Medicare payment locality · Q1 2018 release

Napa, Ca CA Medicare Locality 51

MAC 01112 · Locality 51

This locality's GPCIs are mixed, so the net payment effect varies by code for the Q1 2018 Physician Fee Schedule. For nationally priced services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs using these indexes.

Work GPCI

1.055

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

1.256

Adjusts practice-expense inputs such as staff, rent, and services

Malpractice GPCI

0.458

Adjusts the malpractice component using liability-cost data

1.000 is the national baseline. A value above 1.000 raises that component; below 1.000 lowers it. GPCIs are Medicare payment factors, not general cost-of-living or physician-compensation indexes.

Example rates in Napa, Ca Copy link

National and Napa, Ca Office (non-facility) amounts for frequently reviewed codes in the Q1 2018 release (before sequestration). Conversion factor: 2018 standard (non-QP) physician conversion factor · $35.9996.

Code	National	Napa, Ca	Difference
99214	$109.44	$123.73	+13.1%
99213	$74.16	$84.11	+13.4%
99215	$147.60	$165.81	+12.3%
66984	$656.27	$745.39	+13.6%
99204	$167.40	$186.35	+11.3%
92014	$128.52	$149.42	+16.3%
97110	$31.32	$35.51	+13.4%
88305	$70.20	$81.88	+16.6%
97530	$41.40	$48.24	+16.5%
99203	$109.80	$123.32	+12.3%

Need a specific code or the facility amount? Use the rate calculator and choose this locality. Or start with your field's usual procedure mix on the specialty fee schedules.

ZIP codes in this locality Copy link

Napa, Ca covers 12 ZIP codes across CA, per the CMS ZIP-to-locality crosswalk (Q1 2018). 2 of them span more than one locality and need ZIP+4 for an exact match.

94503 94508 94515 94558 94559 94562 94567 94573 94574 94576 94581 94599

Not sure which locality your ZIP is in? Look it up by ZIP code.

Common questions Copy link

Why do Medicare rates in Napa, Ca differ from the national amount?

For nationally priced Physician Fee Schedule services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs by this locality's three GPCIs before applying the conversion factor. Local costs for physician work, running an office, and liability insurance therefore move the final amount up or down. Napa, Ca currently has mixed GPCI components, so the net payment effect varies by code for the Q1 2018 release.

How do I know if my address is in this locality?

Medicare payment localities are geographic fee-schedule areas, commonly defined with county boundaries. CMS uses the ZIP code where the service was performed to assign a claim to its contractor and locality. Look up your ZIP to find your locality. About 2 ZIP codes in Napa, Ca span more than one locality and need the ZIP+4 to resolve exactly.

Do commercial insurers or Medicare Advantage plans use this locality?

Original Medicare uses these PFS localities directly. Commercial and Medicare Advantage plans are not required to use the same locality structure. A contract may pay a percentage of Medicare, but its own wording decides which Medicare release, percentage, geography, and adjustments apply.

Does my locality affect what I owe as a patient?

For a covered service, a higher allowed amount in your locality usually means a higher 20% coinsurance. The effect depends on the code, the beneficiary's deductible, supplemental coverage, and other claim circumstances.

Why did my Medicare payment change even though I didn't change what I billed?

CMS publishes updated PFS files during the year. A code's amount can change because of conversion-factor, RVU, policy, or correction updates. GPCIs are usually set once a year in the fee schedule rule, though later files can correct them. See what changed each release.

Source & method Copy link

We compute GPCIs and rates from the CMS Medicare Physician Fee Schedule Q1 2018 release (effective January 2018). ZIP coverage from the CMS ZIP-to-locality crosswalk, Q1 2018 release. Example amounts use the standard (non-QP) physician conversion factor ($35.9996) and apply this locality's GPCIs to nationally priced Office (non-facility) RVUs, before the ~2% sequestration cut. Past releases are never edited, so a rate for an earlier quarter always matches what CMS published for it.

Geographic practice cost indices (Q1 2018) · rvu18ar1.zip (GPCI2018.csv row 18)

ZIP code to carrier locality crosswalk (Q1 2018) · Zip-Code-to-Carrier-Locality.zip (ZIP5_JAN18.txt)

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