# Medicare Pricing [Health: Active]

**Category:** 🧬 Biology & Bioinformatics  
**Repository:** https://github.com/pipeworx-io/mcp-medicare-pricing  
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**Directory Page:** https://allmcps.com/mcp/medicare-pricing

## Description
What does Medicare PAY — physician fee schedule, lab rates, and per-day unit

## Tools
Capabilities this server exposes over MCP:

- **medicare_physician_payment** — What does Medicare pay a doctor for a procedure code, in a specific place? Returns the relative value units (work, practice expense, malpractice) and the actual dollar payment for a HCPCS/CPT code, adjusted for the Medicare LOCALITY — payment varies geographically, not just by state. Answers "how much does Medicare pay for 99213", "what is code 27130 worth in Los Angeles", "reimbursement rate for an office visit in Texas", and fee-schedule or contract-rate benchmarking. Gives both the facility and non-facility amount (a procedure pays less in a hospital, because the hospital bills the overhead separately), the global period, and the status code saying whether the code is separately payable at all. States the fee-schedule YEAR and the locality it resolved to on every response, because a rate quoted for the wrong year or locality is a wrong number. Sourced from the CMS Physician Fee Schedule relative value files.
- **medicare_lab_rate** — What does Medicare pay for a laboratory test? Returns the national Clinical Laboratory Fee Schedule rate for a lab HCPCS/CPT code — lab tests are paid from their own national fee schedule rather than the physician schedule, so there is one rate and no locality adjustment. Answers "how much does Medicare pay for a comprehensive metabolic panel", "CLFS rate for 80053", "what does a lipid panel reimburse". States the year and quarter of the schedule used, since lab rates are republished quarterly. Sourced from the CMS Clinical Laboratory Fee Schedule.
- **medicare_lab_test_lookup** — Resolve a branded molecular or genomic lab test by its commercial name (e.g. Signatera, Guardant360 CDx, FoundationOne CDx, FoundationOne Liquid CDx, Tempus xT CDx, DecisionDx-Melanoma, Envisia, Shield) to its CPT PLA / HCPCS billing code, the lab that runs it, what Medicare pays for it now on the Clinical Laboratory Fee Schedule, and the MolDX local coverage determinations (LCDs) and billing-and-coding articles for its test category. Answers "what does Medicare pay for Signatera", "what is the PLA code for Guardant360", "which MolDX LCD covers this test". Also accepts a lab name (e.g. "Natera") or a code. Also covers non-ADLT branded MAAA tests (Oncotype DX, Prosigna, MammaPrint, EndoPredict, Breast Cancer Index, Cologuard, Prolaris, Decipher, Afirma, ConfirmMDx, 4Kscore) and any test whose lab registered its code in the NCBI Genetic Testing Registry. Resolves in order: the CMS list of Advanced Diagnostic Laboratory Tests (ADLTs), a brand-to-code table of MAAA tests with MolDX billing articles, then NCBI GTR live; a test found in none returns brand_not_found naming every source checked. Sourced from CMS (ADLT list, Clinical Laboratory Fee Schedule, Medicare Coverage Database) and NCBI GTR.
- **medicare_dmepos_rate** — What does Medicare pay for a piece of durable medical equipment, prosthetic, orthotic, or medical supply (DMEPOS)? Returns the fee-schedule amount for a HCPCS Level II code (E/K/L/A-codes — CPAP machines, wheelchairs, ostomy supplies, braces, oxygen equipment...) in a given US state, with SEPARATE rural and non-rural amounts, since Medicare pays DMEPOS by state rather than by the physician-fee-schedule locality. Answers "how much does Medicare pay for a CPAP machine (E0601)", "DMEPOS rate for a wheelchair in Texas", "what is the rural rate for this HCPCS code in Montana". Unlike medicare_physician_payment, this DOES include the HCPCS code description — DMEPOS uses HCPCS Level II, which CMS itself maintains and is not AMA copyright (CPT/HCPCS Level I is). States the fee-schedule YEAR and RELEASE (quarterly-ish: A=January, B=April, C=July, D=October) used on every response, and the modifier resolved (many DMEPOS codes price differently for rental "RR" vs. new purchase "NU" vs. used "UE" — pass one if you know it, otherwise the first modifier on file for the code is used and stated).
- **medicare_code_units_limit** — How many units of a procedure code will Medicare pay for one patient in one day? Returns the NCCI Medically Unlikely Edit (MUE) — the maximum units allowed — with the adjudication indicator saying whether the limit is absolute or can be overridden with documentation, and the rationale for it. Answers "what is the MUE for 99213", "how many units of this code can I bill", "why was my claim denied for units". Available for practitioner, outpatient hospital and DME settings, which have different limits for the same code. States the quarterly edit vintage in force. Sourced from the CMS National Correct Coding Initiative.
- **check_code_pair** — Can two procedure codes be billed together on the same day? Checks the CMS National Correct Coding Initiative procedure-to-procedure (PTP) edit for a pair of HCPCS/CPT codes and returns the modifier indicator saying whether the pair can never be unbundled, can be unbundled with an appropriate modifier and documentation, or carries no edit in the loaded data. Answers "can I bill 99214 and 93000 together", "is there an NCCI edit between these two codes", "do I need a modifier for this code combination". Built from CMS's FULL NCCI PTP edit baseline (2026q3, v322r0), not just a rolling change window — a pair not found here has never had a CMS-recorded PTP edit as of the loaded vintage. The response always states the loaded vintage and setting resolved.
- **explain_ncci_edit** — What NCCI procedure-to-procedure edits exist for a single code? Lists the other codes this HCPCS/CPT code has a recorded PTP edit with — whether it is the code you bill (Column 1) or the one bundled into another (Column 2) — with each pair's modifier indicator. Answers "what codes conflict with 99214", "what is bundled into this procedure", "why would this code be denied when billed with something else". Same full-baseline coverage as check_code_pair (CMS's FULL NCCI PTP edit baseline, 2026q3 v322r0, not just a rolling change window) — an empty result means no PTP edit has ever been recorded for this code, not merely "no recent change".
- **medicare_fqhc_pps_rate** — What does Medicare pay a Federally Qualified Health Center (FQHC) per visit? Returns the CMS FQHC Prospective Payment System (PPS) national BASE payment rate for a calendar year — the figure CMS publishes once a year, before any per-FQHC Geographic Adjustment Factor (GAF) is applied. Answers "what is the FQHC PPS base rate", "how much does Medicare pay an FQHC per encounter", "FQHC PPS rate for 2025 vs 2026". Medicare pays an FQHC the LESSER of its actual charges or this PPS rate for all FQHC services furnished to a beneficiary on a day with a qualifying face-to-face visit — it is a per-DAY encounter rate, not a fee per procedure code (unlike medicare_physician_payment/medicare_lab_rate). This tool does NOT compute the GAF-adjusted, FQHC-specific amount — only the national base rate before that adjustment; the GAF table is not loaded here. Omit year for the newest loaded year plus the full known history (small — CMS publishes one number a year); pass year for one row.
- **medicare_pricing_coverage** — What Medicare pricing data is loaded and how current it is: the fee-schedule years and quarters held, how many codes are in each dataset, how many localities, and the PTP pair-edit change window. Use to check a vintage is current enough to quote before relying on a rate, and to see the scope limit on check_code_pair / explain_ncci_edit — they see only pairs that changed within the loaded quarterly window, not the full AMA-licence-gated PTP baseline.

