Fee Schedules

Learn about the fee schedules PIP Fee utilizes and how you can maximum them for your benefit.

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Identify the Service Type and Locality

    The system evaluates three core inputs to locate the proper ambulance pricing row:

  • HCPCS/CPT code (e.g., A0427 for ALS1 emergency, A0429 for BLS emergency, A0430/A0431 for air transports, and A0425/A0435/A0436 for mileage);
  • Locality and carrier derived from the provider’s state and locality; and
  • Rural status for the provider’s ZIP code on the DOS (based on dated rural ZIP releases).

    • Note: Ambulance schedule pricing does not use modifiers. If a row includes a modifier, no AFS match will be found.

    Also note: PIP Fee does not apply the “super rural” bonus payment that Medicare uses for limited ground ambulance transports.

    Step 3: Calculate the Base Component

    From the matched row the system retrieves:

  • Base Rate;
  • GPCI (geographic practice cost index); and
  • RVU (relative value unit).

    • These values yield an adjusted base component. The formula varies by air vs. ground and by rural vs. non-rural setting, reflecting the schedule’s methodology.

  • Air ambulance (fixed/rotary wing):
    The base component incorporates GPCI and RVU, with a higher adjustment in rural settings.
  • Ground ambulance:
    The base component uses RVU and GPCI, with a modest rural uplift compared to non-rural.

    • Step 4: Add the Mileage Component

    Mileage is priced per statute mile using the DOS-appropriate release:

  • Air mileage (A0435/A0436):
    Per-mile amount varies by air type and rural status.
  • Ground mileage (A0425):
    Per-mile amount varies by rural/non-rural.

    • In rural areas, the first 1–17 miles can price at a designated “first-17-miles” rate when available; remaining miles price at the rural per-mile rate.

    In non-rural areas, all miles price at the urban per-mile rate.

    Your line’s Units field is used as the mile count for the mileage calculation.

    Step 5: Combine and Apply State Adjustment

    The total ambulance schedule amount equals:

    Adjusted Base Component + Mileage Cost

    This total is then passed through the state adjustment rules for the provider’s state and DOS. The output includes:

  • Adjusted Fee Schedule (the final allowable);
  • Multiplier Used (how the state rule affected the line); and
  • Calculation Explanation written in plain language.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Find the Base Units

    Once the correct base-unit release is identified, the system locates the code’s Base Unit by matching:

  • Anesthesia code; and
  • Effective release for the DOS.

    • If the code is not found in any applicable release, no anesthesia fee can be calculated.

    Step 3: Find the Conversion Factor

    Next, the system selects the Conversion Factor for the DOS by matching:

  • Medicare contractor (derived from the provider’s state);
  • Locality (from the provider’s details); and
  • Effective release for the DOS.

    • If no conversion factor is found for the contractor–locality pair on the DOS, no anesthesia fee can be calculated.

    Step 4: Compute Time Units

    Medicare time units accrue in 15-minute increments. PIP Fee automatically rounds to 15-minute intervals.

    Step 5: Calculate the Baseline Anesthesia Amount

    The total anesthesia units equal:

    Base Units + Time Units

    The baseline Medicare anesthesia amount is:

    Total Units × Conversion Factor

    Step 6: Apply State Adjustments

    Finally, the baseline amount is processed under state rules. This produces the Fee Schedule value along with:

  • The multiplier applied;
  • A plain-language explanation; and
  • A clear indication of whether the fee came from the Anesthesia Fee Schedule or not.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Find the Laboratory Rate

    With the correct release identified, the system locates the exact amount by matching:

  • HCPCS/CPT code as entered; and
  • Modifier (when applicable).
    Laboratory pricing supports one line-level modifier. If a second modifier is present on the line, the laboratory schedule is not applied to that entry.

    • If a match is found for the applicable release and effective date, the Original Fee Schedule equals the laboratory rate for that code (and modifier, if present).

    Step 3: Apply State Adjustment

    After the laboratory rate is found, the result passes through the state adjustment rules for the provider’s state and the DOS. The output includes:

  • Adjusted Fee Schedule (the final allowable);
  • Multiplier Used (how the state rule affected the line); and
  • Calculation Explanation written in plain language.

    • If the laboratory schedule does not provide a matching amount for that code/modifier on the DOS, the line is shown as No Fee Sched. The state adjustment step can still evaluate the net charge and other applicable factors; the explanation will state the outcome and the reason.

    What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Match Code and Modifiers

    The system searches the DMEPOS fee schedule for an exact match to:

  • Code (entered from the Code field);
  • Modifier 1 and Modifier 2 (if present); and
  • State and ZIP Code of the provider.

    • This guarantees that both national coverage and geographic distinctions are respected.

    Step 3: Determine Rural vs. Non-Rural Rate

    Some DMEPOS items are paid differently depending on whether the provider is in a rural ZIP Code.

  • The system checks your provider’s ZIP Code against the latest Rural ZIP Code file in effect on the date of service.
  • If a match is found, the rural rate is applied. Otherwise, the non-rural rate is used.

    • This step ensures proper payment distinctions based on location.

    Step 4: Apply State Adjustments

    Once the baseline DMEPOS fee is identified, the system applies the state’s statutory multipliers. For example, Michigan’s CPI × Treatment Factor rules, or statutory Medicare multipliers.

