Medicare payment locality · Q4 2018 release

Santa Rosa, Ca CA Medicare Locality 67

MAC 01112 · Locality 67

This locality's GPCIs are mixed, so the net payment effect varies by code for the Q4 2018 Physician Fee Schedule. For nationally priced services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs using these indexes.

Work GPCI

1.023

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

1.111

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

Malpractice GPCI

0.562

Adjusts the malpractice component using liability-cost data

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

Example rates in Santa Rosa, Ca Copy link

National vs. Santa Rosa, Ca office (non-facility) amounts for frequently reviewed codes, Q4 2018 (before sequestration). Conversion factor: 2018 standard (non-QP) physician conversion factor · $35.9996.

Code	National	Santa Rosa, Ca	Difference
99214	$109.44	$114.86	+5.0%
99213	$74.16	$77.93	+5.1%
99215	$147.60	$154.33	+4.6%
66984	$656.27	$690.27	+5.2%
99204	$167.40	$173.93	+3.9%
92014	$128.52	$137.10	+6.7%
97110	$31.32	$32.98	+5.3%
88305	$70.20	$75.02	+6.9%
97530	$41.40	$44.21	+6.8%
99203	$109.80	$114.52	+4.3%

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

ZIP codes in this locality Copy link

Santa Rosa, Ca covers 51 ZIP codes across CA, per the CMS ZIP-to-locality crosswalk (Q3 2018). 3 of them span more than one locality and need ZIP+4 for an exact match.

The Q4 2018 ZIP-to-locality crosswalk file is not on file here; figures are from the Q3 2018 release and may not reflect Q4 2018 revisions.

94922 94923 94926 94927 94928 94931 94951 94952 94953 94954 94955 94972 94975 94999 95401 95402 95403 95404 95405 95406 95407 95408 95409 95412 95416 95419 95421 95425 95430 95431 95433 95436 95439 95441 95442 95444 95446 95448 95450 95452 95462 95465 95471 95472 95473 95476 95480 95486 95487 95492 95497

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

Common questions Copy link

Why do Medicare rates in Santa Rosa, 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 professional labor, office-input, and liability costs therefore move the final amount up or down. Santa Rosa, Ca currently has mixed GPCI components, so the net payment effect varies by code for the Q4 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 service-location ZIP code to map a claim to the applicable carrier and locality. Look up your ZIP to find your locality. About 3 ZIP codes in Santa Rosa, 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 benchmark payment to Medicare, but its language controls the Medicare release, percentage, geographic basis, and other adjustments.

Does my locality affect what I owe as a patient?

For a particular covered service, a higher locality-adjusted allowed amount generally produces a higher percentage-based coinsurance amount. 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. GPCI policy values are generally established through annual rulemaking, although later files can contain corrections. See what changed each release.

Source & method Copy link

GPCIs and rates computed from the CMS Medicare Physician Fee Schedule Q4 2018 release (effective October 2018). ZIP coverage from the CMS ZIP-to-locality crosswalk, Q3 2018 release . Example amounts use the standard (non-QP) physician conversion factor ($35.9996) and apply this locality's GPCIs to nationally priced non-facility RVUs, before the ~2% sequestration cut. Releases are immutable: a rate retrieved for a past quarter always reflects that PFS release.

Geographic practice cost indices (Q4 2018) · rvu18d.zip (GPCI2018.csv row 34)

ZIP code to carrier locality crosswalk (Q3 2018) · Zip-Code-to-Carrier-Locality.zip (ZIP5_JUL18.txt)

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