Medicare physician fee schedule
Medicare's Physician Fee Schedule (PFS) pays for physician and other enrolled professional services. Its payment calculation uses relative value units (RVUs) for work, practice expense and malpractice, geographic practice cost indices (GPCIs), and a conversion factor. Statute and annual rulemaking shape the conversion factor and related adjustments. CMS explains the components and annual rate setting in the CY 2026 PFS final rule fact sheet.
For CY 2026, CMS describes two conversion factors: $33.57 for qualifying Advanced APM participants and $33.40 for other clinicians. These are national conversion factors reported in the final rule, not a group's locality-adjusted allowed amount or a forecast of collections. Confirm the applicable code, modifier, locality, participation status and effective date in the CMS PFS Look-Up Tool and the definitive payment files available from the CMS Physician Fee Schedule page.
Anesthesia owners can compare code-level allowed amounts and RVUs across rule years, then translate the change through actual units, payer mix and modifier use, then check collections. Review work RVU and practice expense changes separately where applicable. Check anesthesia conversion factor files and locality adjustments in CMS payment files; do not infer an anesthesia claim amount from the physician conversion factor alone. The PFS lookup tool explains that geographic practice cost indices adjust the work, practice expense and malpractice RVU components and offers national and locality searches.
Anesthesia code families to monitor
Build the group's own code list from its claims and services. Common anesthesia families include:
- 00100 through 00222
- anesthesia for procedures on the head, neck, thorax, intrathoracic, upper abdomen and related areas.
- 00300 through 00670
- anesthesia for procedures on the spinal procedures.
- 00700 through 00882
- anesthesia for procedures on the upper and lower abdomen.
- 00902 through 01999
- anesthesia for procedures on the perineum, pelvis, lower extremities and other anatomic areas, including obstetric anesthesia within the applicable code range.
- 01996
- daily management of neuraxial or related continuous pain management when criteria are met.
- 62320 through 62327 and 64400 through 64530
- selected peripheral and neuraxial block codes that may be billed by anesthesiologists when supported by the service, documentation, payer policy and coding rules.
- 99100, 99116, 99135 and 99140
- qualifying circumstances add-on codes. Track payer coverage and documentation edits and confirm separate payment in payer policy.
Use this list to build a working code set from actual claims. Verify descriptors, code status, bundling policy and payment indicators, including modifier rules in annual files and payer policies. For each material code, preserve allowed amount, RVU components and units. Record modifiers, denial rates and net collections by facility and payer. Flag a code when CMS changes its value, status or policy, or when payer edits produce a sustained movement in payment.
MACs, national policy and local coverage
Medicare Administrative Contractors (MACs) process claims and administer coverage within assigned jurisdictions. A national coverage determination (NCD) may apply nationally; a local coverage determination (LCD) addresses coverage within the responsible MAC's jurisdiction where applicable. MAC billing and coding articles can add operational detail. Start in the Medicare Coverage Database, review CMS's LCD overview and MAC jurisdiction list, and use the LCD What's New report to spot updates.
Anesthesia groups should map each service location to its MAC and jurisdiction. Search the group's codes, service descriptions and relevant diagnoses; review both the LCD and related billing article, including future effective dates and retired versions. Assign someone to assess whether a change affects documentation, authorization workflows, claim edits, appeals or facility protocols. Not every anesthesia service has a specific LCD, so include national policy and MAC claims guidance in the review.
Medicaid varies by state and delivery system
Medicaid payment is not one national anesthesia fee schedule. States set provider payment rates within federal requirements and may use fee-for-service, managed care or both. Rate methods, anesthesia conversion factors, covered services and managed care plan terms can differ by state and change through state plan amendments. CMS summarizes state flexibility and state plan amendment processes in Medicaid Financial Management and provides amendment records through the Medicaid State Plan Amendments page.
For each state where the group works, record the state fee schedule and anesthesia method, the relevant managed care plans, contract rate exhibits, authorization requirements and effective dates. Check state Medicaid bulletins and plan notices as well as CMS records. Separate state fee-for-service changes from managed care contract changes; a state plan update does not by itself establish the group's contracted rate with every plan.
Commercial contracting levers
Commercial terms are contract-specific. Owners can organize negotiations around the anesthesia conversion factor or other rate basis, annual escalators; code and modifier coverage; time-unit definitions; qualifying circumstances; medical direction; concurrency limits; recognition of CRNAs and anesthesiologist assistants; claims edits; authorization; filing deadlines; audit rights; appeal windows; late-payment interest; recoupment; and amendment notice. Tie each requested term to the group's cases, staffing, call coverage and facility obligations.
Ask the payer to identify the fee schedule version and code mapping incorporated by reference. Define how new, revised or deleted CPT or HCPCS codes are priced and when updates take effect. Compare contract language with remittance data after implementation. Track allowed amount per anesthesia unit and collections by code family. Break results out by facility and payer, then investigate material variance before accepting a rate change as operationally neutral. Have qualified counsel review contract language and applicable state requirements.
Prior authorization and administrative burden
CMS's Interoperability and Prior Authorization final rule, CMS-0057-F, establishes requirements for impacted Medicare Advantage organizations; Medicaid and CHIP fee-for-service programs; Medicaid managed care plans; CHIP managed care entities; and certain federally facilitated exchange plans. The rule includes decision timeframes, denial reasons and API requirements, with implementation dates that vary by provision. CMS identifies as a key implementation date for certain payer provisions. Confirm the specific payer and requirement in CMS materials before changing a workflow.
