No Medicare rate for what you do: the anchors that still work

Why the lookup returned a letter instead of a price

For three of the letters, because no relative value units are on file for the code. The search that returned the letter is CMS's Physician Fee Schedule Look-Up Tool 1Ref 1Centers for Medicare & Medicaid Services (2026).Medicare Physician Fee Schedule (PFS) Look-Up Tool.Names and locates the CMS tool a clinician uses to look up a CPT code's Physician Fee Schedule entry. No pricing fact in this article is sourced to it beyond identifying the tool., and the letter is a status indicator. California's workers' compensation regulator, which builds its own physician schedule on Medicare's file, states what those letters mean for pricing: procedures with status indicator C, N or R do not have RVUs assigned in CMS's National Physician Fee Schedule Relative Value File 2Ref 2California Department of Industrial Relations, Division of Workers' Compensation (2026).FAQs: Physician and Non-Physician Practitioner Fee Schedule (RBRVS).That PFS status indicators C, N and R mean no RVUs are assigned in CMS's National Physician Fee Schedule Relative Value File; that a code with no listed RVUs is paid By Report under California's schedule; and the statutory aggregate cap of 120 percent of the Medicare payment system's fees for physician services as they appeared on July 1, 2012..

Look up the definition of the letter you got before pricing anything. The state regulator names those three together because they share one consequence, an absent relative value, and that shared consequence is what every anchor below works from. Why a given code carries its particular letter is a separate question, and it is worth answering first, because the answer points at who is expected to set the number.

Almost every anchor below is a state instrument, and states do not run the same ones.

California appears throughout this page because its schedule publishes its mechanism in documents anyone can read. Your state may price the same code on a different basis, may price it by a route California never uses, or may publish no physician schedule at all. The rule that governs your bill is your state's.

Borrow a schedule that already priced it

A workers' compensation fee schedule is a public price list built for exactly this problem. California's Official Medical Fee Schedule for physician and non-physician practitioner services is a live regulation, codified at 8 CCR section 9789.10 and following under Labor Code section 5307.1, carrying a revision effective March 1, 2026 3Ref 3California Department of Industrial Relations, Division of Workers' Compensation (2026).Physician and Non-Physician Practitioner Fee Schedule (Official Medical Fee Schedule).That California's workers' compensation physician fee schedule is a live regulation codified at 8 CCR section 9789.10 et seq. under Labor Code section 5307.1, with a revision effective March 1, 2026, so it is a real named public schedule a reader can point to.. It prices codes off Medicare's relative values. It also publishes a rule for the codes Medicare never valued.

By Report is the schedule's name for a service it will not price from a table, billed instead with a description the payer prices from. The fact sheet the state published when it moved to a resource-based relative value scale states the general rule in a single line: if Medicare has not established RVUs for a reimbursable procedure code, the services are priced By Report 4Ref 4California Department of Industrial Relations, Division of Workers' Compensation (2014).Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule, Effective January 1, 2014.The general rule that a reimbursable code Medicare has not valued is priced By Report; the state's own figure that fee-schedule-rate coverage rose from 90 percent to at least 96 percent after the 2014 reform, leaving roughly 4 percent or more By Report; and the published RVU-times-geographic-factor-times-conversion-factor formula, whose dollar figures are that 2014 document's own.. The FAQ says the same thing code by code, from the other direction: if payable, the listed RVUs govern, and if no RVUs are listed, By Report 2Ref 2California Department of Industrial Relations, Division of Workers' Compensation (2026).FAQs: Physician and Non-Physician Practitioner Fee Schedule (RBRVS).That PFS status indicators C, N and R mean no RVUs are assigned in CMS's National Physician Fee Schedule Relative Value File; that a code with no listed RVUs is paid By Report under California's schedule; and the statutory aggregate cap of 120 percent of the Medicare payment system's fees for physician services as they appeared on July 1, 2012..

