If you’re a healthcare provider serving Virginia Medicaid patients, knowing the current fee schedules can mean the difference between getting paid and getting billed incorrectly. The Virginia Medicaid fee schedule is the foundation for all billing activities and sets the maximum payment rates for services across the state.
Whether you’re a physician with a private practice, a hospital billing department or an ancillary service provider, navigating Virginia’s reimbursement system requires staying up to date with the official rates and guidelines. This guide breaks down everything you need to know about Virginia Medicaid fee schedules from accessing current rates to billing requirements.
Virginia Medicaid Fee Schedules Overview
A Virginia Medicaid fee schedule is a comprehensive list of Medicaid covered services, each with a unique procedure code and corresponding maximum payment rate. These schedules are the official reference for billing and reimbursement for all providers who participate in Virginia’s Medicaid program.
The Virginia Department of Medical Assistance Services (DMAS) manages and publishes these fee schedules which set standardized payment caps to prevent overpayment and ensure consistency across providers statewide. This approach helps maintain program integrity and provides clear guidance for healthcare billing.
Virginia’s approach is similar to the Medicare Physician Fee Schedule for many services. However, the state applies specific adjustments to reflect local policy priorities, budget constraints and regional cost variations. For example, the Northern Virginia (NOVA) region gets higher reimbursement rates than the Rest of State (ROS) due to higher practice costs and cost of living factors.
Virginia Medicaid fee schedule rates are updated annually on July 1 of each state fiscal year, but emergency adjustments or legislative mandates can trigger mid-year changes. Providers get notified through DMAS bulletins, portal announcements and subscription alerts so you stay informed of rate changes.
The fee schedules serve multiple purposes beyond just rate setting. They provide transparency in government healthcare spending, create predictable revenue streams for providers and accountability mechanisms for state administrators and healthcare organizations.
Types of Virginia Medicaid Fee Schedules
Virginia Medicaid has separate fee schedules for different categories of services, each for specific provider types and service delivery models.
Physician Fee Schedule
The physician fee schedule covers evaluation and management services, procedures, consultations and specialized medical management. This schedule tracks CMS Medicare values with state adjustments for locality, practice costs and budget. CPT and HCPCS codes are organized by service with payment rates for each region. Common services include office visits, preventive care, diagnostic procedures and minor surgical interventions. The schedule distinguishes between professional and technical components for services like imaging and lab work so you can bill correctly when applicable.
Hospital Fee Schedules
Hospital reimbursement has separate inpatient and outpatient fee schedules. Inpatient hospital payments often use diagnosis-related groups (DRGs) or per diem payment models while outpatient departments get reimbursed through ambulatory payment classifications or fixed fee schedules.
These schedules account for the complexity of hospital operations including emergency department services, surgical procedures and specialized care units. Geographic adjustments apply to reflect the varying operational costs across Virginia’s diverse healthcare markets.
Dental Fee Schedule
Dental services have their own comprehensive fee schedule for oral health assessments, preventive care, restorations, oral surgery and orthodontics. These rates reflect provider qualifications and procedure complexity with special attention to pediatric dental services since they’re so important in Medicaid populations.
The dental fee schedule includes preventive services like cleanings and fluoride treatments, restorative procedures like fillings and crowns and specialized treatments like endodontics and periodontics.
Mental Health and Substance Abuse Treatment Fee Schedules
Dedicated schedules address behavioral health services including individual therapy, group counseling, psychiatric evaluations, medication management and care coordination. These rates align with federal parity requirements so mental health services get the same coverage as medical services.
Substance abuse treatment services include detoxification, rehabilitation programs, medication-assisted treatment and ongoing counseling support. The schedules recognize the specialized training required for these interventions and the importance of access to behavioral health care.
Durable Medical Equipment and Supplies Fee Schedules
The durable medical equipment schedule covers prosthetics, orthotics, wheelchairs, oxygen equipment, incontinence products and similar medical supplies. These rates reference CMS DMEPOS schedules but with state oversight and adjustment authority.