For anesthesia groups, authorization responsibilities may sit with the facility, surgeon or group depending on the service and agreement. Document which party submits the request and who checks its status. Record how procedure or location changes are handled. Ensure the authorization number reaches the claim. Maintain a payer matrix by plan, service, site and responsible party. Measure authorization-related denials, delayed cases and rework, then resolve recurring handoff failures with the facility and payer.
No Surprises Act and federal IDR
The No Surprises Act limits balance billing for certain out-of-network services, including many emergency services and certain non-emergency services at in-network facilities. Anesthesia services may be within the protections depending on the facts and applicable law. Review CMS's No Surprises Act resource page and make sure patient notices and billing processes follow the applicable requirements.
For eligible out-of-network payment disputes, the federal independent dispute resolution (IDR) process follows an open negotiation period. CMS describes a 30 business day negotiation period and a 4 business day window to initiate IDR after it ends, subject to current guidance and extensions, on its About Independent Dispute Resolution page. Owners should establish a dated case log for eligibility review, initial payment or denial, negotiation notice and each deadline. Retain supporting evidence through submission and determination. Review CMS's IDR notices and updates before filing because CMS can revise its forms, fees or operating procedures. IDR does not set a general contracted rate or replace payer contract negotiations.
MIPS and the Quality Payment Program
The Quality Payment Program (QPP) includes MIPS and Advanced Alternative Payment Models. Clinicians who are MIPS eligible can receive a performance-based payment adjustment. Group owners can confirm eligibility and participation method by clinician and group, assign reporting duties, monitor measure and promoting interoperability requirements, and retain submission records. Use the CMS Quality Payment Program page and the QPP portal for current participation and reporting information. Review annual PFS rule changes for QPP policy updates and operational deadlines.
Site of service and ASC considerations
Professional anesthesia payment and facility payment are separate. CMS explains that PFS payments in facility settings generally reflect the physician or practitioner's resources, while the facility is paid through its applicable system. The ASC payment page lists covered procedure codes and facility payment groups; the ASC payment rates and addenda page posts periodic files. Use these to assess facility procedure eligibility and facility payment changes, while checking professional anesthesia rates separately through PFS and the group's payer contract.
When an ASC or hospital changes its service mix, scheduling, ownership or payer participation, compare the facility agreement with staffing and professional billing assumptions. Confirm the responsible party for authorization and credentialing. Confirm claim ownership. Include supplies and required patient notices. Facility eligibility for a procedure does not determine the professional anesthesia group's contracted payment.
Monthly change tracker
| What changed | Where to check | What to do |
|---|---|---|
| PFS RVUs, conversion factors, GPCIs, code status or payment policy | CMS PFS final rule and payment files; PFS Look-Up Tool | Compare affected codes and localities with the prior file; model effect using actual units and claims; update fee schedules and billing edits; revise forecasts separately after confirming effective dates. |
| MAC LCD, billing article or jurisdiction update | Medicare Coverage Database; LCD overview and MACs | Match the policy to group locations and codes; review effective dates; assign documentation and billing steps, plus authorization or appeal changes. |
| Medicaid rate, method or managed care change | Medicaid Financial Management; State Plan Amendments and each state agency or plan bulletin | Record state and plan separately; verify the applicable rate exhibit and effective date; reconcile claims after implementation. |
| Commercial contract amendment, fee schedule or claims edit | Executed agreement, payer notice, provider manual and remittance data | Check notice and amendment rights; compare code mapping, unit rules and payment; negotiate or appeal within contract windows; measure actual collections. |
| Prior authorization requirement or workflow update | CMS CMS-0057-F page; payer medical policy and provider portal | Confirm payer and service. Confirm the site of care. Name the responsible party; update the authorization matrix; track preventable denials and delays. |
| No Surprises Act, IDR forms, deadlines or operations update | CMS No Surprises Act page; IDR overview; CMS notices | Check claim eligibility and current process; calendar each negotiation and filing deadline; retain payment offers and supporting records. |
| MIPS or QPP eligibility, measures, reporting or deadlines | CMS QPP; QPP portal | Confirm each clinician's status and reporting route; assign a reporting owner; review data and preserve submission confirmation. |
| ASC covered code or facility payment file | ASC payment rates and addenda; ASC payment overview | Check facility procedure status and payment group; update facility planning separately from professional anesthesia reimbursement. |
How to use this tracker monthly
- Assign one owner for policy monitoring and one operational lead for billing and contracting follow-through.
- Check CMS PFS, MAC coverage, QPP, No Surprises Act and ASC sources, plus each state Medicaid agency and contracted payer's notices.
- Record the source link, date reviewed, effective date, codes, states and facilities affected, then identify relevant payers.
- Compare the change with contract terms, authorization ownership, claims edits, staffing assumptions and facility agreements.
- Quantify exposure using actual cases and units. Compare allowed amounts with denials and collections; mark estimates as estimates.
- Assign an action and due date, then verify implementation against remittances and contract records; review denials separately.
Contact
For owner resource questions, email richard@doctorsinvestorclub.com. Do not send patient information or confidential payer contracts in an introductory message.
