@pipeworx/medicare-pricing

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

Tools: 4

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
• NCCI Medically Unlikely Edits — quarterly

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.

What this cannot answer, and why

Whether two codes can be billed together. That is an NCCI procedure-to-procedure (PTP) edit, and CMS distributes those behind an AMA licence acceptance page: the download URL returns HTML, not a zip, so they cannot be fetched programmatically. medicare_code_units_limit covers the separate units edit only, and medicare_pricing_coverage says this plainly rather than letting a caller assume pair checking exists.

No procedure descriptions

Every 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.

Refreshing

node scripts/ingest-medicare-pricing.mjs                    # current vintages
node scripts/ingest-medicare-pricing.mjs --year 2025 --rvu rvu25d --clfs 25clabq4

Loaded as of writing: 19,226 RVU rows, 109 localities, 2,081 lab rates, 33,354 MUEs. The loader refuses rather than reporting an empty parse as success.

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_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
• 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 which datasets are absent. Use to che