DME schedules include purchase and rental options for equipment with specific guidelines for replacement timelines and repair coverage. Prior authorization is required for high-cost items.
Transportation and Emergency Services Fee Schedules
Separate schedules cover non-emergent medical transportation (NEMT), advanced life support ambulance services, basic life support transport and other medically necessary transport options. These rates consider mileage, time factors and specialized equipment requirements.
Emergency services schedules address ambulance response, emergency department visits and urgent care services with consideration for rural and urban service delivery challenges.
Specialized Therapy Fee Schedules Ancillary services have detailed fee schedules to reflect the complexity of rehabilitation and therapy interventions.
Physical Therapy Fee Schedule
Physical therapy rates apply to specific CPT codes like therapeutic exercises (97110), manual therapy (97140) and neuromuscular reeducation (97112). The schedule outlines reimbursable time units, service frequency limits and code combinations to prevent over billing.
Regional adjustments ensure fair payment across Virginia’s varied healthcare markets, with higher rates in areas where costs exceed state averages. Documentation requirements specify the level of clinical detail needed to support medical necessity.
Occupational Therapy Reimbursement Rates
Occupational therapy services follow similar structure with rates assigned to evaluation codes, therapeutic activities and adaptive equipment training. The schedule addresses adult and pediatric populations with age-appropriate service definitions.
Special consideration is given to services provided in educational settings, long-term care facilities and community-based programs where occupational therapists address functional independence goals.
Speech-Language Pathology Fee Schedule
Speech therapy rates cover evaluation procedures, individual treatment sessions, group therapy and specialized interventions for swallowing disorders. The schedule recognizes the diverse settings where these services are delivered, from hospitals to schools to outpatient clinics.
Augmentative communication device assessments and training receive specific rate consideration given their importance for individuals with complex communication needs.
Rehabilitation Services and Long-Term Care Therapy Rates
Specialized schedules apply to services provided in skilled nursing facilities, rehabilitation hospitals and long-term acute care settings. These rates account for the intensity of institutional therapy services and the complex medical conditions that require this level of care.
Interdisciplinary team meetings, discharge planning activities and family training components are recognized within these schedules.
How to Get Virginia Medicaid Fee Schedules
Getting current Virginia Medicaid fee schedule information requires familiarity with DMAS digital resources and provider support systems.
Virginia DMAS Website Navigation
The official DMAS website is the primary source for all current and historical fee schedule documents. Fee schedules are organized by service category and effective date in the provider section. The site has a clear file structure to quickly find specific schedules.
The website has a search function to find specific CPT codes or service categories. Frequent users should bookmark frequently used schedules to streamline their workflow.
Downloading Current and Historical Fee Schedule Documents
Fee schedules are available in PDF and Excel formats for reference and billing system integration. Historical versions are available for audit purposes, appeals and compliance verification. Downloaded files include rate tables, modifier guidelines and special billing instructions. Regular updates so you always have the most current information.
Virginia Medicaid Provider Portal
The provider portal allows real-time fee verification so billing staff can check rates before submitting claims. This reduces claim denials by ensuring accurate rate application from the start.
Portal features code looks up, prior authorization verification and personalized notifications of rate changes affecting your provider type or service category.
Subscription Services for Fee Schedule Updates
DMAS offers subscription services that notify you when new fee schedules are published or existing schedules are updated. These notifications include effective dates, summary of changes and links to the updated documents.
Email alerts and portal notifications so you never miss a critical update that could affect your rates or billing.
Contact for Fee Schedule Questions
DMAS has dedicated customer service lines for fee schedule questions and technical support. Your provider rep can help with rate interpretation, billing guidance and system navigation.
Professional associations and billing organizations also offer peer support and continuing education to help you stay current with fee schedule requirements and best practices.
Fee Schedule Layout
To use the Virginia Medicaid fee schedule documents effectively you need to understand the structure and components.
