Part of Iceni Data · Medicare Tools

Medicare Tools: Fee Schedule & LCD Lookup

Prices HCPCS/CPT codes against the current CMS Medicare Physician Fee Schedule, by locality, and attaches any matching NCD/LCD coverage determinations. Built on the CMS PFS Relative Value Files, NCCI MUE tables, and the Medicare Coverage Database. Runs on the Apify platform, so you get scheduling, an API, webhooks, and monitoring for free.

What does Medicare Fee Coverage Lookup do?

For every (HCPCS/CPT code, locality) pair you give it, this computes the base Medicare Physician Fee Schedule payment — (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor — using the non-facility or facility practice-expense RVU depending on where the service is furnished, and the standard or QP-differential conversion factor depending on apm_qualifying. It also attaches the code's NCCI Medically Unlikely Edit limits, any NCD/LCD coverage determination whose own HCPCS code list includes the code, and any Billing & Coding Article that references it (informational only — see What this Actor does not do). The first run downloads and normalizes the source CMS files into a cached lookup table (see Refresh cadence below); every run after that reads from the cache, so most runs finish in seconds.

Why use Medicare Fee Coverage Lookup?

• Billing/RCM teams can batch-price a code list across every locality a multi-site practice operates in, instead of clicking through CMS's own locality-by-locality fee schedule lookup tool one code at a time.
• Health-tech and RCM software builders get a normalized JSON feed of RVUs, GPCIs, MUEs, and coverage matches to embed in their own product, instead of maintaining their own CMS file-parsing pipeline.
• Compliance/coding teams can spot-check whether a code has an NCD, LCD, or Billing & Coding Article they should be aware of before billing it, without manually searching the Medicare Coverage Database per code.

How to use Medicare Fee Coverage Lookup

1. Click Try for free (or Start) on this Actor's page.
2. In the Input tab, set hcpcs_codes (e.g. ["99213", "96900"]), localities (e.g. ["CA"] for every California locality, or ["CA-18"] for just Los Angeles), and site_of_service (office or facility).
3. Click Start. The first run for a given cache period downloads and normalizes the CMS source files (typically 1-3 minutes); every run after that within the 30-day cache window is fast.
4. Open the Dataset tab to view, filter, or export the results (JSON, CSV, Excel, HTML, and more). Use the Payments view for just the RVU/GPCI/payment breakdown.

Input

All fields are described with an example in the Input tab. Full schema: .actor/input_schema.json.

Field	Type	Description
hcpcs_codes	array of strings	HCPCS/CPT codes to price.
localities	array of strings	Locality codes in STATE-LOCALITYNUMBER form (e.g. "CA-18"), or a bare two-letter state/territory code (e.g. "CA") to expand to every locality CMS defines within it.
site_of_service	string	"office" (non-facility PE RVU) or "facility" (facility PE RVU). Default "office".
apm_qualifying	boolean	Price with the 2026 QP-differential conversion factor (for clinicians who are Qualifying APM Participants) instead of the standard one. Default false.
force_refresh	boolean	Maintenance mode: reload all CMS source files and rebuild the cache even if it's under 30 days old. Default false.

Three worked inputs

1. Price a couple of common codes across every California locality (the prefill):

{
  "hcpcs_codes": ["99213", "96900"],
  "localities": ["CA"],
  "site_of_service": "office"
}

2. Compare office vs. facility payment for one code in one locality:

{
  "hcpcs_codes": ["99214"],
  "localities": ["NY-01"],
  "site_of_service": "facility"
}

3. A single narrow lookup, e.g. to check coverage matches for one code:

{
  "hcpcs_codes": ["96900"],
  "localities": ["TX-00"],
  "site_of_service": "office"
}

APM-qualifying pricing — same code/locality as example 1, but with the 2026 QP-differential conversion factor:

{
  "hcpcs_codes": ["99213"],
  "localities": ["CA-18"],
  "apm_qualifying": true
}

