Part of Iceni Data · Medicare Tools

Medicare Tools: Reimbursement Calculator

Prices any HCPCS/CPT code against the Medicare Physician Fee Schedule (PFS) for a given locality, site of service, and modifiers — allowed amount, the Medicare/patient split, sequestration, and (for non-participating providers) the limiting charge. Built on the CMS PFS Relative Value Files (RVUs, GPCIs, and conversion factors), kept current in this Actor's own named key-value store cache. Runs on the Apify platform, so you get scheduling, an API, webhooks, and monitoring for free.

What does Medicare Reimbursement Calculator do?

It looks up a code's work/practice-expense/malpractice RVUs and a locality's GPCIs, applies the national conversion factor, and walks the result through whichever modifiers, unit count, participation status, and sequestration setting you specify — one output row per HCPCS code x locality pair. Every rule a given row actually used (which conversion factor, which modifier math, whether sequestration was cut) is written into that row's own assumptions list, so you never have to guess what was assumed.

What this does not compute

This is a fee-schedule calculator, not a claims adjudicator. It deliberately does not:

• Apply MAC-specific (contractor-specific) pricing — only the national RVU/GPCI/conversion-factor formula, no local MAC pricing overrides or LCD/NCD medical-necessity determinations.
• Track a patient's deductible — patient_coinsurance assumes the deductible has already been met.
• Enforce NCCI edits or bundling — it prices the one code you give it in isolation; it doesn't know whether that code would deny or bundle against another code on the same claim.
• Enforce MUE (Medically Unlikely Edit) unit limits — it will happily price 50 units of a code CMS would actually cap at 1.
• Rank multiple procedures on the same claim for the real multiple-procedure sequence (100%/50%/50%/50%/50% by descending RVU) — modifier 51 is applied as a flat 50% reduction instead, since this calculator prices one code at a time (see the code's own assumptions for the caveat).
• Reconstruct modifier-specific RVUs for 26/professional-component and TC/technical-component splits from CMS's own per-modifier PPRRVU rows — it derives them formulaically from the single global RVU row instead (work+malpractice for 26, practice-expense for TC), which is why a 26/TC pair always sums back to exactly the global amount.

Why use Medicare Reimbursement Calculator?

• Front-desk and billing staff can sanity-check an EOB or a payer estimate against the published fee schedule before appealing a denial, without a coding consultant.
• Practice administrators evaluating whether to add a new CPT code, take on non-participating status, or move a service from the office to a facility setting get an instant side-by-side of the dollar impact.
• Health-tech builders get a scriptable API/webhook-friendly pricing engine instead of hand-copying numbers out of CMS's own PDFs and spreadsheets — schedule it, call it from your own app via the Apify API, or feed its output straight into a billing system.

How to use Medicare Reimbursement Calculator

1. Click Try for free (or Start) on this Actor's page.
2. In the Input tab, set at least hcpcs and locality (comma- or newline-separated for more than one), plus site_of_service, any modifiers, and the participation/sequestration flags.
3. Click Start. When the run finishes, open the Dataset tab to view, filter, or export the results (JSON, CSV, Excel, HTML, and more).
4. The underlying CMS lookup table (RVUs, GPCIs, conversion factors) refreshes itself automatically whenever it's missing or more than 30 days old — you don't need to do anything for that. To force an immediate refresh instead of pricing anything, run this Actor once with refresh_cache: true (owner-only).

Input

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

Field	Type	Description
hcpcs	string	One or more HCPCS/CPT codes, comma- or newline-separated.
locality	string	One or more CMS locality codes (e.g. CA-05) or two-letter states (e.g. CA), comma- or newline-separated. A bare state resolves to its statewide locality (-00) if one exists, else its lowest-numbered locality.
site_of_service	string	"office" (non-facility PE RVU) or "facility" (facility PE RVU). Default "office".
modifiers	array	Any of 26, TC, 50, 51, 80, 81, 82. Default [].
units	integer	Units billed. Default 1.
apm_qualifying	boolean	Use the QP APM conversion factor instead of the standard one. Default false.
participating	boolean	Participating provider (95% reduction + limiting charge when false). Default true.
apply_sequestration	boolean	Apply the 2% Medicare sequestration cut. Default true.
refresh_cache	boolean	Maintenance mode: refresh the shared CMS lookup cache and exit. No rows, no charges. Owner-only. Default false.

Three worked inputs

1. The default case — an office visit:

{
  "hcpcs": "99213",
  "locality": "CA-05",
  "site_of_service": "office"
}

Priced against the cached 2026 RVU26D/GPCI files, this returns allowed_amount: 117.58. The same code with "site_of_service": "facility" returns allowed_amount: 64.37 — the office rate is higher because the non-facility PE RVU (1.46) bakes in overhead the facility rate (0.33) assumes the facility itself absorbs.

2. A professional/technical component split:

{
  "hcpcs": "99213",
  "locality": "CA-05",
  "site_of_service": "office",
  "modifiers": ["26"]
}

Run once with modifiers: ["26"] (allowed_amount: 48.82) and once with modifiers: ["TC"] (allowed_amount: 68.76) for the same code/locality — the two sum to exactly the global 117.58 from example 1, by construction (see "What this does not compute" above).

3. A non-participating, non-office, batch case:

{
  "hcpcs": "99213, 99214",
  "locality": "CA-05, NY-01",
  "site_of_service": "facility",
  "modifiers": ["51"],
  "units": 1,
  "participating": false,
  "apply_sequestration": true
}

Produces 4 rows (2 codes x 2 localities), each non-participating (95% reduction, limiting_charge reported) with a 50% multiple-procedure reduction applied.