CPT Code Organization and Fee Schedule Format
Fee schedules use Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes. Each code has a detailed service description, payment rate and modifiers.
The format presents codes in numerical order with clear column headers for rate amounts, unit definitions and special requirements. Cross references help you find related codes and alternative billing options.
Geographic Practice Cost Index (GPCI) Adjustments
Virginia applies GPCI to recognize cost differences between Northern Virginia and the rest of the state. This ensures fair payment while reflecting actual practice costs in different markets.
For example, personal care services effective July 1, 2025 will be $23.81 per hour in NOVA and $20.23 per hour in the rest of the state. GPCI applies to multiple service categories.
Modifier Usage and Impact on Rates
Modifiers provide important information about the service delivery and can impact the rate. Common modifiers are professional component (-26), technical component (-TC) and bilateral procedure indicators. Proper modifier application prevents claim denials and ensures payment for services rendered. The fee schedules tell you when modifiers are required or optional.
Professional Component vs Technical Component Billing
Many diagnostic and therapeutic services separate into professional and technical components, each with different rates. The professional component is for physician interpretation and reporting; the technical component is for equipment and technical staff.
Providers must know when to split bill and how to code each component to avoid duplicate billing or underpayment.
Global Period for Surgical Procedures
Surgical procedures often have global periods that include pre-op and post-op care in one payment. Understanding these global periods prevents separate billing for included services.
The fee schedules specify global period lengths and what services are included versus separately billable during the global period.
Billing and Reimbursement Guidelines
To use the Virginia Medicaid fee schedule successfully you must follow specific billing procedures and compliance requirements.
Proper Claim Submission
Claims must reference the current fee schedule rates and include all required documentation to support medical necessity. Submission deadlines vary by service type but generally must be filed within a certain timeframe from the date of service.
Electronic claims through approved clearinghouses are faster and reduce errors. Paper claims are accepted in limited circumstances but may take longer to process.
Prior Authorization
Some services require prior authorization to ensure medical necessity and appropriate utilization. The fee schedules tell you which codes require authorization and how to get it.
Authorization requests must include clinical documentation to support the medical necessity of the requested services. Retroactive authorization is generally not available so advance planning is key.
Documentation Requirements
Comprehensive medical documentation must support all billed services to show medical necessity and service delivery. Documentation standards vary by service type but generally require detailed clinical notes, treatment plans and progress assessments.
Electronic health record systems should be configured to capture all required documentation elements to make billing easier and support audits.
Appeal Process for Denied Claims
Providers can appeal denied claims through DMAS’s appeal process, referencing fee schedule documentation and medical necessity requirements. Appeals must be filed within certain timeframes and include clinical documentation.
The appeal process has multiple levels of review, from initial reconsideration to administrative hearings for complex cases. Understanding this process helps you recover payment for legitimate services.
Compliance
Billing compliance goes beyond rate application to include coding, documentation and federal and state regulations. Regular compliance audits help you identify potential issues before they become big problems. Staff training on current billing requirements, fee schedule updates and regulatory changes ensures ongoing compliance and reduces the risk of billing errors or fraud allegations.
Fee Schedule Updates
Virginia Medicaid fee schedule updates follow a predictable pattern but allow for emergency changes when needed.
Annual Fee Schedule Update Cycle
Annual updates align with Virginia’s fiscal year starting July 1 and include federal Medicare rate changes, state budget and legislative mandates. The update process begins months in advance with stakeholder input and budget planning.
DMAS publishes preliminary schedules for provider review before final implementation to allow time for billing system updates and staff training on rate changes.
Mid-Year Adjustments and Emergency Rate Changes
Emergency changes can occur in response to federal rate changes, legislative actions or public health emergencies. These changes follow expedited process while maintaining provider notification requirements.
Recent examples include rate changes during the COVID-19 pandemic and implementation of federal parity for behavioral health services.
