medicare-pricing

What Medicare pays — physician fee schedule, lab rates, and per-day unit limits. The companion to medicare-coverage, which answers whether something is covered but not what it is worth.

Part of Pipeworx — an MCP gateway connecting AI agents to 1683+ live data sources.

Tools

Auth

None. No key, no account.

Data sources

All from CMS, all downloadable files with no API:

• Physician Fee Schedule relative value files (RVUs + GPCIs) — annual
• Clinical Laboratory Fee Schedule — quarterly
• DMEPOS fee schedule (durable medical equipment, prosthetics, orthotics, supplies) — quarterly (as necessary): A=Jan, B=Apr, C=Jul, D=Oct
• NCCI Medically Unlikely Edits — quarterly
• NCCI PTP quarterly additions/deletions/revisions files — quarterly (see below — a narrower source than the other three)

ADLT list — brand name to billing code

medicare_lab_test_lookup exists because callers name a test by its brand ("Signatera"), not its code ("0340U"), and nothing else in the catalog maps one to the other (fleet #2426).

Source, and why it is the only one. CMS's list of Advanced Diagnostic Laboratory Tests (https://www.cms.gov/files/document/advanced-diagnostic-laboratory-tests-under-medicare-clfs.pdf) gives code, lab, proprietary test name, approval date and initial-period payment for 18 tests. It is a US federal work (17 USC 105). The sources that were checked and rejected:

• AMA PLA long-descriptor PDF — "CPT® Copyright 2026 American Medical Association. All rights reserved." It also lists only the codes changed in the latest cycles (143 of them), and 0340U is not among them.
• Palmetto MolDX DEX registry — needs a registered account, even for the "public user" catalog, and hides Z-codes from public users. That's an auth wall.
• CMS Coverage API article code tables — need a caller's CMS/AMA licence token (already how medicare-coverage handles it).
• NCBI GTR — knows Signatera and Guardant360 but its cptcode field is empty for them.

That made coverage ADLT-only, and fleet #2458 measured the cost: Oncotype DX (81519, a Category I MAAA code, not an ADLT) routed here 5/5 and came back found: false. Resolution now runs through three sources in order:

1. CMS ADLT list (src/adlt.ts, below).
2. MAAA brand table (src/brand-codes.ts) -- non-ADLT branded tests whose proprietary name is tied to a code in CPT Appendix O and which each have a brand-named or category MolDX billing article on the CMS MCD (Oncotype DX breast/DCIS/colon/prostate, Prosigna, MammaPrint, EndoPredict, Breast Cancer Index, Cologuard, Prolaris, Decipher, Afirma, ConfirmMDx, 4Kscore). Only brand -> code -> lab FACTS are kept, never AMA descriptor text. Every code was checked to carry a CLFS rate on 2026-09-26. To add a row: confirm the pair in a public source, confirm medicare_lab_rate has a rate, and set coverage_topic to a phrase from a live MolDX article title.
3. NCBI GTR, live -- where the performing lab registered a CPT code (e.g. Afirma -> 81546, Decipher -> 81542). Labelled lab-reported. Sparse: Oncotype DX and Signatera carry no code there, which is why it is last.

A test found in none returns found: false, reason: brand_not_found with sources_checked naming all three, and a pointer to medicare_lab_rate.

Copy, not proxy. The list is a two-page PDF with no API, and the gateway has no PDF parser, so the rows are baked into src/adlt.ts. The PDF's "Test Descriptor" column is AMA PLA text and is not copied. Every call sends a HEAD to the PDF and compares Last-Modified with the snapshot's. If CMS has republished, the response carries snapshot_current: false. To refresh: download the PDF, extract its text (pypdf works), update the rows in src/adlt.ts, and bump ADLT_DATA_AS_OF and SNAPSHOT_LAST_MODIFIED.

Coverage. Each test has a coverage_topic, a phrase that is ours and not CMS's. It matches the title of the MolDX LCD/article family for the test's category (for Signatera, "Minimal Residual Disease"). The tool reads the live, keyless CMS Coverage API reports and returns the active LCDs and billing articles with that title. Retired ones come back only with include_retired: true. This matters because contractors re-issue MolDX policies under new numbers: Noridian's L38816 and A58456 were retired 2026-02-05 and replaced by L38814 and A58454. Whether a specific test is listed is answered by the billing article's code table, not by the title match.

Vintage is not a detail

Fee schedules change annually and NCCI/CLFS quarterly. Quoting a 2026 procedure at 2024 rates is a wrong number with billing consequences, so every response states the year (and quarter where quarterly) it used, and sets year_was_defaulted when the caller did not name one. Asking for a year that is not loaded returns year_not_loaded rather than silently answering with a different year's rates.

Locality is not state

Medicare pays by geographic locality. California alone has nine. The same office visit (99213, 2026) pays:

A 13% swing a state-shaped answer would hide. medicare_physician_payment resolves the locality explicitly, states what it resolved to, and lists other localities that matched so a caller can pick a different one.

Payment is computed with the real formula and the arithmetic is returned so it can be audited:

((work RVU × PW GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI)) × conversion factor

Facility and non-facility are both given — a procedure pays less in a hospital because the facility bills its own fee separately.

Whether two codes can be billed together — the full PTP baseline

check_code_pair and explain_ncci_edit now cover the FULL NCCI procedure-to-procedure (PTP) edit baseline, not a rolling change window (fleet #1293, 2026-09-07). CMS distributes the complete PTP edit table behind an AMA CPT licence click-through (/license/ama?file=... on cms.gov). Bruce authorized accepting that licence on the company's behalf via the Needs Bruce dashboard (2026-09-07); the licence text was read in full before any data shipped — see "NCCI PTP licence" below for the quoted terms and the reasoning for why this pack's serving shape stays inside them.

Loaded: the 2026 Quarter 3 baseline (v322r0, effective 2026-07-01 — the newest vintage actually in effect; CMS had already posted Q4 2026 at ingest time, but that isn't effective until 2026-10-01 and using it would have answered today's queries with tomorrow's rules). The 8 baseline files (practitioner + hospital × 4 code-range splits each) hold 4,498,118 raw historical-episode rows — the same (column1, column2) pair can have several add/delete/re-add episodes over the years — collapsed to 4,109,749 distinct pairs by keeping each pair's open-ended (currently active) episode, or else its most recently closed one. The prior 2025q1..2026q3 quarterly change files are re-applied ON TOP of the baseline, in that order, so a pair the quarterly files recorded as deleted cannot be resurrected by an older baseline row.

A NOT-FOUND answer now means CMS has never recorded a PTP edit for that pair — not merely "no recorded change in this window", which was the scope limit before this fleet task. medicare_code_units_limit remains the separate units edit (one code, not a pair) and was never affected by this limit.

NCCI PTP licence

The CMS licence click-through (same boilerplate CMS uses across its whole AMA CPT-derived file family — the physician fee schedule, MUE, and PTP downloads all carry it) reads, in relevant part:

CPT codes, descriptions and other data only are copyright 1995-2025 American Medical Association. All rights reserved... You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS... Any use not authorized herein is prohibited, including... making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT.