Part of Iceni Data · Medicare Tools

Medicare Tools: Fee Schedule Lookup

Prices HCPCS/CPT codes against the Medicare Physician Fee Schedule, Clinical Laboratory Fee Schedule, or DMEPOS fee schedule; compares office/facility/ASC/hospital-outpatient payment side by side; or checks LCD coverage by MAC jurisdiction. Built on the CMS PFS Relative Value Files, the Clinical Laboratory Fee Schedule Files, the DMEPOS Fee Schedule Files, the ASC Payment Rates & Addenda, the OPPS quarterly Addendum B, 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?

Two inputs shape every run: mode picks what kind of result you get, and schedule picks which fee schedule a plain lookup prices against.

mode: "lookup" (default) — a plain per-code lookup, dispatched by schedule:

• schedule: "pfs" (default): computes the base Medicare Physician Fee Schedule payment — (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor — for each (HCPCS/CPT code, locality) pair, using the office or facility PE RVU and the standard or QP-differential conversion factor. Also attaches NCCI MUE limits, any NCD/LCD coverage match, and any related Billing & Coding Article.
• schedule: "clfs": looks up the national Clinical Laboratory Fee Schedule rate for each lab or PLA code — no locality involved.
• schedule: "dmepos": looks up the DMEPOS fee schedule rate for each code, per state (states) and rural/non-rural (rural), across every rental/purchase modifier CMS prices it under.

mode: "site_of_service" — for each (HCPCS code, locality) pair, returns the PFS office and facility payment alongside the ASC and OPPS (hospital-outpatient) national payment rates, so you can see all four sites of service for one code in one row. schedule is ignored.

mode: "lcd_matrix" — for each HCPCS code, returns covered / not_covered / no_policy per MAC jurisdiction, built from the LCD data already in the cache. schedule is ignored.

Every mode/schedule combination reads from the same cached lookup table (see Refresh cadence below); the first run downloads and normalizes all of it, 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.
• Lab billing teams can batch-check the national CLFS rate for a panel of CPT lab codes and PLA codes in one run, instead of looking each one up on CMS's own CLFS file by hand.
• DME suppliers can compare a rental vs. purchase rate for a code across the states they ship to in one run, instead of downloading CMS's own fee-schedule spreadsheet and building the state/modifier lookup themselves.
• Practice administrators deciding where to furnish a service can pull office/facility/ASC/hospital-outpatient payment for the same code side by side with mode: "site_of_service", instead of cross-referencing four separate CMS files by hand.
• 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 (mode: "lookup"), or see the full per-MAC-jurisdiction coverage picture at once (mode: "lcd_matrix").
• Health-tech and RCM software builders get a normalized JSON feed of RVUs, GPCIs, MUEs, coverage matches, and CLFS/DMEPOS/ASC/OPPS rates to embed in their own product, instead of maintaining five separate CMS file-parsing pipelines.

How to use Medicare Fee Coverage Lookup

1. Click Try for free (or Start) on this Actor's page.
2. In the Input tab, choose mode ("lookup", "site_of_service", or "lcd_matrix") and, for "lookup", schedule ("pfs", "clfs", or "dmepos").
3. Set hcpcs_codes, plus whichever of localities / states / rural / site_of_service / apm_qualifying your mode/schedule needs (see the Input table below).
4. Click Start. The first run for a given cache period downloads and normalizes every CMS source file this Actor reads (typically 2-5 minutes, across seven quarterly releases); every run after that within the 30-day cache window is fast.
5. Open the Dataset tab to view, filter, or export the results (JSON, CSV, Excel, HTML, and more). Use the matching view — Payments, Lab, DMEPOS, Site of service, or Coverage matrix — for a pre-shaped table.

Input

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

Field	Type	Description
mode	string	"lookup" (default, dispatched by schedule), "site_of_service", or "lcd_matrix".
schedule	string	"pfs" (default), "clfs", or "dmepos". Only consulted when mode is "lookup".
hcpcs_codes	array of strings	HCPCS/CPT codes to price or check.
localities	array of strings	Locality codes ("CA-18") or a bare state code ("CA", expands to every locality in it). Required for schedule: "pfs" and mode: "site_of_service".
site_of_service	string	"office" or "facility" — which PE RVU to price. Default "office". schedule: "pfs" only.
apm_qualifying	boolean	Price with the 2026 QP-differential conversion factor instead of the standard one. Default false. schedule: "pfs" and mode: "site_of_service".
states	array of strings	Two-letter state codes. schedule: "dmepos" only.
rural	boolean	Price at the rural rate instead of non-rural (falls back to non-rural where CMS hasn't published a distinct rural rate). Default false. schedule: "dmepos" only.
force_refresh	boolean	Maintenance mode: reload every CMS source file 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. CLFS lab-code lookup — a PLA code and two CPT lab codes, no locality needed:

