Medicare payment locality · Q4 2014 release

Puerto Rico PR Medicare Locality 20

MAC 09202 · Locality 20

This locality's GPCIs are all at or below the national baseline, so normally RVU-priced services tend to price below the national amount for the Q4 2014 Physician Fee Schedule. For nationally priced services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs using these indexes.

Work GPCI

1.000

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

0.692

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

Malpractice GPCI

0.271

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 Puerto Rico Copy link

National vs. Puerto Rico office (non-facility) amounts for frequently reviewed codes, Q4 2014 (before sequestration). Conversion factor: 2014 standard (non-QP) physician conversion factor · $35.8228.

Code	National	Puerto Rico	Difference
99214	$107.83	$89.66	-16.9%
99213	$73.08	$60.22	-17.6%
99215	$144.37	$121.22	-16.0%
66984	$673.11	$540.49	-19.7%
99204	$166.22	$138.52	-16.7%
92014	$126.10	$101.42	-19.6%
97110	$32.24	$27.12	-15.9%
88305	$70.57	$56.81	-19.5%
97530	$35.11	$29.00	-17.4%
99203	$108.18	$88.57	-18.1%

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.

Common questions Copy link

Why do Medicare rates in Puerto Rico 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. Puerto Rico currently has all three GPCI components at or below the national baseline, so normally RVU-priced services tend to price below the national amount for the Q4 2014 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. A few ZIPs nationally span multiple localities and need 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 2014 release (effective October 2014). Example amounts use the standard (non-QP) physician conversion factor ($35.8228) 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 2014) · rvu14d.zip (CY 2014 GPCI _12172013.csv row 70)

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