Fee schedule
A fee schedule is a payer's published list of the amounts it will pay for each covered service code, used to derive the allowed amount on a claim.
Updated
A fee schedule is a payer's structured list of the payment amounts assigned to each billable service code — CPT, HCPCS, or a diagnosis-related group, for example. It is the basis from which the allowed amount on a claim is derived, before adjustments for provider agreements, coordination of benefits, or patient cost-sharing.
Medicare publishes its fee schedules (the Physician Fee Schedule, the Outpatient Prospective Payment System, and others), and each state Medicaid program publishes its own. Commercial payers maintain proprietary fee schedules agreed under contract, which may differ from Medicare's and from each other.
In practice
Fee schedules are updated on published cycles — Medicare's Physician Fee Schedule is updated annually, with corrections through the year — and a payer may revise a rate prospectively or, where rules permit, retrospectively. A claim's payment reflects the fee schedule in effect for the date of service and any contractual adjustment the provider's agreement applies.
Commonly confused with
- Allowed amount: The fee schedule states the base rate for a code; the allowed amount is what the payer determines is payable for a specific claim after applying the schedule, contract terms, and any limiting rules.
- Billed charge: A billed charge is the provider's listed price; the fee schedule is the payer's contracted or statutory rate that usually determines the allowed amount, not the billed charge.