Medicare Pricing

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.

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".

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.

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).

What is the FQHC Geographic Adjustment Factor (GAF) for a place, and what does Medicare pay a Federally Qualified Health Center per visit THERE? Returns the official CMS FQHC PPS GAF for a Medicare locality and calendar year, and the GAF-adjusted per-visit rate (national base rate x GAF). Answers "FQHC PPS GAF for Orlando, Florida 2025", "CY2026 FQHC geographic adjustment Rest of California", "what is the FQHC PPS rate in Alaska". The GAF is CMS's own published number per locality (adapted from the work and practice-expense GPCIs, with the 1.0 floor), not something this tool estimates. A state returns all its localities; a city is not a locality, so name the locality or pick from the list (Florida has Fort Lauderdale, Miami and Rest of Florida). Complements medicare_fqhc_pps_rate (national base rate) and medicare_gpci_lookup (the underlying GPCIs). Years 2018-2026 loaded; the GAF-adjusted rate is returned for 2022-2026 (years whose national base rate this pack carries) and is null with a stated reason for 2018-2021. Sourced from the CMS FQHC PPS geographic adjustment factor tables.

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 returns only the national base rate before the geographic adjustment; for the GAF-adjusted amount in a named locality use medicare_fqhc_gaf. Omit year for the newest loaded year plus the full known history (small — CMS publishes one number a year); pass year for one row.

What are the Medicare geographic adjustment indices (GPCIs) for a place — with NO procedure code needed? Returns the work, practice-expense and malpractice GPCI for a Medicare payment locality (or every locality in a state), for a calendar year. Answers "GPCI for Rest of Florida locality 99", "Medicare geographic practice cost index for San Francisco", "work GPCI Manhattan 2025", "which Medicare localities does California have". Medicare pays by LOCALITY, not state (California has nine), so a state or ambiguous name returns every matching locality rather than one chosen quietly, and the resolution is stated. The work GPCI is the floored value CMS pays on (1.0 floor where it applies). Pass state ("FL" or "Florida"), a locality name ("Bakersfield"), and/or locality_number ("99"); year defaults to the newest loaded and is stated. For the FQHC-specific adjustment see medicare_fqhc_gaf; for a dollar payment see medicare_physician_payment. Sourced from the CMS Physician Fee Schedule geographic practice cost indices.

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.

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.

What does Medicare pay a HOSPITAL OUTPATIENT department for a procedure, device, or drug code? Returns the status indicator, Ambulatory Payment Classification (APC), relative weight, national payment rate, and beneficiary copayment for a HCPCS/CPT code under the Hospital Outpatient Prospective Payment System (OPPS) — the schedule that applies when the same service is billed by a hospital's outpatient department rather than a physician office (medicare_physician_payment) or a lab (medicare_lab_rate). Answers "what does Medicare pay for CPT 33289 in a hospital outpatient setting", "what is the APC for C2624", "is this device on pass-through status", "what is the OPPS payment rate and copay for this code". Flags device_pass_through and drug_or_biological_pass_through — whether the code is CURRENTLY in a CMS pass-through category (status indicator H or G), meaning it is paid separately, outside the normal APC amount, rather than packaged into the procedure it goes with. A packaged code (status indicator N, among others) still has a valid status_indicator but no apc/payment_rate_usd, because OPPS pays for it only as part of whatever procedure it is billed with — that is a normal result, not a missing one. States the fee-schedule YEAR and QUARTER (Q1=Jan, Q2=Apr, Q3=Jul, Q4=Oct) used on every response. Sourced from CMS, OPPS Addendum B.

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.

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.