Fee Schedule Frequently Asked Questions (FAQs)
Below are a few frequently asked questions about the fee schedule lookup.
Why are there two sets of rates for the same CPT code?
Some health plans have a different reimbursement rate when a service is provided in an office setting than when provided in a facility setting. The place of service on the claim will dictate which rate is paid. If you/your provider only see patients in one place of service, use the applicable filter when downloading the fee schedule.
For example, the fee schedule will show “MEDICARE 01/17 Facility” for services provided in a facility setting and “MEDICARE 01/17 Non-Facility” for services provided in an office setting.
Some CPT codes have different rates when billed with modifiers. The modifiers, if applicable, are listed after the CPT code on the fee schedule.
For example, the fee schedule will show “7372026” for CPT code 73720 with modifier 26 and “73720TC” for CPT code 73720 with modifier TC.
Why are there different rates for PCPs vs Specialists?
In an effort to recognize PCPs for additional administrative responsibilities, some health plans reimburse PCPs a slightly higher rate than Specialists for certain E&M codes. Use the applicable filter for your specialty type when downloading the fee schedule.
How can I tell the effective date of the fee schedule?
The fee schedules should display the most current fee schedule available from the health plans. The effective date of the fee schedule is shown in the title after the health plan.
For example, the rates displayed for “MEDICARE 01/17 Non-Facility” are for Medicare rates effective as of January 1, 2017.