Maintenance run — force a fresh pull of the CMS source files:

{
  "hcpcs_codes": ["99213"],
  "localities": ["CA-18"],
  "force_refresh": true
}

What this Actor does not do

• No MAC-specific fee schedule adjustments. This computes the base national PFS formula. Some Medicare Administrative Contractors apply their own further adjustments for specific codes/situations that aren't captured here.
• No sequestration or other claims-processing reductions. The payment figure is the pre-sequestration PFS allowed amount, not the actual amount a claim would remit.
• No anesthesia base-unit pricing. Anesthesia codes (001xx-019xx, status J) are priced by anesthesia base units × a separate anesthesia conversion factor, not the RVU formula this Actor uses — anesthesia codes will show implausible figures if priced through this endpoint.
• Billing & Coding Articles are informational only, not a coverage determination. They're returned in related_articles, separate from coverage_matches, and are never charged for (coverage_returned only fires when coverage_matches is non-empty). A code can have related Articles and still show zero coverage_matches — that's expected, not a bug.
• coverage_matches only counts a code as covered when it's directly enumerated in that NCD or LCD's own HCPCS code list — never because it's merely referenced from a related document. In practice this means coverage_matches will almost always be empty for standard office-visit E/M codes like 99213: NCDs carry no structured per-code list at all in CMS's downloads (so no code path in this Actor can currently produce an NCD match), and Durable Medical Equipment LCDs — the only LCD type CMS still attaches codes to directly — mostly cover DME/supply codes, not E/M visits. A code that does appear in a DME LCD's own code list will still show a real LCD match.

Output

One flat JSON object per (HCPCS code, locality) pair, pushed to the default dataset. You can download it as JSON, CSV, Excel, HTML, XML, or RSS from the Export results button. Missing values are null, never empty strings (see my_actor/common/models.py); partial_data: true marks a row where the code, the locality, or a payment component couldn't be resolved.

Example output row

{
  "hcpcs": "99213",
  "description": "Office o/p est low 20 min",
  "status_code": "A",
  "locality_code": "CA-18",
  "locality_name": "LOS ANGELES-LONG BEACH-ANAHEIM (LOS ANGELES/ORANGE CNTY)",
  "state": "CA",
  "site_of_service": "office",
  "work_rvu": 1.30,
  "pe_rvu": 1.46,
  "mp_rvu": 0.09,
  "work_gpci": 1.041,
  "pe_gpci": 1.183,
  "mp_gpci": 0.664,
  "conversion_factor": 33.4009,
  "conversion_factor_type": "non_qualifying",
  "payment": 104.89,
  "mue_practitioner": 1,
  "mue_facility": 1,
  "coverage_matches": [],
  "related_articles": [
    {
      "type": "Article",
      "id": "A57654",
      "title": "Billing and Coding: Evaluation and Management Services",
      "contractor": "Noridian Healthcare Solutions, LLC",
      "effective_date": "2026-01-01",
      "url": "https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57654"
    }
  ],
  "data_as_of": "2026-09-04",
  "source_urls": [
    "https://downloads.cms.gov/medicare-coverage-database/downloads/exports/current_article.zip",
    "https://downloads.cms.gov/medicare-coverage-database/downloads/exports/current_lcd.zip",
    "https://www.cms.gov/files/zip/medicare-ncci-2026-q4-facility-outpatient-hospital-services-mue-table.zip",
    "https://www.cms.gov/files/zip/medicare-ncci-2026-q4-practitioner-services-mue-table.zip",
    "https://www.cms.gov/files/zip/rvu26d-updated-08-26-2026.zip"
  ],
  "partial_data": false
}

Note the code in this example (99213, a standard office-visit E/M code) has zero coverage_matches and one related_articles entry — see What this Actor does not do for why that's the expected shape, not a bug.

