CMS Drug Fee Schedule

The CMS Drug Fee Schedule tool lets you calculate reimbursements based on the national Medicare drug fee schedule.

  • The CMS Drug Fee Schedule tool allows you to calculate reimbursements based on a national Medicare drug fee schedule and define an effective date, code range, or procedure lookup table for each percentage. If you enter multiple percentage lines, the lines are calculated from top to bottom. A procedure code matches an entry in a lookup table according to standard matching rules. For more information, refer to Reimbursement Tools.

The following table describes the fields on the CMS Drug Fee Schedule reimbursement tool.

Field

Description

+

Clicking the plus (+) adds another percentage line to the tool and lets you define a fee schedule and place of service.

-

Clicking the minus (-) sign removes that percentage line from the reimbursement tool.

Codes From

The beginning value for your code range. This field is inclusive, that is if you enter a Code From value of 90000, your range begins with code 90000, not 90001.

Codes To

The ending value for your code range. This field is inclusive, that is if you enter a Code To value of 90000, your range ends with code 90000, not 8999.

Consume Resources

Indicates whether units are consumed. Selecting this check box consumes resources. If you do not select this check box, resources are not consumed.

Effective Date

The effective service date of the CMS Drug Fee Schedule you want to use.

Or

A list that lets you select a specific procedure lookup table as a code filter. Only procedures found within this table will be priced.

Percentage

Sets the percent of the base amount in the fee schedule at which the procedure code is reimbursed. For example, if you enter 75, all procedures that match the code range or procedure lookup table and have not been repriced by another tool are repriced at 75% of amount listed in the fee schedule.

When codes are found in multiple CMS Drug Fee Schedules, pay

Indicates what to do if a particular procedure code is found in multiple CMS Drug Fee Schedules. You can select First Occurrence to use the first (top) CMS Drug Fee Schedule listed in the tool, Highest Reimbursement, or Lowest Reimbursement to use the CMS Drug Fee Schedule that returns the highest or lowest reimbursement of those listed in the tool.