    This produces the Fee Schedule amount, along with:

  • The multiplier used;
  • A clear explanation (e.g., “Medicare × 190%” or “CDM Price × 52.5% × CPI”); and
  • The adjusted final allowable for that service.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Find the Correct Fee

    Once the right release is identified, the system locates the exact payment amount by matching:

  • Drug code; and
  • The effective quarterly release for the DOS.

    • From this match, the system retrieves the Payment Limit, the code description, and the dosage unit (for example, “1 mL,” “0.5 mL”).

    Note: Part B drug codes do not use modifiers. If a row includes a modifier, no Part B match will be found.

    Step 3: Apply Medicare’s ASP Rule

    Medicare reimburses ASP plus 6 percent.

  • The Payment Limit from the ASP table is multiplied by 1.06.
  • That amount is then multiplied by the quantity administered as entered in the project row.

    • This step produces the baseline Medicare amount before any state rules are applied.

    Step 4: Apply State Adjustments

    The baseline amount then passes through the state adjustment rules. This produces the Fee Schedule value along with:

  • The multiplier used;
  • A plain-language explanation; and
  • A clear indication of whether the fee came from the Part B Drug ASP or not.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Find the Correct PEN Row

    With the correct release identified, the system locates the exact amount by matching:

  • HCPCS/CPT as entered; and
  • Modifiers (supports Modifier 1 and Modifier 2 for PEN pricing).

    • If a matching row exists for that code/modifier combination in the applicable release, PIP Fee proceeds with deriving the correct rural or nonrural rate.

    Step 3: Determine Rural vs. Nonrural Rate

    PEN pricing provides state-specific rural and nonrural columns. The system chooses the correct column using the provider’s ZIP code and state on the DOS.

    To decide rural vs. nonrural, the system checks the provider ZIP against the latest rural ZIP release effective on or before the DOS.

    Step 4: Apply State Adjustment

    After the schedule rate is selected (rural or nonrural), the amount passes through the state adjustment rules for the provider’s state and the DOS. The output includes:

  • Adjusted Fee Schedule (the final allowable);
  • Multiplier Used (how the state rule affected the line); and
  • Calculation Explanation written in plain language.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Step 1: Match the Date of Service to the Correct Release

    This fee schedule is published on a rolling basis. For each date of service (DOS), the system reviews all past releases and uses the most recent release in effect on or before that DOS. This ensures the right schedule is applied to the right date.

    Step 2: Find the Correct Fee

    Once the right schedule is identified, the system locates the exact amount by matching:

  • Procedure code (HCPCS/CPT);
  • Modifier (when applicable);
  • Geographic locality; and
  • Place of service (facility vs. non-facility).

    • This step guarantees the fee reflects the correct circumstances of the service.

    Step 3: Apply Participation Rules

    If the provider is marked as non-participating, Medicare’s non-participation rules are applied. This adjusts the baseline fee before any further calculations.

    Step 4: Check the Code’s Status

    Some codes have special status designations:

  • Bundled: Already included in payment for another service.
  • Potentially bundled: May be included when billed with other services.
  • Excluded: Not covered under the Physician Fee Schedule.

    • When one of these applies, the fee is set to $0.00 and a note is added explaining why.

    Step 5: Apply State Adjustments

    Finally, the amount goes through the state adjustment rules. This produces the Fee Schedule value along with:

  • The multiplier applied;
  • A plain-language explanation; and
  • A clear indication of whether the fee came from the Physician Fee Schedule or not.

    • What You Will See on the Line Item

    Each line item shows:

  • Medicare Amount: The fee schedule amount for the DOS when a match is found.
  • Fee Schedule Amount: The final allowable after state adjustment.
  • Multiplier Used: The factor(s) applied under state rules.
  • Calculation Explanation: A concise narrative of how the amount was determined.
  • Source: Shows the applicable fee schedule a match was found, or “No Fee Sched.” when not.
  • Code Description: A description of the code, when available, in everyday language.

    • When No Match Is Found

    If the exact combination (code, modifier, effective release) is not present for the DOS, the system lists the line as No Fee Sched. The state adjustment step still runs and will explain how the final amount (if any) was determined relative to the net charge and applicable rules.

    Some codes require modifiers to work. Learn more ›

    Example: DME Code A4236

  • Code entered without modifier: A4236 → Returns No Fee Sched.
  • Code entered with modifier: A4236/NU → Returns the correct Medicare fee.

    • In this case, the NU modifier is required for the code to match the DMEPOS Fee Schedule. Without it, the code is incomplete and cannot return a value.

    What to Do

  • Double-check whether the code requires a modifier.
  • If a Medicare code shows as No Fee Sched., review the Medicare Fee Schedule or the provider’s billing guide for required modifiers.
  • Add the correct modifier in the Modifier 1 or Modifier 2 field and re-run the search.

    • Tip: Many DME codes, like A4236, cannot match unless paired with the correct modifier. Always include the modifier when one is required.

    Because Medicare distinguishes between codes with and without modifiers, Medicare tables will show multiple rows for the same base code. However, unless your claim line has the exact modifier combination shown in the table, the system will not find a perfect match.

    Key Points

  • Multiple table entries do not necessarily mean duplicate coverage.
  • If your line does not carry the correct modifier, or carries no modifier when one is required, it will not map to a fee schedule row and will return “No Fee Sched.”