@pipeworx/medicare-pricing

Connect: https://gateway.pipeworx.io/medicare-pricing/mcp · Install: one-click buttons

Tools: 7

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.

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)

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.

Read maximally literally, “internal use” and “CMS-administered programs only” would forbid nearly all third-party commercial reuse of ANY Medicare fee-schedule data — an interpretation the entire health-IT industry operates against daily (claims clearinghouses, EHR vendors, and billing software all reference CPT codes commercially). This pack’s existing, already-shipped design applies the standard industry reading of the opening sentence — “CPT codes, descriptions and other data” are the copyrighted, licensed material; the CMS-computed derivative numbers indexed by those codes (RVUs, payment amounts, edit modifier indicators) are federal work product and are returned, while the AMA’s own descriptive text is never stored or served. The PTP baseline’s own “PTP Edit Rationale” column (a ~12-value CMS-authored categorical reason set, e.g. “Standards of medical/surgical practice”) is not stored either, purely to keep this load a strict superset of the existing table shape (no schema change) — not because it reads as AMA content. This is the same theory already governing this pack’s RVU/CLFS/MUE data; the PTP click-through does not introduce a new prohibition beyond what the rest of the pack already operates under, but the literal breadth of “internal use” / “CMS-administered programs” language is flagged here for anyone reviewing licence exposure across the pack.

No procedure descriptions — except DMEPOS

Every PFS/CLFS source file opens with “CPT codes, descriptions and other data only are copyright American Medical Association”. The RVU file scopes it precisely — codes and descriptions only — so the CMS-computed numbers are federal data and are returned, while the AMA’s descriptive text is neither stored nor served. Callers pass a code they already hold.

DMEPOS is the exception, on purpose. It uses HCPCS Level II codes (E/K/L/A-codes), which CMS itself maintains — unlike CPT (HCPCS Level I), which is AMA copyright. The DMEPOS source file’s own DMEREAD/DMEBACK documentation carries no AMA/copyright notice anywhere (checked), so medicare_dmepos_rate DOES return the code description.

DMEPOS pays by state, not locality

Medicare pays DMEPOS by state (not by the physician-fee-schedule locality), with a separate rural and non-rural amount per state. CMS’s own source file is one row per (HCPCS, modifier) with 53 state/territory columns × 2 (non-rural/rural) = 106 rate columns; this pack keeps that row grain and folds the 106 columns into one JSONB map rather than exploding to ~374,000 rows per release. medicare_dmepos_rate always returns both figures, labelled, and says explicitly when a state carries no separately-adjusted rural amount (a real “no adjustment” fact from the source file, not a missing value) rather than presenting a bare null.

Refreshing

node scripts/ingest-medicare-pricing.mjs                    # current vintages: RVU, GPCI, CLFS, MUE
node scripts/ingest-medicare-pricing.mjs --year 2025 --rvu rvu25d --clfs 25clabq4

node scripts/ingest-ncci-ptp.mjs                             # PTP quarterly change overlay (default: 2025q1..2026q3)
node scripts/ingest-ncci-ptp.mjs --quarters 2026q4            # add just the newest quarter on a refresh

node scripts/ingest-ncci-ptp-baseline.mjs --dir /path/to/8-zips  # full PTP baseline re-load (rare — new CMS vintage only)
                                                                  # ALWAYS re-run ingest-ncci-ptp.mjs immediately after —
                                                                  # the quarterly overlay must land on top of the baseline,
                                                                  # not the other way around (see script header comment).
                                                                  # Requires manually downloading the 8 baseline zips
                                                                  # through the CMS AMA-licence click-through first — no
                                                                  # automated fetch can complete that flow (503s to curl
                                                                  # and to a bare browser GET of the file URL; only a real
                                                                  # interactive click on the license page's Accept button
                                                                  # works).

node scripts/ingest-dmepos.mjs                                # newest DMEPOS release (default: 2026 release C)
node scripts/ingest-dmepos.mjs --year 2026 --release D         # add a new release when CMS posts one

Loaded as of writing: 19,226 RVU rows, 109 localities, 2,081 lab rates, 3,531 DMEPOS code/modifier rows (2026 release C, 53 states/territories each), 33,354 MUEs, 4,109,749 distinct NCCI PTP pairs — the FULL CMS baseline (2026q3, v322r0) with the 2025q1..2026q3 quarterly change files layered on top (fleet #1293, 2026-09-07; superseded the prior 182,286-pair change-window-only coverage). All loaders refuse rather than reporting an empty parse as success.

ingest-dmepos.mjs resolves the current download from the DMEPOS release subpage rather than guessing the zip filename — CMS’s DMEPOS naming is not stable (a release page 404s before it is posted, and old release URLs have 301-redirected to renamed paths), so it reads .../dmepos-fee-schedule/dme<yy>[-<letter>] for the current .zip href on every run, the same pattern ingest-medicare-pricing.mjs already uses for the PFS RVU page.

ingest-ncci-ptp.mjs is additive/idempotent by design — re-running the full default window is safe (upserts on service_type,column1,column2), and adding a new quarter to --quarters widens the window forward without needing to re-fetch history.

Tools

• 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, ad
• 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
• 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 machi
• 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 whe
• 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 i
• 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 i
• 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