What Does Medicare Pay For....?

One of the most common questions is about the DMEPOS fee schedule and what the allowed amounts are for specific HCPCS codes in specific states. Read on to learn about the ways to easily access this information.

The DMEPOS fee schedule is updated yearly with updates throughout the year, as needed. The allowable amount for each HCPCPS is determined by evaluating and establishing the value of the professional time and product cost.

When establishing the fee schedule, CMS adjusts for each state, taking into consideration cost of living, rent, and overall expenses in a specific location. There is a “ceiling” and “floor” for each HCPCS. The “ceiling” is the maximum amount allowed for any state. The “floor” is the minimum amount allowed for any state.

The full DMEPOS fee schedule, which includes allowable amounts for all HCPCS codes and all states, can be downloaded here.  Download the file, open the contents, and use a spreadsheet program to sort the full schedule. This date includes the ceiling, floor and allowable by state.

When you need an allowable amount for a specific HCPCS code, Durable Medical Equipment Coding Systems (DMECs) is available on the PDAC site. You can search for a specific code here.

CGS Medicare, Jurisdiction B and C, has a specific Fee Schedule Lookup Tool by code and by state.

What does this mean for you?

Knowing the allowable amount helps you communicate financial responsibility with patients and predict your reimbursements. Most private payers base their fee schedule amounts on a percentage of the CMS allowable. Be aware of what this means in terms of bottom line and patient copays. Download the fee schedule for your state(s) and use them as a valuable reference in your practice.