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PFS Payment Amount File

This file contains locality-specific physician fee schedule payment amounts for services covered by the Medicare Physician Fee Schedule (MPFS) with one record for each unique combination of carrier, locality, procedure code and modifier.

mac Carrier Number Medicare Administrative Contractor ID
locality Locality Pricing Locality ID
hcpcs HCPCS Code HCPCS Code
mod Modifier Diagnostic Tests, NA denotes Global Service, Mods 26 & TC identify Components. Mod 53 indicates Separate RVUs & PFS Amount for Procedures Terminated Before Completion.
status Status Code Indicates if in Fee Schedule, if Covered, if Separately Payable. Only A, R and T used for Medicare payment.
mult_surg Multiple Surgery Indicator Indicates Applicable Payment Adjustment Rule: Mod 51
flat_vis Flat Rate Visit Fee Contains Flat Visit Fee for Primary Care First Model
nther Non-Facility Therapy Reduction Fee reflects 50% PE payment for Non-facility services
fther Facility Therapy Reduction Fee reflects 50% PE payment for Facility services
fee_nf Non-Facility Fee Schedule Amount Non-Facility Pricing Amount
fee_f Facility Fee Schedule Amount Facility Pricing Amount
opps OPPS Indicator OPPS Payment Cap Determination: 1 = Applies, 9 = Does Not Apply
opps_nf OPPS Non-Facility OPPS Capped Non-Facility Pricing Amount
opps_f OPPS Facility OPPS Capped Facility Pricing Amount

PFS Relative Value File

This file contains information on services covered by the Medicare Physician Fee Schedule (MPFS) in 2024. For more than 10,000 physician services, the file contains the associated relative value units (RVUs), a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.).

The Medicare physician fee schedule amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure’s relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.

hcpcs HCPCS Code HCPCS Code
description Description HCPCS Procedure Description
mod Modifier Diagnostic Tests, NA denotes Global Service, Mods 26 & TC identify Components. Mod 53 indicates Separate RVUs & PFS Amount for Procedures Terminated Before Completion.
status Status Code Indicates if in Fee Schedule, if Covered, if Separately Payable. Only A, R and T used for Medicare payment.
wrvu Work RVU RVUs for Physician Work
nprvu Non-Facility Practice Expense RVU RVUs for Non-Facility Practice Expense
fprvu Facility Practice Expense RVU RVUs for Facility Practice Expense
mrvu Malpractice RVU RVUs for Malpractice Expense
cf Conversion Factor Multiplier that Transforms RVUs into Payment Amounts
nprvu_opps Non-Facility PE Used for OPPS Payment Amount Non-Facility Practice Expense RVUs for OPPS Payment
fprvu_opps Facility PE Used for OPPS Payment Amount Facility Practice Expense RVUs for OPPS Payment
global Global Days Number of Global Days
op_ind Operative Percentage Indicator 1 = Has percentages, 0 = Does not have percentages
op_pre Preoperative Percentage Preoperative % of Global Package
op_intra Intraoperative Percentage Intraoperative % of Global Package, including Postoperative Work in Hospital
op_post Postoperative Percentage Postoperative % of Global Package, Provided in Office, Post-Discharge
pctc PCTC Indicator PCTC Payment Adjustment
mult_proc Multiple Procedure Indicator Multiple Procedures (Mod 51) Payment Adjustment
surg_bilat Bilateral Surgery Indicator Bilateral Procedure (Mod 50) Payment Adjustment
surg_asst Assistant Surgery Indicator Assistant at Surgery (Mods 80, 81, 82, or AS) Payment Adjustment
surg_co Co-Surgery Indicator Co-surgeons (Mod 62) Payment Adjustment
surg_team Team Surgery Indicator Team Surgeons (Mod 66) Payment Adjustment
endo Endoscopic Base Code Endoscopic Base Code for HCPCS with Multiple Surgery indicator 3
supvis Physician Supervision Indicator Physician Supervision Level Required for Service
dximg Diagnostic Imaging Family Indicator Diagnostic Service Family for HCPCS with Multiple Procedure indicator 4
unused Not Used for Medicare Payment Whether Code used for Medicare Payment
rare Rarely/Never Performed Procedure rarely/never performed in: 00 (Neither), 01 (Facility), 10 (Non-Facility), 11 (Both)

Modifier (26/TC/53)

