To look up what a code pays under Medicare, you need five things: the year of service, the HCPCS or CPT code, any payment-changing modifier, your MAC and locality, and the setting. Change any one of them and the number changes. A code on its own is not an answer, and nobody can audit a figure you saved without those five assumptions.
That is the whole discipline. Practices lose more money to sloppy lookups than to payer error, because a wrong rate spreads quietly into forecasts, contract models and physician compensation before anyone checks it.
This guide covers the five assumptions, how to read the policy indicators that most people skip, and why you cannot apply a Medicare rate to a commercial contract without reading the contract first.
A code on its own is not an answer
Five choices decide whether a fee schedule number is usable. Set them here and the builder writes the auditable label to paste beside the figure in your spreadsheet.
99214 · 2026 · non-facility · no modifier · locality not set
Label every number you save. “99214: $X” is not auditable. The same code with the year, setting, modifier and locality attached can be checked by anyone later.
The lookup returns more than a dollar amount, and the policy indicators often explain why the paid amount differs from the schedule value. Do not apply a Medicare rate straight to a commercial contract either. Those agreements may use a percentage of Medicare, a different year’s schedule, a proprietary schedule or code-specific rates, so read the contract first.
What do you need before you look anything up?
| Assumption | Why it changes the number |
|---|---|
| Year of service | RVUs and the conversion factor change annually. The rule in effect on the date of service controls the comparison. |
| HCPCS or CPT code | Obvious, but confirm you have the code actually billed rather than the one described in a policy. |
| Modifier | Component splits, bilateral rules and reduced services all move the allowed amount. |
| MAC and locality | Geographic practice cost indices adjust work, practice expense and malpractice separately by area. |
| Setting | Facility and non-facility practice expense values differ, sometimes substantially. |
Record all five beside every figure you save. “99214: $X” tells a colleague nothing in six months. “99214, 2026, non-facility, no modifier, Michigan locality 01” lets anyone re-check it without guessing what produced it.
Why does the setting change the rate so much?
Most codes carry two practice expense values. The non-facility value applies where the practice pays for staff, space, equipment and supplies, typically a physician office. The facility value applies in a hospital outpatient department or an ambulatory surgical center, where the facility carries those costs and bills separately under a different system.
The facility rate is therefore generally lower for the same code, because it covers only the practitioner’s own resources. Using an office rate for hospital-based work overstates a forecast, and that same error later appears in contract negotiations and compensation formulas where it is much harder to unwind.
Which policy indicators should you actually read?
The lookup returns more than a dollar amount, and the indicators usually explain why a paid amount differs from the schedule value.
- Global surgery indicator. Tells you whether a 0, 10 or 90-day global period applies, which governs what you can bill separately afterwards.
- Professional and technical component indicator. Tells you whether the code splits into components, which determines whether modifier 26 or TC even applies.
- Bilateral surgery indicator. Governs how payment works when the clinician performs the procedure bilaterally. It does not always mean the amount doubles.
- Multiple procedure indicator. Governs reductions when several procedures occur in one session.
- Assistant at surgery indicator. Tells you whether Medicare pays for an assistant on that code at all.
Skipping these is why teams conclude a payer underpaid when the schedule itself predicted the amount. Read the indicators before you open a dispute.
How do you use the CMS lookup tool without misreading it?
CMS publishes a searchable Physician Fee Schedule lookup along with the underlying relative value and payment files on its Physician Fee Schedule page. Four habits keep the output trustworthy.
- Set the year first. Defaults change, and pricing a 2025 claim against 2026 values produces a confident wrong answer.
- Choose your specific locality, not a national average. National figures are teaching examples.
- Pick the setting deliberately rather than accepting whatever appears first.
- Screenshot or export the result with its parameters visible. Six months later you will not remember which locality you selected.
If you want to understand the arithmetic behind the figure the tool returns, our guide to calculating RVUs works through a full example with both 2026 conversion factors.
Can you apply a Medicare rate to a commercial contract?
Not without reading the contract. Commercial agreements reference Medicare in several different ways, and each one produces a different number.
- A percentage of the current Medicare schedule.
- A percentage of a different year’s schedule, sometimes frozen years back.
- A proprietary schedule with no Medicare relationship at all.
- Code-specific rates negotiated individually, which override any general formula.
Practices that assume the first option and actually hold the second consistently overestimate expected revenue. Check which year the contract names, then build your expected-payment model on that, not on today’s schedule.
How does this connect to your denial work?
Directly. A correct expected amount is what makes underpayment visible. Without it, a line paid below contract looks like normal adjustment and posts as a write-off without anyone querying it, which is exactly the pattern described in our post on CO-45, CO-97 and PR-204.
Two habits close that gap. Load expected allowables into your billing system so variances surface automatically, and review your charge master against contracted allowables annually so you never bill below a rate you could have collected.
If you suspect underpayment but cannot prove it, a free instant revenue audit will compare paid amounts against expected rates and quantify the variance by payer and code.
Frequently asked questions
How do I look up the Medicare fee schedule for a CPT code?
Use the CMS Physician Fee Schedule lookup, then set five things deliberately: the year of service, the code, any payment modifier, your MAC and locality, and the facility or non-facility setting. Save all five alongside the figure.
What is the difference between facility and non-facility rates?
The non-facility rate applies where the practice bears the cost of staff, space and supplies, such as a physician office. The facility rate applies in a hospital outpatient department or an ASC and covers only the practitioner’s resources, so it is generally lower for the same code.
Why does the Medicare rate differ between two states?
Geographic practice cost indices adjust the work, practice expense and malpractice components separately by locality. Practice expense varies most, because wages and rent vary most, so the same code genuinely pays different amounts in different areas.
Is the Medicare fee schedule amount what I actually receive?
Not exactly. Sequestration, other claim-level adjustments, patient coinsurance and deductible amounts, and payment policy indicators all affect the deposit. Treat the schedule amount as the allowed amount before those adjustments.
Can I use Medicare rates to estimate commercial payments?
Only if the contract references Medicare, and only for the year the contract names. Some agreements use a frozen prior year, a proprietary schedule, or individually negotiated code rates that override any percentage formula.
How often does the Medicare fee schedule change?
Annually, through the Physician Fee Schedule rulemaking cycle, and CMS can issue corrections during the year. Re-verify your key codes each January rather than carrying last year’s figures into a new forecast.