Medicare service payment limits

CMS quarterly ASC addenda support arbitrary HCPCS-level lookup of approved ASC procedures and facility payment rates. Dated quarterly Addenda AA and BB provide the service code, payment indicator, payment rate, multiple-procedure discounting status, and pass-through-expiration context needed to identify the applicable national ASC Medicare amount or basis for that release period.

CMS quarterly OPPS Addenda A and B are effective-quarter snapshots publishing HCPCS codes, APC assignments, status indicators, OPPS payment rates, and copayment fields. They directly establish the national unadjusted Medicare hospital-outpatient amount and pricing classification for the selected code and release quarter.

CMS quarterly CLFS public-use files publish each laboratory HCPCS code and modifier with calendar year, effective date, national-or-local pricing indicator, and Medicare payment rate. The release and row fields identify the applicable laboratory-service amount or local-pricing basis at the required temporal grain.

CMS publishes quarterly-as-necessary complete DMEPOS replacement files with the Medicare fee-schedule amount, floor, and ceiling by HCPCS code, modifier, state or jurisdiction, category, and rural status. Calendar year and the named quarterly release pin the result.

CMS provides release-pinned Physician Fee Schedule relative-value, GPCI, locality, and conversion-factor files defining the Medicare pricing basis, together with a public lookup for buyer-selected CPT or HCPCS codes at national, MAC, or MAC-locality level. The artifact documents facility and nonfacility payment formulas and release-specific factors.

FH Medicare GapFill PLUS consolidates official CMS nonfacility schedules by current CPT or HCPCS code and fee-schedule geographic area. Its separately developed geographically adjusted values for codes CMS does not value are supplemental FAIR Health estimates and must remain labelled non-official; this coverage claim rests on the product’s official-CMS schedule portion.