Medicare outpatient pricer: hospital outpatient and ASC

cmswebpricer.comIndependent · not affiliated with CMS
CY2026 outpatient rates

Independent pricing tool. Not affiliated with, endorsed by, or operated by CMS or any government agency. Estimates are not a claims determination.

Service

Payment system

Procedure and site

Colonoscopy w/lesion removal
New York-Presbyterian Hospital · CCN 330101 · New York, NY · wage index 1.3697

EAPG line

EAPG base rates and weights are set by each state or plan. Enter the ones from your fee schedule.

Claim lines

Payment

Sample result for the example procedure, saved from the pricing engine. Change the inputs and press Price to price your own.

    How the payment builds

    StepHospital outpatientASCDifference

    Checks

    Status and payment indicators

    Claim edits

    Not screened
    Screen this code on a claim for NCCI pair, medically unlikely units, packaging and add-on edits.

    Patient share

    Edit reference

    Hospital outpatient vs ASC, explained

    Enter a HCPCS or CPT code and, optionally, a hospital. The pricer looks up the code's APC and status indicator for hospital outpatient payment and its payment indicator for ambulatory surgical centers, applies each setting's labor share to the local wage index, and splits the allowed amount into program payment and patient share.

    The site-of-service difference shows how much more the hospital outpatient department is paid for the same procedure. Claim edits mode screens a claim's lines for NCCI procedure pairs, medically unlikely units, packaging and add-on codes, and EAPG mode prices a Medicaid outpatient line from your own base rate and weight.

    Questions

    Why does the hospital outpatient rate differ from the ASC rate?

    The two settings have separate conversion factors and labor shares, so the same procedure is paid at different rates. The difference is shown in dollars and as a ratio.

    What does status indicator T mean?

    A significant procedure subject to the multiple-procedure reduction: when billed with another T procedure the same day, the lower-paid one is reduced 50%.

    Can I price without a hospital?

    Yes. Leave the hospital blank to see the national rate, or enter a wage index.