{
  "schedule": "clfs",
  "hcpcs_codes": ["0011U", "80053", "81479"]
}

3. DMEPOS rental vs. purchase comparison — one code, one state, every modifier CMS prices it under:

{
  "schedule": "dmepos",
  "hcpcs_codes": ["E0607"],
  "states": ["CA"],
  "rural": false
}

Site-of-service comparison — office vs. facility vs. ASC vs. hospital-outpatient for one code/locality:

{
  "mode": "site_of_service",
  "hcpcs_codes": ["99213"],
  "localities": ["CA-05"]
}

LCD coverage matrix — covered/not_covered/no_policy per MAC jurisdiction for a code:

{
  "mode": "lcd_matrix",
  "hcpcs_codes": ["96900"]
}

Maintenance run — force a fresh pull of every CMS source file:

{
  "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/ASC/OPPS formula or rate. 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. Every payment figure is the pre-sequestration 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.
• 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_matches and mode: "lcd_matrix" only count a code as covered when it's directly enumerated in that LCD's own HCPCS code list — never because it's merely referenced from a related document. NCDs carry no structured per-code list at all in CMS's downloads, so no code path here can produce an NCD match.
• No CLFS/DMEPOS/ASC/OPPS coverage matching. coverage_matches/related_articles only ever populate on schedule: "pfs" rows.
• No MAC gapfill history. When a CLFS code has no national rate (payment_rate: null) or a DMEPOS code/state has no published rural rate, this Actor doesn't attempt to reconstruct what an individual MAC gapfilled it to in a given jurisdiction or prior year — only the current national/quarterly file is read.
• No commercial-payer rates. Every number here is a Medicare rate, never a commercial insurer's contracted or list rate.
• No AMA CPT long descriptors, and no AMA PLA code list. description/short_description are CMS's own short-description fields; this Actor never reads or stores the AMA's copyrighted long descriptor text or its separate PLA code list, even though the underlying CMS files carry AMA-copyrighted CPT data.
• mode: "site_of_service"'s ASC/OPPS amounts are national, unadjusted rates — not wage-index-adjusted for the requested locality, unlike the PFS office/facility figures alongside them. A code with no separate ASC or OPPS payment (most E/M codes, for instance) legitimately shows null for those two fields; that's expected, not partial data.

Output

One flat JSON object per row, pushed to the default dataset — the row unit depends on mode/schedule: (HCPCS code, locality) for schedule: "pfs" and mode: "site_of_service"; HCPCS/PLA code alone for schedule: "clfs" and mode: "lcd_matrix"; (HCPCS code, state) for schedule: "dmepos". 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/locality/state or its core payment/rate couldn't be resolved.

Example output row (PFS lookup)

{
  "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": [],
  "data_as_of": "2026-09-06",
  "source_urls": ["https://www.cms.gov/files/zip/rvu26d-updated-08-26-2026.zip"],
  "partial_data": false
}

One row per view

Lab (schedule: "clfs"):

{ "hcpcs": "80053", "short_description": "Comprehen metabolic panel", "payment_rate": 10.56, "status_indicators": { "indicator": "N" }, "is_pla": false, "effective_quarter": "2026-Q3", "data_as_of": "2026-09-06", "source_urls": ["https://www.cms.gov/files/zip/26clabq3.zip"], "partial_data": false }

DMEPOS (schedule: "dmepos"):

{ "hcpcs": "E0607", "description": "Blood glucose monitor home", "category": "IN", "jurisdiction": "D", "state": "CA", "rural": false, "rates": { "NU": 95.23, "RR": 9.52, "UE": 71.40 }, "data_as_of": "2026-09-06", "source_urls": ["https://www.cms.gov/files/zip/dme26-c.zip"], "partial_data": false }

Site of service (mode: "site_of_service") — 99213 in CA-05 (San Francisco-Oakland-Berkeley), no ASC/OPPS payment for a plain office visit:

{ "hcpcs": "99213", "description": "Office o/p est low 20 min", "locality_code": "CA-05", "locality_name": "SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY)", "state": "CA", "office_payment": 117.58, "facility_payment": 64.37, "asc_payment": null, "hospital_outpatient_payment": null, "conversion_factor_type": "non_qualifying", "data_as_of": "2026-09-06", "source_urls": ["https://www.cms.gov/files/zip/rvu26d-updated-08-26-2026.zip"], "partial_data": false }

Coverage matrix (mode: "lcd_matrix"):

