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Medicare payment locality · Q2 2015 release

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Puerto Rico

Puerto Rico MAC 09202 · Locality 20

Work GPCI
1.000
Practice expense GPCI
0.705
Malpractice GPCI
0.293

All three GPCIs are at or below the national baseline of 1.000, so codes priced with the standard RVU formula usually pay less here than the national amount.

Effective CMS RVU15B Updated

Price a code in Puerto Rico Copy link

The locality-adjusted amount for the Q2 2015 release, with the facility and office settings and the full calculation.

What common codes pay in Puerto Rico Copy link

99214 is $90.73 here, 16.3% below national. Across these 10 codes, local Office (non-facility) amounts run from 19.1% below to 15.8% below national, depending on each code's mix of work, practice-expense and malpractice RVUs.

Code National Local Difference
99214 $108.34 $90.73 -16.3%
99213 $72.94 $60.77 -16.7%
99215 $146.24 $123.00 -15.9%
66984 $647.16 $537.13 -17.0%
99204 $165.90 $139.35 -16.0%
92014 $124.07 $101.71 -18.0%
97110 $32.54 $27.39 -15.8%
88305 $72.94 $59.04 -19.1%
97530 $35.04 $29.20 -16.7%
99203 $109.05 $89.65 -17.8%

Office (non-facility), Q2 2015, before sequestration; 2015 standard (non-QP) physician conversion factor $35.7547. For the facility amount, a modifier or a date of service, use the rate calculator, already set to this locality, or start from your field's procedure mix on the specialty fee schedules.

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 costs for physician work, running an office, and liability insurance therefore move the final amount up or down. Puerto Rico currently has all three GPCIs at or below the national baseline, so services priced with the standard RVU formula usually come out below the national amount for the Q2 2015 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. 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 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.

Have its GPCIs changed? Copy link

These GPCIs took effect January 2015: PE 0.692 → 0.705, MP 0.271 → 0.293.

Release Work PE MP
January 2026 to October 2026 1.000 1.011 0.985
January 2024 to October 2025 1.000 1.007 0.982
October 2023 1.000 1.008 0.984
January 2023 to July 2023 1.000 1.000 1.000
January 2015 to October 2016 (this page) 1.000 0.705 0.293

Newest first; releases with unchanged GPCIs share a row.

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

  1. 01 CY2015_GPCIs.csv · Q2 2015 (RVU15B) · row 70—the three GPCIs limits
    Source
    Geographic practice cost indices (GPCI), Q2 2015 release
    Effective
    Effective April 2015
    Locator
    CY2015_GPCIs.csv in rvu15b.zip · row 70 of 90 · via CMS
    Fields read
    MAC 09202 Locality 20 Work GPCI 1.000 PE GPCI 0.705 MP GPCI 0.293
    SHA-256 ce389037033017a1…
    Doesn’t establish
    An amount for any code by itself: that needs the code’s RVUs and status from the same release.
  2. 02 Example amounts · Q2 2015 · $35.7547—the common-code table limits
    Source
    Each code’s Office (non-facility) RVUs from the same release, × these GPCIs, × the 2015 standard (non-QP) physician conversion factor
    Effective
    Effective April 2015
    Doesn’t establish
    Facility amounts, modifier adjustments or the payment after the ~2% sequestration cut; codes outside the standard RVU formula aren’t listed.
    Note
    Past releases are never edited, so a rate for an earlier quarter always matches what CMS published for it.

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