Data table

Field	Type	Description
hcpcs	string	HCPCS/CPT code priced.
description	string | null	Short CMS description of the code.
status_code	string | null	PFS status code (e.g. A = active/payable).
locality_code	string	STATE-LOCALITYNUMBER locality identifier.
locality_name	string | null	CMS locality name.
state	string | null	Two-letter state/territory code.
site_of_service	string	"office" or "facility" — which PE RVU was used.
work_rvu, pe_rvu, mp_rvu	number | null	Work, practice expense (site-specific), and malpractice RVUs.
work_gpci, pe_gpci, mp_gpci	number | null	The three Geographic Practice Cost Indices for this locality.
conversion_factor	number | null	The conversion factor actually used (matches conversion_factor_type).
conversion_factor_type	string	"non_qualifying" or "qualifying_apm" — which 2026 conversion factor was used.
payment	number | null	Computed base PFS payment amount.
mue_practitioner, mue_facility	integer | null	NCCI Medically Unlikely Edit unit limits.
coverage_matches	array	{type, id, title, contractor, effective_date, url} for each NCD/LCD whose own code list includes this code. Never Articles.
related_articles	array	Same shape, for Billing & Coding Articles that reference this code — informational only, never charged for.
data_as_of	string (date)	Date the row's data was current as of.
source_urls	array of strings	CMS source file URL(s) this row was built from.
partial_data	boolean	true if the code, locality, or a payment component couldn't be resolved.

Refresh cadence & how caching works

On first use, this Actor downloads the current-quarter CMS PFS RVU release (both the standard and QP-differential conversion factor files), the current NCCI MUE practitioner/facility tables, and the Medicare Coverage Database LCD/Article exports, normalizes them into one lookup table, and caches it for 30 days in a store shared across runs. The MUE table's own quarter (e.g. 2026-q4) is read straight out of its filename and folded into the cache's version key, alongside the PFS release label, so the cache key always reflects the actual source files behind it. Every run within that window reuses the cache — CMS's own quarterly release schedule (RVU/MUE updates every ~3 months) means the underlying numbers rarely change more often than that anyway. Each run also does a cheap check for a newer quarterly PFS release and refreshes early if one has appeared, even inside the 30-day window. Set force_refresh: true to rebuild the cache immediately regardless of its age.

Pricing / Cost estimation

This Actor uses the Pay Per Event model:

• lookup_returned — charged once per (HCPCS code, locality) row returned.
• coverage_returned — charged once per row whose coverage_matches is non-empty (an NCD or LCD directly lists the code). Related Articles (related_articles) are never charged for.

Free-plan users are capped at 25 rows per run (see my_actor/common/free_tier.py); paying users are not capped. A run pricing 2 codes across 18 California localities (36 rows) with, say, half of them having a coverage match costs 36 lookup_returned events + 18 coverage_returned events.

Tips / Advanced options

• Pass a bare two-letter state ("CA", "TX", "NY") in localities to price a code everywhere in that state without looking up every locality number yourself.
• Batch as many hcpcs_codes and localities as you need in one run — the cache means the marginal cost of a big run is just the per-row charges, not extra fetch time.
• Use force_refresh: true sparingly — it re-downloads and re-parses ~150MB of CMS zip files, which takes real time. The 30-day cache plus the automatic new-release check cover the normal case.

FAQ, disclaimers, and support

This Actor reads only from public CMS data downloads (CMS Physician Fee Schedule, NCCI, and Medicare Coverage Database file exports); it does not scrape any paywalled or ToS-restricted site. It is not legal, billing, or coding advice, and CMS payment rules change — always confirm against the source files linked in source_urls before relying on a number for actual billing. Found a code or locality that looks wrong, or a CMS file structure change this Actor doesn't handle? Open an issue on the Actor's Issues tab.

Related tools

Part of the Medicare Tools family on Apify:

• Medicare Reimbursement Calculator — prices a single HCPCS/CPT code with modifiers, participation status, and sequestration, one code at a time.