## Claude Desktop Quick Installation
Install path detected from listing signals. Uses `npx` (confidence: high):

```json
"mcpServers": {
  "medicare-pricing": {
    "command": "npx",
    "args": ["-y","@pipeworx/mcp-medicare-pricing"]
  }
}
```

## Documentation

## What Medicare Pricing does

Medicare Pricing answers what Medicare pays and how CMS applies billing edits. It covers physician fee-schedule payments, national laboratory rates, DMEPOS amounts, hospital outpatient prospective payment rates, FQHC per-visit base rates, NCCI medically unlikely edits, and procedure-to-procedure code relationships. A separate lookup resolves branded molecular and genomic tests to billing codes, performing laboratories, CLFS rates, and related MolDX coverage documents.

The returned context is part of the result, not an afterthought. Physician payments identify the fee-schedule year, resolved Medicare locality, RVU components, facility and non-facility amounts, global period, and payment status. Laboratory results identify the schedule year and quarter. DMEPOS results distinguish rural from non-rural state pricing and report the applicable year, release, and modifier. NCCI responses include their quarterly or loaded edit vintage.

## How it works

The integration reads CMS-published downloadable files rather than calling a CMS pricing API. Physician pricing uses the Physician Fee Schedule relative value files; laboratory pricing uses the Clinical Laboratory Fee Schedule; DMEPOS uses its quarterly fee schedule; and hospital outpatient results use OPPS Addendum B. NCCI tools use CMS edit data, while FQHC PPS values come from a maintained annual table based on CMS transmittals.

Branded test lookup checks CMS’s ADLT list first, then a maintained table for selected non-ADLT branded tests, and finally live NCBI Genetic Testing Registry records where laboratories have registered a code. It also queries keyless CMS Coverage API reports for active LCDs and billing articles associated with the test category.

## Tools and capabilities

- `medicare_physician_payment` calculates locality-adjusted physician payments and returns work, practice-expense, and malpractice RVUs.
- `medicare_lab_rate` returns the national CLFS amount for a laboratory HCPCS or CPT code.
- `medicare_lab_test_lookup` maps supported branded tests, laboratories, or codes to billing and coverage information.
- `medicare_dmepos_rate` prices HCPCS Level II equipment, supplies, prosthetics, and orthotics by state and rural status.
- `medicare_opps_rate` returns OPPS status indicators, APC data, relative weight, national payment, copay, and pass-through details.
- `medicare_code_units_limit` returns NCCI MUE limits, adjudication indicators, and rationales for practitioner, outpatient hospital, or DME settings.
- `check_code_pair` and `explain_ncci_edit` inspect PTP edits and modifier indicators.
- `medicare_fqhc_pps_rate` returns the national FQHC PPS base rate by year, before the local GAF adjustment.
- `medicare_pricing_coverage` reports loaded schedule vintages, dataset sizes, localities, and PTP coverage information.

## Setup and configuration

Authentication is not required: the server uses no API key and no account. Queries can reference HCPCS or CPT codes, branded test names, laboratories, states, localities, years, quarters, releases, settings, and applicable DMEPOS modifiers. For FQHC requests, omit the year to retrieve the newest loaded value and historical rows, or provide a year for a single result.

## Limitations and notes

Payment figures are schedule amounts, not guarantees of claim payment. Physician rates vary by Medicare locality, while laboratory rates are national and DMEPOS rates are state-based. The FQHC tool reports only the national base rate; it does not calculate the FQHC-specific Geographic Adjustment Factor.

Branded-test matching depends on the maintained CMS and MAAA tables plus live NCBI GTR registrations. An unresolved brand returns a not-found result with the sources checked. CMS coverage documents may include active LCDs and billing articles, while retired documents require an explicit request.

Schedule data changes by year or quarter, and NCCI results are tied to a stated edit vintage. Check `medicare_pricing_coverage` before relying on a rate for a particular reporting period. The project is an independent, unofficial integration and is not affiliated with CMS or another upstream provider.

_Full upstream README: https://allmcps.com/mcp/medicare-pricing/readme_