01 (25% off 2012-2016). Reduces the pre-OPPS-cap amount, then re-applies the cap—so a top-ranked line whose cap binds is still capped correctly.

Limit: Whether CMS imposes any procedure-count cap on this reduction (the way indicator 2 suspends the sixth-and-later to by-report) is not confirmed to our shippable-confidence bar—the reduction is applied unbounded. A line missing both TC and PC dollar amounts bills at full amount with a reason.

Only the practice-expense (PE) dollar amount is ranked and reduced—work and malpractice are always paid in full. Ranking runs per unit as well as per procedure (a 2-unit line contributes 2 ranking slots), at 50% off since 2013-04-01 (ATRA §633); the pre-2013-04-01 window additionally requires a claim_type (professional/institutional) to select the correct 20%/25% split.

Limit: Same unconfirmed by-report-cap caveat as indicators 4/6/7. A line missing a PE dollar amount, or dated in the pre-2013-04-01 window without a claim_type, bills at full amount with a reason.

The technical component ranks and reduces on its own (25% off since 2013-01-01); the professional component, if billed, is always paid in full—CMS never reduces it for this indicator.

Limit: Same unconfirmed by-report-cap caveat as indicators 4/5/7. A line missing a TC dollar amount bills at full amount with a reason.

The technical component ranks and reduces on its own (20% off since 2013-01-01—CMS proposed 25%, finalized 20% after public comment); the professional component, if billed, is always paid in full.

Limit: Same unconfirmed by-report-cap caveat as indicators 4/5/6. A line missing a TC dollar amount bills at full amount with a reason.

Indicator 5 (therapy) ranks per unit as well as per procedure—a multi-unit line contributes one ranking slot per unit, all sharing that line's per-unit practice-expense amount.

Limit: Every other indicator (2/3/4/6/7) still ranks by procedure only; a line's units feed the medically-unlikely-edit check but do not multiply into those rankings.

PTP pairs are checked against the NCCI release covering the date of service, honoring each edit's effective window and modifier indicator, including the bypass modifiers on the correct line. A bundled line keeps its computed amount—the flag explains why a payer would deny it.

Limit: When no NCCI release covers the period, the check is reported as absent with a warning—never as "no edits".

Line units are checked against the MUE limit for the code, honoring the adjudication indicator that decides whether units aggregate per line or per day.

Each code's global-period indicator is ingested and shown on its code page.

Limit: Claim checks do not yet enforce it: no warning when a service falls inside another procedure's global period, and post-operative-period modifiers are not adjudicated. Enforcing this across claims needs visit history a single-claim check does not have.