DermatologistsMedicare Physician Fee Schedule
The Medicare Physician Fee Schedule (PFS) uses relative value units (RVUs) for clinician work, plus practice and malpractice expenses. CMS applies geographic practice cost indices (GPCIs) to account for local cost differences and multiplies the adjusted RVUs by the conversion factor. CMS sets the conversion factor through annual rulemaking within statutory requirements and finalized policy updates; the annual rule also revises RVUs along with GPCIs and payment policy. The CY 2026 PFS final rule fact sheet states that 2026 has separate conversion factors: $33.57 for qualifying APM participants and $33.40 for clinicians who are not qualifying APM participants. Those are national conversion factors, not a practice-specific allowed amount. Locality, code, modifiers along with site and other payment rules affect the claim result.
Use the CMS PFS Look-Up Tool to compare code pricing along with RVUs and payment policies by year and locality. CMS describes the tool as an aid; the definitive payment files are available through the applicable Medicare Administrative Contractor (MAC). Preserve the year, locality, participating status where relevant along with modifier and place of service in any internal comparison.
Dermatology code families to monitor
CMS pricing and coverage can change by code, component along with locality and place of service. Build an internal code list from the services your clinicians actually bill. Common families include:
| Service line | Code families to include | Owner review |
|---|---|---|
| Evaluation and management | Office and outpatient E/M, preventive services where applicable | Compare established and new patient mix, documentation patterns, modifier use and payer edits. |
| Diagnostic procedures | Skin biopsy along with pathology and laboratory services | Reconcile professional and technical components, billing entity, pathology arrangements and bundling edits. |
| Destruction and lesion treatment | Benign and premalignant lesion destruction, including actinic keratosis services | Check code-specific unit rules, diagnosis edits, frequency limits and MAC coverage articles. |
| Excision and repair | Benign and malignant lesion excision, intermediate or complex repair | Track lesion size, anatomic grouping, pathology results, global period and payer bundling edits. |
| Mohs surgery | Mohs stages and associated tissue examination, with repair services as applicable | Review annual code changes, stage reporting along with documentation and local coverage requirements. |
| Phototherapy and other office procedures | Phototherapy along with injections and other recurring in-office services | Validate supervision along with drug and supply billing, authorization requirements and equipment cost allocation. |
For each high-volume code, compare work, practice expense and malpractice RVUs along with facility and non-facility pricing, payment indicators along with GPCI and allowed amount across the current and prior fee schedule years. Investigate material movement against the final rule and the code's actual payer remittance. Do not assume an RVU change creates the same percentage change in collections: conversion factors, locality, contract terms, edits along with denials and volume also matter.
MAC jurisdictions and local coverage
Original Medicare is administered through regional MAC jurisdictions. The MAC serving a practice can affect claims processing, local pricing for certain codes and local coverage policy. Use CMS's MAC and LCD information and the Medicare Coverage Database to identify the contractor, active local coverage determinations (LCDs), related billing articles, proposed policies, effective dates and revisions for the practice's states and services.
Dermatology owners should prioritize policies that may intersect with lesion destruction, excision, biopsy, pathology, phototherapy, wound care and drugs or biologics. An LCD is local to the MAC jurisdiction. Verify whether a rule is active and applies to the billed code and diagnosis before changing workflows. Keep a dated policy copy, implementation owner and a record of affected claims. National Coverage Determinations and Medicare manuals may also apply; a local policy search is not a complete coverage review.
Medicaid and commercial contracts
Medicaid fee schedules, covered benefits, medical necessity criteria, authorization processes and managed care arrangements vary by state and, in many markets, by plan. Use the Medicaid state agency directory to reach the state's current provider materials. Compare state fee-for-service schedules with each contracted Medicaid managed care plan's provider manual and contract. Separate covered service policy from reimbursement rate; both can differ.
Commercial negotiations are most useful when tied to claim-level evidence. Prepare payer and product level allowed amounts along with denial and appeal rates, authorization turnaround, clean-claim performance, patient responsibility, timely filing and credentialing data. Contract levers can include fee schedule basis and annual updates, code-specific rates, carve-outs for high-cost drugs or services, multiple procedure and assistant rules, bundling edits, authorization lists, medical policy notice along with audit and recoupment periods, timely payment, escalation contacts, termination rights, and data access. Confirm whether amendments apply to every product and location, how the plan defines the benchmark, and which document controls if terms conflict. Have qualified contracting counsel review proposed language.
Prior authorization
Authorization rules depend on payer, product, service along with diagnosis and location. Track each plan's current authorization list and submission channel for dermatology procedures, drugs along with imaging and pathology-related services. Record decision deadlines, required clinical or administrative materials, approval duration, retrospective review rules, peer-to-peer steps, appeal path and denial reasons. Measure staff hours and days to decision alongside authorization-related cancellations and denials.