For Diagnostic Tests, a blank in this field denotes the Global Service & the following Modifiers identify the components:
26 Type CPT
Category General
Description Professional Component
Information Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
Instructions Indicates physician's interpretation or professional component reported separately (from technical component) for diagnostic, lab or pathology procedures; Check Medicare Physician Fee Schedule (MPFS) Indicator and Descriptor Lists; Certain codes are divided from global with TC/26 modifiers; Technical and professional component fees equal total global allowance; Report in first field as a payment modifier
Correct Use Involves global, professional and technical. E.g. 71010, 71010 26 and 71010 TC. Place of Service (POS) 21, 22 and 23 only. Services appended with modifier 26. Facility pays technical portion with modifier TC. If 26 and TC are provided in different service locations (enrolled practice locations), professional and technical must be billed separately
Incorrect Use Do not use with evaluation and management (E/M) or Anesthesia codes. An independent laboratory may not bill TC of a physician pathology service furnished to a hospital inpatient or outpatient. Cannot use separately if provider performed global service (In this case, no modifier would be necessary). Claim Coding Example
Resources CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 20.1 and 150 - Payment Conditions for Radiology Services
53 Type CPT
Category General
Description Discontinued Procedure
Information Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. Note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
Correct Use Append in first pricing position. Under certain circumstances, physician may elect to terminate surgical or diagnostic procedure. Surgical or diagnostic procedure started and discontinued by physician. Prior to or after anesthesia is administered. Bill Medicare percentage of service completed (see second example below). Medicare Claims Processing System does not automatically reduce payment
Incorrect Use Do not use to report elective procedure cancellation, in operating suite, prior to patient's anesthesia induction and/or surgical preparation. Inappropriate with E/M or anesthesia codes. Inappropriate to use for Ambulatory Surgery Center (ASC) or hospital facility claims. Use facility modifiers 73 or 74. Do not confuse with reduced procedure modifier 52. Claim Coding Example. Claim Reduction Fee Example
Resources CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.1
TC Type HCPCS
Description Technical component
Information Under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles

Status

Medicare Status Codes
Indicates whether the code is in the fee schedule and whether it is separately payable if the service is covered. Only RVUs associated with status codes of A, R, or T, are used for Medicare payment.
A Active Separately paid if covered. RVUs and payment amounts. Carriers responsible for coverage decisions in absence of an NCD.
B Payment Bundle Payment bundled into payment for other services not specified. No RVUs, no payment made. When covered, payment subsumed by payment for services to which they are incident.
C Carrier Priced Carriers establish RVUs and payment following documentation review.
D Deleted Codes Deleted effective with beginning of year.
E Regulatory Exclusion Excluded by regulation. No RVUs, no payment made. When covered, payment made under reasonable charge procedures.
F Deleted/Discontinued Not subject to 90 day grace period
G Not Valid for Medicare Another code used for payment. Subject to a 90 day grace period.
H Deleted Modifier Had TC/26 mod in previous year, TC/26 component now deleted.
I Not Valid for Medicare Another code used for payment. Not subject to a 90-day grace period.
J Anesthesia Service No RVUs or payment amounts. Only identifies anesthesia services.
M Measurement Code Used for reporting purposes only.
N Restricted Coverage Not covered by Medicare.
P Non-Covered Service No RVUs, no payment made. If covered as Incident To and provided on same day as physician service, payment bundled into payment for Incident To service. If covered as other than Incident To, paid under other payment provision.
R Bundled/Excluded Code Special coverage instructions apply. If covered, service is contractor priced. Assigned to limited number of codes covered in unusual circumstances. Majority of codes are dental codes.
T Injections RVUs and payment amounts. Paid only if no other payable services billed on same date by same provider. If payable services billed, bundled into payment.
X Statutory Exclusion Not in statutory definition of Physician Services. No RVUs or payment amounts, no payment made.

Global Days

000 Endoscopic or minor procedure with related Preoperative and Postoperative RVUs on the day of the procedure only included in the fee schedule payment amount. E&M services on the day of the procedure generally not payable.
010 Minor procedure with Preoperative RVUs on the day of the procedure and Postoperative RVUs during a 10-day postoperative period included in the fee schedule amount. E&M services on the day of the procedure and during the 10-day postoperative period generally not payable.
090 Major surgery with a 1-day Preoperative period and 90-day Postoperative period included in fee schedule amount.
MMM Maternity codes. Usual Global period does not apply.
XXX Global concept does not apply.
YYY Carrier determines if Global concept applies and, if appropriate, establishes Postoperative period.
ZZZ Code related to another service and is always included in Global period of other service.