By Report did not disappear when the schedule improved. Describing the 2014 reform, the state put the share of payments made at fee schedule rates rather than By Report at 90 percent rising to at least 96 percent 4Ref 4California Department of Industrial Relations, Division of Workers' Compensation (2014).Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule, Effective January 1, 2014.The general rule that a reimbursable code Medicare has not valued is priced By Report; the state's own figure that fee-schedule-rate coverage rose from 90 percent to at least 96 percent after the 2014 reform, leaving roughly 4 percent or more By Report; and the published RVU-times-geographic-factor-times-conversion-factor formula, whose dollar figures are that 2014 document's own.. Read from the other end, that leaves roughly 4 percent or more of payments still priced from a written description, after a reform built to shrink that exact residue.

But a workers' compensation schedule prices workers' compensation work. It obligates no commercial payer and no cash patient to anything. What it hands you is a published number for your service, produced by a state agency and dated, which is a different grade of evidence from a competitor's posted price.

What a by-report price has to survive

A by-report price is a number you have to explain. The schedule prices from your description, so the description carries the fee: what was done, how long it took, what it required, what made it unlike the nearest code that does have a value. California's schedule then adds a ceiling that anyone anchoring to Medicare should read closely. Its statute sets the aggregate at 120 percent of the estimated annualized aggregate fees prescribed in the Medicare payment system for physician services as it appeared on July 1, 2012 2Ref 2California Department of Industrial Relations, Division of Workers' Compensation (2026).FAQs: Physician and Non-Physician Practitioner Fee Schedule (RBRVS).That PFS status indicators C, N and R mean no RVUs are assigned in CMS's National Physician Fee Schedule Relative Value File; that a code with no listed RVUs is paid By Report under California's schedule; and the statutory aggregate cap of 120 percent of the Medicare payment system's fees for physician services as they appeared on July 1, 2012..

That anchor is frozen to a date.

A schedule or a contract that promises a multiple of Medicare may be promising a multiple of a Medicare that stopped moving years ago. Anyone pricing off medicare should find out which year the clause names before treating this year's conversion factor as the base, whether the term in the document is a Medicare multiple or a fee schedule anchor. The two phrases behave identically and the frozen date is the thing that moves the money.

Find the documentation requirement in your own schedule before you send the first by-report bill. A description written after a denial is a rebuttal, and it gets read as one.

Crosswalk to a comparable code, the way Medicare does

Medicare's own answer to an unpriced code is to find one that resembles it. Under the Clinical Laboratory Fee Schedule, crosswalking is used if it is determined that a new test is comparable to an existing one, and the new code takes the existing test's payment amount 5Ref 5Code of Federal Regulations (Centers for Medicare & Medicaid Services) (2026).42 CFR 414.507 -- Payment for clinical diagnostic laboratory tests.The definition of crosswalking for a new clinical diagnostic laboratory test comparable to an existing one, and that a test furnished on or after January 1, 2018 is paid at the weighted median of reported private payer rates without geographic or budget-neutrality adjustment.. Where no comparable existing test is available, the regulation names a second route, gapfilling, in which a local Medicare contractor sets the amount instead 6Ref 6Code of Federal Regulations (Centers for Medicare & Medicaid Services) (2026).42 CFR 414.508 -- Payment for a new clinical diagnostic laboratory test.The definition of gapfilling, used when no comparable existing clinical diagnostic laboratory test is available, in which a local Medicare contractor sets the amount..

Both rules are laboratory rules. They govern the Clinical Laboratory Fee Schedule, a separate schedule from the Physician Fee Schedule, and they do not describe how a new physician-service code gets its relative values. But the reasoning is the reasoning a payer already recognizes, whatever schedule you are arguing under: name the closest priced code, say why it is comparable, and price from there.

The same regulation also shows where a public rate comes from when relative values play no part. For a test furnished on or after January 1, 2018, the payment rate equals the weighted median for the test, computed from reported private payer rates and not adjusted for geography or budget neutrality 5Ref 5Code of Federal Regulations (Centers for Medicare & Medicaid Services) (2026).42 CFR 414.507 -- Payment for clinical diagnostic laboratory tests.The definition of crosswalking for a new clinical diagnostic laboratory test comparable to an existing one, and that a test furnished on or after January 1, 2018 is paid at the weighted median of reported private payer rates without geographic or budget-neutrality adjustment.. That is a federal fee schedule assembled out of what commercial payers paid. A cash price set from a survey of what payers in your area pay for the nearest comparable service is the same move at your scale.