CMS's Interoperability and Prior Authorization final rule, CMS-0057-F, sets requirements for specified Medicare Advantage, Medicaid along with CHIP and federally facilitated marketplace payers. CMS states that certain provisions began applying in 2026, with API requirements and other provisions on different implementation schedules. The rule does not impose one universal authorization policy on every commercial product. Check the final rule and payer communications for the provision and effective date that apply to each plan. Map electronic workflows and track decision notices, denial reasons and turnaround against the applicable requirements.
No Surprises Act and independent dispute resolution
The CMS No Surprises page summarizes federal protections and provider resources. The law restricts balance billing in specified circumstances, including many emergency services and certain non-emergency services furnished by out-of-network providers at in-network facilities. It does not make every out-of-network dermatology claim eligible for federal independent dispute resolution (IDR). Check whether the service along with plan and state fall under federal or state rules before treating a claim as eligible.
CMS's IDR overview explains the open negotiation period and federal process. For eligible disputes, the parties generally complete a 30-business-day open negotiation period before initiating IDR; the overview describes a four-business-day filing window after that period, subject to extensions. Track notice dates, negotiation offers, eligibility basis, filing deadlines, fees along with determinations and payment. Use current CMS notices because procedures and fees can change. IDR is a defined process for eligible out-of-network payment disputes, not a general appeal route for ordinary in-network underpayment.
MIPS and QPP
The CMS Quality Payment Program has two tracks: MIPS and Advanced APMs. Check each clinician's eligibility and participation status in the QPP portal. For clinicians in MIPS, identify the applicable performance year, reporting route, measure requirements, submission owner and deadlines. Review quality, improvement activities, promoting interoperability and cost requirements as applicable. Confirm whether group, individual, virtual group, MVP or APM participation changes the reporting approach. Retain submission receipts and review feedback and payment adjustment notices. Do not assume that all clinicians in a dermatology group share the same status.
Site of service and ASC considerations
Office, hospital outpatient department and ambulatory surgical center (ASC) claims can have different professional and facility payment treatment. Confirm place of service, billing entity, ownership, enrollment, contract terms and applicable facility rules before comparing rates. The CMS ASC payment page links to approved codes and rates; CMS's ASC payment addenda provide current code files. Verify whether a procedure is on the ASC Covered Procedures List and its payment indicator. The CMS Medicare Payment Systems guide notes that office-based procedures performed in a physician office at least half the time may be paid under a specific lower-of method in an ASC. ASC inclusion does not require a procedure to be performed in an ASC; the service setting remains subject to applicable coverage, safety along with enrollment and payer rules.
For each location, compare net professional receipts, facility revenue where applicable, staffing, supplies, rent, equipment, authorization, patient cost sharing and denials. A higher professional fee alone does not establish which setting produces better practice economics.
Monthly change log
| What changed | Where to check | What to do |
|---|---|---|
| PFS RVUs, conversion factors, GPCIs or payment policy | CMS PFS final rule and fact sheets and PFS Look-Up Tool | Reprice the practice's high-volume code list by locality and service setting; compare with remittances and flag margin shifts. |
| MAC, LCD or billing article status | CMS LCD information and Medicare Coverage Database | Confirm effective date along with scope and affected codes; assign workflow and documentation updates to a named owner. |
| Medicaid benefit, fee schedule or managed care policy | State Medicaid agency directory and each plan's provider portal | Update the state and plan matrix, authorization rules and expected allowed amounts; notify scheduling and billing teams. |
| Commercial fee schedule, edits or contract language | Contract amendments, payer bulletins and internal remittance analysis | Validate product and location scope, update contract modeling, and route disputed terms or underpayments for review. |
| Prior authorization requirements or deadlines | CMS-0057-F rule page and payer manuals | Update the authorization matrix and submission workflow; monitor turnaround along with denials and affected appointments. |
| No Surprises Act or federal IDR procedure | CMS No Surprises resources and IDR overview | Review eligibility and current deadlines; reconcile open negotiations, filings along with determinations and payments. |
| QPP or MIPS participation and reporting | QPP portal and CMS QPP page | Recheck clinician status, reporting requirements along with deadlines and submission evidence for each performance year. |
| ASC code list, rates or site-of-service rules | CMS ASC payment files and place of service codes | Confirm code eligibility and payment indicator; validate claim setting and compare professional and facility economics. |
How to use this tracker monthly
- Assign one owner to check CMS rule and payment updates, MAC notices, Medicaid plans and commercial payer bulletins.
- Refresh a short list of the practice's highest volume and highest variance codes, including locality along with modifiers and site of service.
- Compare allowed amounts, denials, authorization delays, write-offs and appeals by payer and product against the prior month.
- Log each relevant policy change with its source, effective date, affected services, implementation owner and completion date.
- Escalate unexplained payment shifts, coverage questions and contract disputes to the appropriate billing, compliance or qualified professional adviser.
Contact
For owner resource questions, email Richard@DoctorsInvestorClub.com. Do not include patient-level or confidential payer information in an introductory message.