PCTC Indicator

0 Physician Service: PC/TC does not apply
1 Diagnostic Tests for Radiology Services: Have both a PC and TC. Mods 26/TC can be used.
2 Professional Component Only: Standalone code. Describes PC of diagnostic tests for which there is a code that describes TC of diagnostic test only and another code that describes the Global test.
3 Technical Component Only: Standalone code. Mods 26/TC cannot be used. Describe TC of diagnostic tests for which there is a code that describes PC of the diagnostic test only. Also identifies codes that are covered only as diagnostic tests and do not have a PC code.
4 Global Test Only: Standalone code. Mods 26/TC cannot be used. Describes diagnostic tests for which there are codes that describe PC of the test only, and the TC of the test only. Total RVUs is sum of total RVUs for PC and TC only codes combined.
5 Incident-To: Mods 26/TC cannot be used. Services provided by personnel working under physician supervision. Payment may not be made when provided to hospital inpatients or outpatients.
6 Lab Physician Interpretation: Mod TC cannot be used. Clinical Lab codes for which separate payment for interpretations by laboratory physicians may be made. Actual performance of tests paid by lab fee schedule.
7 Physical Therapy: Payment may not be made if provided to hospital outpatient/inpatient by independently practicing physical or occupational therapist.
8 Physician Interpretation: Identifies PC of Clinical Lab codes for which separate payment made only if physician interprets abnormal smear for hospital inpatient. No TC billing recognized, payment for test made to hospital. No payment for CPT 85060 furnished to hospital outpatients or non-hospital patients. Physician interpretation paid through clinical laboratory fee schedule.
9 PCTC Concept does not apply

Multiple Procedures

0 No adjustment. If procedure is reported on the same day as another procedure, base the payment on the lower of (a) the actual charge, or (b) the fee schedule amount for the procedure.
1 Standard adjustment. If reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). Base payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.
2 Standard adjustment. If reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50% and by report). Base payment on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage.
3 Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the Endobase column. Apply the multiple endoscopy rules to a family before ranking the family with the other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.
4 Special rules for the technical component (TC) of diagnostic imaging procedures apply if procedure is billed with another diagnostic imaging procedure in the same family (per the diagnostic imaging family indicator, below). If procedure is reported in the same session on the same day as another procedure with the same family indicator, rank the procedures by fee schedule amount for the TC. Pay 100% for the highest priced procedure, and 50% for each subsequent procedure. Base the payment for subsequent procedures on the lower of (a) the actual charge, or (b) the fee schedule amount reduced by the appropriate percentage. Subject to 50% reduction of the TC diagnostic imaging (effective for services July 1, 2010 and after). Subject to 25% reduction of the PC of diagnostic imaging (effective for services January 1, 2012 through December 31, 2016). Subject to 5% reduction of the PC of diagnostic imaging (effective for services January 1, 2017 and after).
5 Subject to 50% of the practice expense component for certain therapy services.
6 Subject to 25% reduction of the second highest and subsequent procedures to the TC of diagnostic cardiovascular services, effective for services January 1, 2013, and thereafter.
7 Subject to 20% reduction of the second highest and subsequent procedures to the TC of diagnostic ophthalmology services, effective for services January 1, 2013, and thereafter.
9 Concept does not apply

Diagnostic Imaging Family

01 NA
02 NA
03 NA
04 NA
05 NA
06 NA
07 NA
08 NA
09 NA
10 NA
11 NA
88 Subject to Reduction of TC or PC Diagnostic Imaging
99 Concept does not apply

Geographic Practice Cost Indices

This file contains the Geographic Practice Cost Index (GPCI) component for each carrier/locality for 2024 as well as the locality/county crosswalk. The GPCI reflects the relative costs of physician work, practice expense, and malpractice insurance in a geographic area compared to the national average costs for each component.

