Fee Schedules

Published 02/15/2024

As a national Medicare contractor, Railroad Medicare adjudicates claims based on the Medicare fee schedules set forth by the Centers for Medicare & Medicaid Services (CMS). Payments made by Railroad Medicare are based on the fee schedule for your state and locality. You can verify the Medicare allowed amount on the fee schedules posted on your local Medicare Administrative Contractor’s website or with the fee schedules found on the CMS website.

This fee schedule applies to all ambulance services including volunteer, municipal, private, independent, institutional (e.g., hospitals and critical access hospitals, except when it is the only ambulance service within 35 miles), and skilled nursing facilities.

Section 1834 (l) also requires mandatory assignment for all ambulance services. Ambulance providers and suppliers must accept the Medicare allowed charge as payment in full and not bill or collect from the beneficiary any amount other than any unmet Part B deductible and the Part B coinsurance amounts.

The complete lists of ASC covered surgical procedures and ASC covered ancillary services; the applicable payment indicators; payment rates for each covered surgical procedure and ancillary service before adjustment for regional wage variations; the wage adjusted payment rates; and wage indices are available on the CMS website.

Resource: CMS Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication 100-04, Chapter 14 (PDF, 182 KB), Sections 30 and 40. 

The durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedules contain fee schedule amounts, floors and ceilings for each procedure code subject to the DMEPOS fee schedule payment methodology.

The average sale price (ASP) methodology is based on quarterly data submitted to CMS by manufacturers. CMS will supply contractors with the ASP and not otherwise classified (NOC) drug pricing files for Medicare Part B drugs on a quarterly basis.

See Influenza (flu) and Pneumococcal Vaccines Pricing for more information.

Outpatient clinical laboratory services are paid based on a fee schedule in accordance with Section 1833(h) of the Social Security Act. Payment is the lesser of the amount billed, the local fee for a geographic area, or a national limit. In accordance with the statute, the national limits are set at a percent of the median of all local fee schedule amounts for each laboratory test code. Each year, fees are updated for inflation based on the percentage change in the Consumer Price Index. However, legislation by Congress can modify the update to the fees.

Medicare Part B pays for physician services based on the Medicare Physician Fee Schedule (MPFS), which include office visits, surgical procedures, anesthesia services, and a range of other diagnostic and therapeutic services. 

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