How to create a Medicare reference fee schedule (part 4)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 4: Drugs/vaccines fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice/index.html.
Select the most recent year from the left hand column.
Then select the most recent month's ASP Pricing File and download it.
In the zip file, choose the ASP Pricing File (eg Oct 18 ASP Pricing File) Excel file.
In the Excel file, the relevant columns are A, B, and D.
Unmerge the cells in this file. Type Ctrl-A to select all the cells, then choose Home > Alignment > Merge and Center > Unmerge Cells. Then move the columns so that the HCPCS Code is in column A, the HCPCS Description is in column C, and the Payment Limit column is in column F.
These cells can be selected, copied, and pasted to the bottom of the Physician Fee Schedule (PFS) file.

 

How to create a Medicare reference fee schedule (part 3)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 3: Durable Medical Equipment fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.
Select a time period. The latest data will have the most recent year and highest letter. In this particular case, since DME18-D (orange arrow) links to no updates, we will select DME18-C (green arrow) in this case.
Download the file (e.g. DME18-C.zip).
In the zip file, open the DMEPOS file (e.g. DMEPOS_JUL.xls)
The relevant columns in this file are the HCPCS code column (column A), the HCPCS code description column (column DJ), and the appropriate state column for your state.
Each state has two columns, nonrural (NR) and rural (R). To determine if you're in a rural or nonrural location, look in the DMERuralZip file (e.g. DMERuralZip_Q32018). If your zip code is listed, then use the rural (R) payments as a guide.
Delete all state columns that are irrelevant for your location.
If you are in a rural area, combine the nonrural and rural fee schedules into a single column. If the rural column shows 0.00 (green arrow), the rural payment for that HCPCS is the same as the nonrural payment. If the rural column shows a nonzero value (orange arrow), the higher rural column payment applies to rural areas.
To simply combine the rural/nonrural fees in this way, you can create a formula to take the maximum of the two columns into a third column.
To propagate the formula down to the bottom of the sheet, select the cell with the formula, Ctrl-C to copy it, click on an empty cell, drag down to the bottom, then type Ctrl-V.
To save the values so you can delete the two source columns, select the resulting column (here column J),
Now you can delete the two source columns.
Copy and paste the columns so that the HCPCS code is in column A, the HCPCS description is in column C, and the payment column is in column F.
Select the three resulting DME columns and copy them.
Paste the data to the bottom of the PFS data.

 

How to create a Medicare reference fee schedule (part 2)

Medicare provides public reference fee schedules for medical services, laboratory and radiology services, DME, and drugs and injectibles.  Making your own Medicare fee schedule provides a ready reference for your practice payments.

Medicare fee schedule part 2: Clinical laboratory fee schedule

Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/Clinical-Laboratory-Fee-Schedule-Files.html.
Select a time period. The latest data will have the most recent year and most recent quarter. For example, Q3 (third quarter) is the most recent here of the 2018 files.
Click to download the file (e.g. 18CLABQ3.)
In the zip file, open the Excel file (e.g. CLFS 2018Q3.)
The file can be used as-is for lab reference pricing, or you can combine it with the Medicare Physician Fee Schedule file into a single reference file. Column B is the HCPCS/CPT code, column G is the description of the HCPCS/CPT code, and column F is the payment rate.
To combine it with the PFS file, rearrange the columns so that the HCPCS column is in column A, the description is in column C, and the payment is in column F. To copy/paste an entire column at once, click on the letter column header, Ctrl-C, click on the target column header letter, then Ctrl-V.
Once the columns are reorganized, copy and paste the result at the bottom of the PFS file.