When the pieces are valued but the whole is not

Sometimes the service has no rate while its components do, and the schedule publishes the arithmetic that turns components into dollars. California's fact sheet prints its own worked example for an office visit: work, practice expense and malpractice relative values, each multiplied by a statewide geographic adjustment factor, summed, then multiplied by a category-specific conversion factor. Those are 2014 figures in a 2014 document, reproduced here as the shape of the calculation and not as current pricing 4Ref 4California Department of Industrial Relations, Division of Workers' Compensation (2014).Fact Sheet on the Resource Based Relative Value Scale (RBRVS) Fee Schedule, Effective January 1, 2014.The general rule that a reimbursable code Medicare has not valued is priced By Report; the state's own figure that fee-schedule-rate coverage rose from 90 percent to at least 96 percent after the 2014 reform, leaving roughly 4 percent or more By Report; and the published RVU-times-geographic-factor-times-conversion-factor formula, whose dollar figures are that 2014 document's own..

`[(3.17 x 1.040) + (2.35 x 1.1606) + (0.26 x 0.6636)] x $38.3542 = $237.67`

The dollar figure at the end belongs to that document and that year. The equation is the part you keep: relative values times geographic factors, summed, times a conversion factor. Where your service has no relative values of its own, the equation still runs on the closest code that does, and the difference between that code and your service becomes the thing you describe, the thing you price, and the thing you defend if anyone asks.

Cash prices and the ceilings that already exist

A cash price has fewer public anchors, and one of them is now statutory. Congress wrote a dollar ceiling into the tax code for direct primary care in 2025: such an arrangement is excluded from counting as a disqualifying health plan for health savings account purposes only while the aggregate monthly fee stays at or under $150 per individual, or twice that amount where the arrangement covers more than one individual 7Ref 7119th Congress (2025).Public Law 119-21 -- An Act To provide for reconciliation pursuant to title II of H. Con. Res. 14 (Sec. 71308, Treatment of Direct Primary Care Service Arrangements).The statutory monthly fee ceiling of $150 per individual, twice that for an arrangement covering more than one individual, that keeps a direct primary care service arrangement outside the HSA-disqualifying health plan definition, effective for months beginning after December 31, 2025 and inflation-indexed for taxable years beginning after 2026 off a calendar year 2025 base.. It applies to months beginning after December 31, 2025.

That ceiling is about tax eligibility. It says nothing about what direct primary care practices actually charge, and it sets no price control, so a fee above the line is not prohibited. It simply falls outside the exclusion, which is a consequence for the patient's health savings account and a question to run with your CPA before you build a membership price around it.

The caps are indexed for taxable years beginning after 2026, off a calendar year 2025 base 7Ref 7119th Congress (2025).Public Law 119-21 -- An Act To provide for reconciliation pursuant to title II of H. Con. Res. 14 (Sec. 71308, Treatment of Direct Primary Care Service Arrangements).The statutory monthly fee ceiling of $150 per individual, twice that for an arrangement covering more than one individual, that keeps a direct primary care service arrangement outside the HSA-disqualifying health plan definition, effective for months beginning after December 31, 2025 and inflation-indexed for taxable years beginning after 2026 off a calendar year 2025 base.. That is the quality that makes a statute usable as an anchor when nothing else is published: a number with a date, a citation and a stated direction of travel, which a patient can look up without taking your word for it.

Set the floor from your own numbers, and write the reason down

Where no public schedule reaches your service, the price starts at your own cost per hour and stops where a patient stops agreeing. That floor is arithmetic you already hold: the hours the service consumes, the room and staff time behind it, the share of overhead it carries, and the self-employment tax that comes out of the margin before anything is yours. The same conversion that turns locum and 1099 rates into an hourly number runs here, in the same direction.

Whatever anchor you land on, record which one it was and what you compared it against. A payer's review, a patient's question and your own repricing eighteen months from now all want the same thing, and a fee with no written basis has nothing to give any of them. Name the schedule and the section, or the comparable code and the reason it is comparable, or the cost build and the date you ran it.

A clinician weighing opting out mid-career is asking a nearby but different question, and that one turns on enrollment status rather than on where a rate comes from. For pricing, the work is the same either way. Save the note in the same file as the fee itself, so the next person who opens it finds the reasoning attached to the number.