A fee schedule is a list of the maximum amounts a payer will allow for each billed code. Medicare uses the Medicare Physician Fee Schedule (MPFS); commercial payers use their own, often set as a percentage of Medicare. For an in-network claim, the fee-schedule amount is the allowed amount.
How it's used
- The allowed amount for a code comes from the applicable fee schedule (or your contract).
- The difference between your charge and the fee-schedule amount is a contractual adjustment (CO-45).
- The patient's cost-share (deductible, coinsurance, copay) comes out of the allowed amount.
Frequently asked
Is the fee-schedule amount what I get paid?
It's the ceiling. The plan pays the allowed amount minus the patient's cost-share, which the patient then owes.
Where does the Medicare fee schedule come from?
It's built from RVUs adjusted by geography (GPCI) and a conversion factor — the RBRVS system.
Primary sources: CMS — Medicare Physician Fee Schedule. General information, not legal or medical advice — confirm against the governing rule for the plan type.
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