Impact of Federal Medicare Rate Changes
Virginia’s alignment with Medicare rates means CMS changes often trigger Medicaid changes. However, the state has discretion to modify these rates based on budget and policy priorities.
Providers should monitor both CMS and DMAS communications to understand how federal changes will affect their Virginia Medicaid reimbursement.
Provider Notification
DMAS uses multiple channels to notify providers of fee schedule changes including email bulletins, provider portal announcements and professional association partnerships. Subscription services get you automatic updates.
Effective notification systems help providers implement changes quickly and avoid billing errors from using outdated rates.
Transition Periods for New Rates
Significant rate changes may have transition periods to allow providers time to update their billing systems and train staff on new requirements. These periods balance the need for timely implementation with operational practicalities.
Grace periods for claim corrections allow providers to adjust to new rates without financial penalties for good faith billing errors during transition periods.
Provider Resources
DMAS has comprehensive resources to help providers navigate the Virginia Medicaid fee schedule.
Training Materials and Webinars
Regular training sessions cover fee schedule navigation, billing best practices and regulatory updates. Live and recorded sessions are available.
Specialized training for unique billing situations, complex coding scenarios and common compliance issues providers face in daily operations.
Provider Manuals and Billing Guidelines Provider manuals cover billing procedures, documentation requirements and fee schedule application across all service categories. These are the authoritative source for billing staff and compliance officers.
Manuals are updated regularly to keep information current with changing regulations and fee schedule changes.
Customer Service
Dedicated customer service reps for fee schedule questions, billing guidance and system navigation. Multiple contact methods to accommodate provider preferences and urgency.
Specialized teams for complex billing situations and escalation paths for tough cases.
Online Tools
Interactive online tools for real-time fee verification, prior authorization checking and code lookup. These integrate with provider workflows to streamline billing.
Mobile responsive design so you can access from any device.
Professional Associations
Professional associations for peer networking, continuing education and advocacy for Virginia Medicaid fee schedule issues. These often serve as intermediaries between providers and DMAS for policy discussions.
Regional support groups for localized assistance and shared learning among providers in the same market.
FAQ
Current Virginia Medicaid fee schedule documents are on the official DMAS website under provider resources. All schedules are downloadable in PDF and Excel, with effective dates and version control.
Fee schedules are updated annually on July 1 to align with Virginia’s fiscal year. Mid-year changes can occur due to legislative changes, federal rate changes or emergency situations.
Contact DMAS customer service for services not listed. Generally, services not in published fee schedules are not covered unless special authorization is obtained or the service falls under an established coverage category with alternative billing.
Virginia Medicaid rates use Medicare rates as a base but can be adjusted based on state budget and policy priorities. Northern Virginia may have higher rates than Medicare due to regional cost differences, while other services may be below Medicare.
While fee schedule rates are set by state policy, you can appeal a specific claim denial or reimbursement through DMAS’s appeals process. Appeals must be filed within timeframes and include supporting documentation.
Documentation requirements vary by service but generally include clinical notes supporting medical necessity, treatment plans, progress assessments and prior authorization approvals. Electronic health records should capture all required elements for each billable service.
Prior authorization requirements are in the fee schedule and can be checked through the DMAS provider portal. The portal allows real-time authorization checking and submission for required approvals.
Billing with outdated schedules may result in claim denials, reduced payments or administrative penalties. Providers should always verify current rates before submission and have systems that update automatically with new fee schedule releases.
The Virginia Medicaid fee schedule is a complex but critical part of healthcare reimbursement in Virginia. Success requires ongoing attention to updates, proper documentation and adherence to billing guidelines. By using the resources available and staying current with fee schedule requirements, providers can get paid properly and deliver quality care to Medicaid patients.
Providers should bookmark the DMAS website, subscribe to updates and establish regular review processes to stay current with fee schedule changes. This proactive approach will keep you compliant and maximize revenue from Virginia Medicaid services.