Medicare coverage and fee-schedule amounts for CPT/HCPCS codes against a diagnosis
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For a diagnosis and one or more CPT/HCPCS codes, report what CMS Local Coverage Articles record for each code, which ICD-10 diagnoses those articles list as covered or non-covered, and the CMS Physician Fee Schedule PROFESSIONAL amount where a national rate exists. Setting matters and is stated: codes performed only in a facility return not_applicable_in_this_setting rather than an invented office price, and codes CMS does not pay under the PFS (status I, X, N, E, B, P) return not_payable_under_pfs rather than a figure computed from published RVUs. Coverage is contractor-specific. Does NOT compare clinical effectiveness or recommend treatment, and a missing national rate is never treated as non-coverage. The amount is the clinician fee only — not the facility fee, device or imaging.
Comma-separated CPT/HCPCS codes, e.g. "27447,20610"
ICD-10 code or prefix, e.g. "M17" (knee osteoarthritis)
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For a diagnosis and one or more CPT/HCPCS codes, report what CMS Local Coverage Articles record for each code, which ICD-10 diagnoses those articles list as covered or non-covered, and the CMS Physician Fee Schedule PROFESSIONAL amount where a national rate exists. Setting matters and is stated: codes performed only in a facility return not_applicable_in_this_setting rather than an invented office price, and codes CMS does not pay under the PFS (status I, X, N, E, B, P) return not_payable_under_pfs rather than a figure computed from published RVUs. Coverage is contractor-specific. Does NOT compare clinical effectiveness or recommend treatment, and a missing national rate is never treated as non-coverage. The amount is the clinician fee only — not the facility fee, device or imaging.
| Argument | Type | Description |
|---|---|---|
| codes | string | Comma-separated CPT/HCPCS codes, e.g. "27447,20610" |
| diagnosis | string | ICD-10 code or prefix, e.g. "M17" (knee osteoarthritis) |
{
"type": "object",
"required": [],
"properties": {
"codes": {
"type": "string",
"description": "Comma-separated CPT/HCPCS codes, e.g. \"27447,20610\""
},
"diagnosis": {
"type": "string",
"description": "ICD-10 code or prefix, e.g. \"M17\" (knee osteoarthritis)"
}
}
}