{ "hcpcs": "96900", "description": "Actinotherapy uv light", "jurisdictions": { "CGS Administrators, LLC": "not_covered", "Noridian Healthcare Solutions, LLC": "covered", "Palmetto GBA": "not_covered" }, "data_as_of": "2026-09-06", "source_urls": ["https://downloads.cms.gov/medicare-coverage-database/downloads/exports/current_lcd.zip"], "partial_data": false }

Data table

Field	Type	Description	Applies to
hcpcs	string	HCPCS/CPT code priced.	all
description	string | null	Short CMS description of the code.	pfs, site_of_service, lcd_matrix
status_code	string | null	PFS status code (e.g. A = active/payable).	pfs
locality_code, locality_name, state	string | null	Locality identifiers.	pfs, site_of_service
site_of_service	string	"office" or "facility" — which PE RVU was used.	pfs
work_rvu, pe_rvu, mp_rvu, work_gpci, pe_gpci, mp_gpci	number | null	RVU/GPCI components.	pfs
conversion_factor, conversion_factor_type	number/string | null	PFS conversion factor used.	pfs, site_of_service
payment	number | null	Computed base PFS payment.	pfs
mue_practitioner, mue_facility	integer | null	NCCI Medically Unlikely Edit limits.	pfs
coverage_matches, related_articles	array	{type, id, title, contractor, effective_date, url} per LCD match / related Article.	pfs
short_description	string | null	CMS's own short description (never the AMA long descriptor).	clfs
payment_rate	number | null	National CLFS rate. null if no national rate exists.	clfs
status_indicators	object	Pass-through of the CLFS file's own indicator field(s).	clfs
is_pla	boolean	true for a PLA code (ends in "U").	clfs
effective_quarter	string | null	CLFS release quarter.	clfs
category, jurisdiction	string | null	DMEPOS benefit category / pricing jurisdiction code.	dmepos
rural	boolean	Whether the rural rate was requested.	dmepos
rates	object	Rate per modifier ("flat", or "NU"/"RR"/"UE").	dmepos
office_payment, facility_payment, asc_payment, hospital_outpatient_payment	number | null	Payment at each site of service.	site_of_service
jurisdictions	object	MAC jurisdiction name -> "covered" | "not_covered" | "no_policy".	lcd_matrix
data_as_of	string (date)	Date the row's data was current as of.	all
source_urls	array of strings	CMS source file URL(s) this row was built from.	all
partial_data	boolean	true if the code/locality/state or its core payment/rate couldn't be resolved.	all

Refresh cadence & how caching works

On first use, this Actor downloads the current-quarter CMS PFS RVU release (standard and QP-differential conversion factor files), the current NCCI MUE practitioner/facility tables, the current-quarter CLFS national rate file, the current-quarter DMEPOS fee schedule, the current ASC Addendum AA and OPPS Addendum B, and the Medicare Coverage Database LCD/Article exports — seven quarterly CMS releases in total — normalizes them into one lookup table, and caches it for 30 days in a store shared across runs. Each release's own label (e.g. RVU26D, 26CLABQ3, DME26-C) is folded into the cache's version key, so it always reflects the actual source files behind it. Every run within the 30-day window reuses the cache. Each run also does a cheap check for a newer quarterly PFS or CLFS release and refreshes early if one has appeared, even inside the window (DMEPOS/ASC/OPPS don't get this early-refresh check — the 30-day TTL and force_refresh cover them). 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 row returned for mode: "lookup" (any schedule) and mode: "lcd_matrix".
• coverage_returned — charged once per schedule: "pfs" row whose coverage_matches is non-empty. Related Articles are never charged for; no other schedule/mode triggers this event.
• comparison_returned — charged once per row returned for mode: "site_of_service".

Free-plan users are capped at 25 rows per run (see my_actor/common/free_tier.py); paying users are not capped. A schedule: "pfs" run pricing 2 codes across 18 California localities (36 rows) with half having a coverage match costs 36 lookup_returned + 18 coverage_returned events. A mode: "site_of_service" run for 1 code across 5 localities costs 5 comparison_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. (schedule: "pfs" and mode: "site_of_service".)
• Batch as many hcpcs_codes, localities, and states 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 CMS zip files across seven source families, which takes real time. The 30-day cache plus the PFS/CLFS new-release check cover the normal case.
• A null payment_rate on a schedule: "clfs" row (e.g. some Tier 2 molecular pathology codes) means CMS hasn't set a national CLFS rate for that code — it's priced by each MAC instead.
• A null in rates for a schedule: "dmepos" row means that state has no rate published for that modifier at all — different from a genuine 0, which would appear as 0.0.

FAQ, disclaimers, and support

This Actor reads only from public CMS data downloads (CMS Physician Fee Schedule, CLFS, DMEPOS, ASC, OPPS, 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, locality, or state 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.