Payer reimbursement calculators
Price a professional-service line two ways: Medicare's Physician Fee Schedule, or your state's Medicaid Title XIX professional fee schedule — either way flags when your own charge is priced below it.
| CPT/HCPCS | Modifier | Description | Site of service | Units | Your charge ($) | Diagnosis (ICD-10) |
|---|
| Code | Modifier | Description | Site | Pricing | Medicaid rate | Your charge |
|---|---|---|---|---|---|---|
| Total Medicaid allowable | ||||||
Oklahoma (SoonerCare): OHCA's own published Title XIX Professional Services fee schedule amount for the code — the facility amount when billed facility, else OHCA's base amount — × units. No RVU math; OHCA's file already gives the final dollar figure. Anesthesia codes (00100–01999) are deliberately excluded — OHCA's own State Plan prices those by base units + time units × a conversion factor, not a flat total, which this calculator doesn't model. See docs/MEDICAID-PROFEE.md.
Modifiers — one per line: 26/TC look up OHCA's own published professional/technical-component amount when it publishes one; 50 (bilateral), 62 (co-surgeon), and 80/81/82/AS (assistant at surgery) apply CMS's standard Medicare payment percentage, gated by that code's real CMS payment-policy indicator (OHCA follows Medicare RBRVS methodology for professional services); 51 (multiple procedures) ranks every modifier-51 line on the claim by fee and reduces the 2nd–5th to 50%, same as CMS; 59 and 66 are recorded but priced with no dollar change — 59 bypasses an NCCI edit this app doesn't model, and 66 is CMS "by report" with no fixed percentage. Every priced line shows the exact rule applied underneath it. Not Oklahoma's own published policy — CMS's standard percentages, used because OHCA documents none of its own for these modifiers. The MPFS (Medicare) tab applies the same CMS payment-policy rules to its own RVU-based formula.
Texas (HHSC): Medicare RVU (national, no GPCI/locality adjustment) × HHSC's own published conversion factor × units — HHSC's documented Resource-Based Fee methodology. Uses the adult ($26.7305) conversion factor; this calculator has no patient-age input, so the pediatric rate is not applied. See docs/MEDICAID-PROFEE.md.
No Local Coverage Determination (LCD) / medical-necessity check here — LCDs are a Medicare concept, not Medicaid's. This tool does not cap payment at your charge — it reports the Medicaid fee, and flags when your charge is below it.
| Code | Modifier | Description | Site | Total RVU | Medicare rate | Your charge | Coverage |
|---|---|---|---|---|---|---|---|
| Total Medicare allowable | |||||||
Medicare allowable = (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor × professional multiplier × units.
PE RVU uses the facility or non-facility value depending on the line's site of service — Medicare assumes a facility absorbs more of the practice-expense overhead, so the facility PE RVU (and therefore the rate) is lower.
Professional multiplier is 1 for standard (Method I) billing, or 1.15 for a Critical Access Hospital billing under Method II (the CAH bills for the professional component itself).
Modifiers — one per line, applied to the Medicare rate: 26 swaps in the code's own published professional-component RVU row from CMS's RVU26A file; TC does the same for the technical-component row. 50 (bilateral) pays 150% when CMS's Bilateral Surgery indicator for the code is "1". 62 (co-surgeon) pays 62.5% of the global fee when CMS allows it (Co-Surgeons indicator 1 or 2). 80/81/82 (physician assistant at surgery) pay 16% of the global fee; AS (non-physician practitioner assistant) pays 13.6%. 51 (multiple procedures) ranks every modifier-51 line on the claim by its already-adjusted fee, pays 100% for the highest and 50% for ranks 2–5. 59 and 66 are recorded but priced with no dollar change — 59 bypasses an NCCI edit this app doesn't model, and 66 is CMS "by report" with no fixed percentage. Each priced line shows the exact rule applied underneath it. All percentages are CMS Medicare Claims Processing Manual Ch. 12 / RVU26AR.pdf policy, gated by the real per-code CMS payment-policy indicators.
Coinsurance is estimated at the standard 20% of the Medicare allowable, assuming your annual Part B deductible is already met.
Coverage checks every diagnosis entered on a line against real Local Coverage Determinations (LCDs) for MAC Jurisdiction H (Novitas Solutions — covers both Oklahoma and Texas). This is advisory only: it never changes the Medicare rate shown. You'll see it flagged before you even calculate — looking up a code that's governed by an LCD shows a warning in the lookup result, and its row in the Codes to Price table shows "LCD Lxxxxx applies" with the Diagnosis field highlighted until you add one. After you calculate, the Coverage column breaks it down per diagnosis: a ✓ green chip for each one that's on the LCD's covered list, a ✗ chip for each one that isn't, a status badge, and a citation line naming the exact LCD (and its linked Local Coverage Article) that justifies the flag — everything you need for an appeal is right there, no hovering required. "No LCD" (the common case) means the code isn't restricted by any LCD. "Diagnosis needed" means an LCD governs the code and none was entered yet. A line reads "Covered" if ANY ONE of its diagnoses matches (standard diagnosis-pointer convention); "Not covered" means none of them do — consider an Advance Beneficiary Notice (ABN) in that case.
This tool does not cap payment at your charge the way the EAPG/DRG calculators do — it reports Medicare's own rate, and flags when your charge is below it.