Output

One flat JSON object per HCPCS x 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.

Example output row

Real output from the cached 2026 RVU26D/GPCI files, for hcpcs: "99213", locality: "CA-05", site_of_service: "office", no modifiers, participating, with sequestration applied:

{
  "hcpcs": "99213",
  "hcpcs_description": "Office o/p est low 20 min",
  "locality": "CA-05",
  "locality_name": "SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY)",
  "site_of_service": "office",
  "modifiers": [],
  "units": 1,
  "apm_qualifying": false,
  "participating": true,
  "apply_sequestration": true,
  "conversion_factor_type": "standard",
  "conversion_factor": 33.4009,
  "work_rvu": 1.3,
  "pe_rvu": 1.46,
  "mp_rvu": 0.09,
  "allowed_amount": 117.58,
  "medicare_pays": 92.18,
  "patient_coinsurance": 23.52,
  "sequestration_adjustment": 1.88,
  "net_to_provider": 115.7,
  "limiting_charge": null,
  "adjustments": [],
  "assumptions": [
    "Used the standard national conversion factor ($33.4009); no MAC-specific or locality-specific conversion factor variation applied.",
    "Allowed amount = (work RVU x work GPCI + practice-expense RVU x PE GPCI + malpractice RVU x MP GPCI) x conversion factor, per CMS Physician Fee Schedule methodology.",
    "Practice-expense RVU selected for site of service 'office' (non-facility PE RVU).",
    "1 unit(s) billed; the per-unit fee schedule amount was multiplied by units.",
    "Medicare pays 80% of the allowed amount and the patient owes the standard 20% Part B coinsurance; the patient's deductible status was not tracked.",
    "The mandatory 2% Medicare sequestration cut was applied to Medicare's payment only, not to the patient's coinsurance.",
    "Net to provider assumes the provider accepts assignment; it does not model non-assigned balance billing up to the limiting charge."
  ],
  "data_as_of": "2026-09-04",
  "source_urls": ["https://www.cms.gov/files/zip/rvu26d-updated-08-26-2026.zip"],
  "partial_data": false
}

Data table

Field	Type	Description
hcpcs	string	The HCPCS/CPT code priced.
hcpcs_description	string or null	CMS's short description of the code.
locality	string or null	Resolved CMS locality code (e.g. CA-05).
locality_name	string or null	Human-readable locality name.
site_of_service	string	"office" or "facility".
modifiers	array of strings	Modifiers requested on input.
units	integer	Units billed.
apm_qualifying	boolean	Whether the QP APM conversion factor was requested.
participating	boolean	Whether the billing provider participates in Medicare.
apply_sequestration	boolean	Whether the 2% sequestration cut was applied.
conversion_factor_type	string or null	"standard" or "qp_apm".
conversion_factor	number or null	National conversion factor used, in dollars.
work_rvu, pe_rvu, mp_rvu	number or null	The RVU components used (PE RVU is site-of-service-specific).
allowed_amount	number or null	Medicare-recognized allowed amount, in dollars.
medicare_pays	number or null	Medicare's 80% share, after sequestration if applied.
patient_coinsurance	number or null	Patient's 20% coinsurance share.
sequestration_adjustment	number or null	Amount withheld from Medicare's payment by sequestration.
net_to_provider	number or null	medicare_pays + patient_coinsurance.
limiting_charge	number or null	Non-participating limiting charge (115% of the reduced allowed amount); null when participating.
adjustments	array	One entry per modifier actually applied, with its effect on the amount.
assumptions	array of strings	Every rule this row actually applied.
data_as_of	string (date)	Date the underlying CMS data was fetched.
source_urls	array of strings	URL(s) the row was built from.
partial_data	boolean	true if the HCPCS/locality couldn't be found or a modifier was unsupported.

Pricing / Cost estimation

This Actor charges per row returned (the calculation event), via Actor.push_data(rows, charged_event_name='calculation'). Free-plan users are capped at 25 rows per run (my_actor/common/free_tier.py); paying users are uncapped. A single HCPCS x locality lookup is one row; a batch of, say, 5 codes x 5 localities is 25 rows.

Tips / Advanced options

• Batch codes and localities in one run (comma- or newline-separated in hcpcs/locality) instead of one run per pair — it's the same shared CMS lookup table either way, so batching avoids redundant cache reads.
• The CMS lookup table is cached in this Actor's own named key-value store (cms-reimb-calc-cache) and shared across every run of this Actor, refreshed automatically when it's stale (>30 days) or CMS publishes a new quarterly release — most runs don't pay any fetch cost at all. Named key-value stores are permission-scoped per Actor on the Apify platform, so this cache is not shared with any other Actor, including the companion medicare-fee-coverage-lookup Actor — each maintains its own independent copy.
• Check assumptions on any row before trusting a number for anything consequential — it tells you exactly which simplifications (see "What this does not compute") applied to that specific code/modifier combination.

FAQ, disclaimers, and support

This tool estimates Medicare Part B fee-schedule reimbursement using CMS's own published RVU, GPCI, and conversion-factor files; it is not medical, legal, or billing advice, and CMS payment rules (MAC-specific pricing, NCCI edits, LCD/NCD coverage, deductibles) can change what a real claim actually pays. See "What this does not compute" above for the full list of known limitations. Found a discrepancy or have a request? Use this Actor's Issues tab — custom pricing logic (e.g. contractor-specific pricing, real multiple-procedure ranking across a full claim) is available on request.

Related tools

Part of the Medicare Tools family on Apify:

• Medicare Fee Coverage Lookup — batch-prices codes across every locality in a state and attaches NCD/LCD coverage matches.