Why isn't a procedure code listed on the Medicare Physician Fee Schedule (MPFS)?

Answer: There may be many reasons as to why the code is not listed:

• The code may be priced on a fee schedule other than the MPFS. Check the other fee schedules, if appropriate, to locate the reimbursement amount.
• The code may be designated as "contractor priced" in the MPFS, which means that the MPFS will not contain a fee schedule amount
• The Centers for Medicare & Medicaid Services (CMS) establishes reimbursement amounts for many procedures through various fee schedules and other pricing methodologies. Medicare contractors, however, have the authority to determine reimbursement for some services. These codes are designated as status C in the Medicare Physician Fee Schedule Database (MPFSDB). These services are known as contractor priced procedures. Contractors will establish relative value units (RVUs) and payment amounts for these services, generally on an individual case basis following review of documentation such as an operative report.
• If Palmetto GBA can establish reimbursement for individual contractor priced procedures, these reimbursement procedures will be listed on our website:
  • Select Topics, then select Fee Schedules
  • For contractor priced procedures, Palmetto GBA determines the reimbursement amount based on the complexity or variable nature of the procedure and payment will be determined on the documentation submitted with the claim