Medicare Pricing

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.