GPCIwk GPCIpe GPCImp GPCIgaf
AL 10112 00 ALABAMA 1 0.87 0.58 2.44
AK 02102 01 ALASKA 1.5 1.08 0.59 3.17
AZ 03102 00 ARIZONA 1 0.97 0.85 2.83
AR 07102 13 ARKANSAS 1 0.86 0.52 2.38
CA 01112 54 BAKERSFIELD 1.02 1.09 0.66 2.77
01112 55 CHICO 1.01 1.09 0.56 2.67
01182 71 EL CENTRO 1.01 1.09 0.57 2.68
01112 56 FRESNO 1.01 1.09 0.56 2.67
01112 57 HANFORD-CORCORAN 1.01 1.09 0.56 2.67
01182 18 LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY) 1.04 1.19 0.69 2.93
01112 58 MADERA 1.01 1.09 0.56 2.67
01112 59 MERCED 1.01 1.09 0.56 2.67
01112 60 MODESTO 1.01 1.09 0.56 2.67
01112 51 NAPA 1.06 1.31 0.52 2.89
01182 17 OXNARD-THOUSAND OAKS-VENTURA 1.03 1.18 0.65 2.86
01112 61 REDDING 1.01 1.09 0.56 2.67
01112 62 RIVERSIDE-SAN BERNARDINO-ONTARIO 1.01 1.09 0.89 3
01112 63 SACRAMENTO-ROSEVILLE-FOLSOM 1.03 1.16 0.56 2.75
01112 64 SALINAS 1.03 1.17 0.56 2.76
01182 72 SAN DIEGO-CHULA VISTA-CARLSBAD 1.03 1.19 0.57 2.79
01112 05 SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) 1.09 1.42 0.45 2.95
01112 52 SAN FRANCISCO-OAKLAND-BERKELEY (MARIN CNTY) 1.09 1.42 0.47 2.98
01112 65 SAN JOSE-SUNNYVALE-SANTA CLARA (SAN BENITO CNTY) 1.1 1.43 0.56 3.1
01182 73 SAN LUIS OBISPO-PASO ROBLES 1.01 1.13 0.56 2.71
01112 09 SAN JOSE-SUNNYVALE-SANTA CLARA (SANTA CLARA CNTY) 1.1 1.43 0.42 2.96
01112 66 SANTA CRUZ-WATSONVILLE 1.02 1.21 0.56 2.79
01182 74 SANTA MARIA-SANTA BARBARA 1.02 1.18 0.56 2.76
01112 67 SANTA ROSA-PETALUMA 1.03 1.23 0.56 2.82
01112 68 STOCKTON 1.01 1.09 0.56 2.67
01112 53 VALLEJO 1.06 1.31 0.47 2.84
01112 69 VISALIA 1.01 1.09 0.56 2.67
01112 70 YUBA CITY 1.01 1.09 0.56 2.67
01112 75 REST OF CALIFORNIA 1.01 1.09 0.56 2.67
CO 04112 01 COLORADO 1.01 1.05 0.83 2.89
CT 13102 00 CONNECTICUT 1.02 1.09 1.21 3.32
DC 12202 01 DC + MD/VA SUBURBS 1.06 1.19 1.17 3.42
DE 12102 01 DELAWARE 1.01 0.99 0.95 2.95
FL 09102 03 FORT LAUDERDALE 1 1 1.77 3.77
09102 04 MIAMI 1 1.03 2.5 4.53
09102 99 REST OF FLORIDA 1 0.94 1.47 3.41
GA 10212 01 ATLANTA 1 1 1.13 3.12
10212 99 REST OF GEORGIA 1 0.88 1.12 3.01
HI 01212 01 HAWAII, GUAM 1 1.15 0.56 2.71
ID 02202 00 IDAHO 1 0.91 0.46 2.37
IL 06102 16 CHICAGO 1.01 1.02 2.02 4.05
06102 12 EAST ST. LOUIS 1 0.92 1.78 3.7
06102 15 SUBURBAN CHICAGO 1.01 1.05 1.56 3.61
06102 99 REST OF ILLINOIS 1 0.91 1.38 3.29
IN 08102 00 INDIANA 1 0.92 0.49 2.41
IA 05102 00 IOWA 1 0.91 0.46 2.37
KS 05202 00 KANSAS 1 0.91 0.54 2.45
KY 15102 00 KENTUCKY 1 0.88 0.91 2.79
LA 07202 01 NEW ORLEANS 1 0.94 1.16 3.09
07202 99 REST OF LOUISIANA 1 0.88 0.98 2.86
ME 14112 03 SOUTHERN MAINE 1 1.01 0.66 2.67
14112 99 REST OF MAINE 1 0.91 0.65 2.56
MD 12302 01 BALTIMORE/SURR. CNTYS 1.02 1.08 1.31 3.41
12302 99 REST OF MARYLAND 1.01 1.02 0.97 3
MA 14212 01 METROPOLITAN BOSTON 1.04 1.2 0.89 3.13
14212 99 REST OF MASSACHUSETTS 1.02 1.06 0.8 2.87
MI 08202 01 DETROIT 1 0.99 1.72 3.71
08202 99 REST OF MICHIGAN 1 0.91 1.17 3.08
MN 06202 00 MINNESOTA 1 1.02 0.3 2.32
MS 07302 00 MISSISSIPPI 1 0.85 0.77 2.62
MO 05302 02 METROPOLITAN KANSAS CITY 1 0.95 0.99 2.94
05302 01 METROPOLITAN ST. LOUIS 1 0.95 0.99 2.95
05302 99 REST OF MISSOURI 1 0.86 0.97 2.83
MT 03202 01 MONTANA 1 1 0.98 2.98
NE 05402 00 NEBRASKA 1 0.92 0.3 2.22
NV 01312 00 NEVADA 1 1 0.84 2.84
NH 14312 40 NEW HAMPSHIRE 1 1.03 0.9 2.93
NJ 12402 01 NORTHERN NJ 1.06 1.17 1.03 3.27
12402 99 REST OF NEW JERSEY 1.04 1.11 1.07 3.22
NM 04212 05 NEW MEXICO 1 0.91 1.17 3.08
NY 13202 01 MANHATTAN 1.06 1.17 1.66 3.89
13202 02 NYC SUBURBS/LONG ISLAND 1.06 1.2 1.91 4.18
13202 03 POUGHKPSIE/N NYC SUBURBS 1.05 1.11 1.27 3.42
13292 04 QUEENS 1.06 1.2 1.46 3.72
13282 99 REST OF NEW YORK 1 0.95 0.73 2.68
NC 11502 00 NORTH CAROLINA 1 0.93 0.66 2.59
ND 03302 01 NORTH DAKOTA 1 1 0.52 2.52
OH 15202 00 OHIO 1 0.91 1.03 2.94
OK 04312 00 OKLAHOMA 1 0.89 0.81 2.7
OR 02302 01 PORTLAND 1.01 1.1 0.69 2.8
02302 99 REST OF OREGON 1 0.99 0.64 2.63
PA 12502 01 METROPOLITAN PHILADELPHIA 1.02 1.05 1.18 3.25
12502 99 REST OF PENNSYLVANIA 1 0.93 0.93 2.85
PR 09202 20 PUERTO RICO 1 1.01 0.98 2.99
RI 14412 01 RHODE ISLAND 1.02 1.04 0.85 2.91
SC 11202 01 SOUTH CAROLINA 1 0.91 0.82 2.73
SD 03402 02 SOUTH DAKOTA 1 1 0.38 2.38
TN 10312 35 TENNESSEE 1 0.9 0.54 2.44
TX 04412 31 AUSTIN 1 1.05 0.91 2.96
04412 20 BEAUMONT 1 0.9 0.95 2.85
04412 09 BRAZORIA 1.01 1.01 0.79 2.81
04412 11 DALLAS 1.01 1.01 0.88 2.89
04412 28 FORT WORTH 1.01 1 0.9 2.91
04412 15 GALVESTON 1.01 1 0.86 2.87
04412 18 HOUSTON 1.01 1 1.41 3.43
04412 99 REST OF TEXAS 1 0.94 0.93 2.88
UT 03502 09 UTAH 1 0.93 0.93 2.86
VT 14512 50 VERMONT 1 0.99 0.52 2.51
VA 11302 00 VIRGINIA 1 0.98 0.76 2.74
VI 09202 50 VIRGIN ISLANDS 1 1.01 0.98 2.99
WA 02402 02 SEATTLE (KING CNTY) 1.04 1.22 0.85 3.12
02402 99 REST OF WASHINGTON 1.01 1.04 0.8 2.85
WV 11402 16 WEST VIRGINIA 1 0.86 1.33 3.2
WI 06302 00 WISCONSIN 1 0.96 0.33 2.29
WY 03602 21 WYOMING 1 1 0.74 2.74