Medicare payment locality · Q2 2020 release

Metropolitan Boston MA Medicare Locality 01

MAC 14212 · Locality 01

This locality's GPCIs are mixed, so the net payment effect varies by code for the Q2 2020 Physician Fee Schedule. For nationally priced services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs using these indexes.

Work GPCI

1.041

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

1.191

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

Malpractice GPCI

0.952

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 Metropolitan Boston Copy link

National and Metropolitan Boston Office (non-facility) amounts for frequently reviewed codes in the Q2 2020 release (before sequestration). Conversion factor: 2020 standard (non-QP) physician conversion factor · $36.0896.

Code	National	Metropolitan Boston	Difference
99214	$110.43	$122.46	+10.9%
99213	$76.15	$84.75	+11.3%
99215	$148.33	$163.94	+10.5%
66984	$557.58	$619.72	+11.1%
99204	$167.09	$183.96	+10.1%
92014	$128.12	$144.47	+12.8%
97110	$31.40	$34.79	+10.8%
88305	$71.46	$80.87	+13.2%
97530	$40.42	$45.59	+12.8%
99203	$109.35	$121.43	+11.0%

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

Metropolitan Boston covers 257 ZIP codes across MA, per the CMS ZIP-to-locality crosswalk (Q2 2020). 2 of them span more than one locality and need ZIP+4 for an exact match.

01431 01432 01434 01450 01460 01463 01464 01469 01470 01471 01472 01474 01701 01702 01703 01704 01705 01718 01719 01720 01721 01730 01731 01741 01742 01746 01748 01749 01752 01754 01760 01770 01773 01775 01776 01778 01784 01801 01803 01805 01806 01807 01808 01813 01815 01821 01822 01824 01826 01827 01850 01851 01852 01853 01854 01862 01863 01864 01865 01866 01867 01876 01879 01880 01886 01887 01888 01889 01890 02019 02021 02025 02026 02027 02030 02032 02035 02038 02052 02053 02054 02056 02062 02067 02070 02071 02072 02081 02090 02093 02101 02102 02103 02104 02105 02106 02107 02108 02109 02110 02111 02112 02113 02114 02115 02116 02117 02118 02119 02120 02121 02122 02123 02124 02125 02126 02127 02128 02129 02130 02131 02132 02133 02134 02135 02136 02137 02138 02139 02140 02141 02142 02143 02144 02145 02146 02147 02148 02149 02150 02151 02152 02153 02154 02155 02156 02157 02158 02159 02160 02161 02162 02163 02164 02165 02166 02167 02168 02169 02170 02171 02172 02173 02174 02175 02176 02177 02178 02179 02180 02181 02184 02185 02186 02187 02188 02189 02190 02191 02192 02193 02194 02195 02196 02199 02201 02202 02203 02204 02205 02206 02207 02208 02209 02210 02211 02212 02215 02216 02217 02222 02228 02238 02239 02241 02254 02258 02266 02269 02272 02277 02283 02284 02293 02295 02297 02298 02322 02343 02368 02420 02421 02445 02446 02447 02451 02452 02453 02454 02455 02456 02457 02458 02459 02460 02461 02462 02464 02465 02466 02467 02468 02471 02472 02474 02475 02476 02477 02478 02479 02481 02482 02492 02493 02494 02495 02762

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

Common questions Copy link

Why do Medicare rates in Metropolitan Boston 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. Metropolitan Boston currently has mixed GPCI components, so the net payment effect varies by code for the Q2 2020 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 Metropolitan Boston 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 Q2 2020 release (effective April 2020). ZIP coverage from the CMS ZIP-to-locality crosswalk, Q2 2020 release. Example amounts use the standard (non-QP) physician conversion factor ($36.0896) 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 (Q2 2020) · rvu20b-updated-05012020.zip (GPCI2020.csv row 64)

ZIP code to carrier locality crosswalk (Q2 2020) · Zip-Code-to-Carrier-Locality.zip (ZIP5_APR2020.txt)

Did this answer your question about Metropolitan Boston (MA)?

We're building this out in the open. Tell us what you were actually trying to work out and we'll either answer you directly or build the page that does.