Revising a contractor fee | FCSO Medicare

Revising a contractor fee

June 2, 2026

What we need

To reconsider a contractor developed fee, it is necessary to provide supporting documentation that was not available at the time of our initial decision. Relevant materials are suggested below.
The current fee will remain in place when a request does not provide compelling information.
Forward your request and the necessary information to medicalaffairs@guidewellsource.com

Code types	Supporting documentation
Category I Examples: 15011, 15012, 15013, etc.	Education about the procedure A clinical vignette that describes a typical patient, procedure, and/or device What specialties are mainly involved in performing the procedure and any specialty guidelines that have been published What services may be considered integral when performing the procedure Physician time involved Direct and indirect costs Any supporting materials submitted to the CPT Panel and/or RUC Additional supplies or device Level of physician effort Potential crosswalk codes for comparison Product life expectancy Published literature Random Clinical Trial (RCT) results Bibliography Articles Society guidelines
Category III Examples: 0202T, 0338T, etc.	Education about the procedure A clinical vignette that describes a typical patient, procedure, and/or device What specialties are mainly involved in performing the procedure and any specialty guidelines that have been published What services may be considered integral when performing the procedure Physician time involved Direct and indirect costs Any supporting materials submitted to the CPT Panel and/or RUC Additional supplies or device Level of physician effort Potential crosswalk codes for comparison Product life expectancy Published literature Random Clinical Trial (RCT) results Bibliography Articles Society guidelines
Clinical laboratory and proprietary laboratory analyses (PLA) - Examples: 0581U, 0585U, etc.	Education about the procedure Direct costs Labor costs Capital equipment costs Goods cost Indirect costs Summary of sample processing Algorithm involvement Randomized-controlled trials (RCT) results Published literature
Drugs, biologicals, and biosimilars - Examples: J0207, J0567, Q5157, etc.	Change in average wholesale price (AWP) or wholesale acquisition cost (WAC) Change to code descriptor
HCPCS - Examples: G0555, G0564, G0565, etc.	Education about the procedure A clinical vignette that describes a typical patient, procedure, and/or device What specialties are mainly involved in performing the procedure and any specialty guidelines that have been published What services may be considered integral when performing the procedure Physician time involved Direct and indirect costs Any supporting materials submitted to the CPT Panel and/or RUC Additional supplies or device Level of physician effort Potential crosswalk codes for comparison Product life expectancy Published literature Random Clinical Trial (RCT) results Bibliography Articles Society guidelines
Radiopharmaceuticals - Examples: A9513, A9515, etc.	Change in average wholesale price (AWP) Change to code descriptor

References
•    CMS ASP Pricing Files
•    CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 20
•    CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 17
•    Understanding local pricing