Medicare payment locality · Q2 2021 release

Puerto Rico PR Medicare Locality 20

MAC 09202 · Locality 20

This locality's GPCIs are mixed, so the net payment effect varies by code for the Q2 2021 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

1.008

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

Malpractice GPCI

0.986

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 Puerto Rico Copy link

National and Puerto Rico Office (non-facility) amounts for frequently reviewed codes in the Q2 2021 release (before sequestration). Conversion factor: 2021 standard (non-QP) physician conversion factor · $34.8931.

Code	National	Puerto Rico	Difference
99214	$131.20	$131.60	+0.3%
99213	$92.47	$92.77	+0.3%
99215	$183.19	$183.71	+0.3%
66984	$548.17	$550.10	+0.4%
99204	$169.93	$170.39	+0.3%
92014	$128.41	$129.00	+0.5%
97110	$30.36	$30.46	+0.3%
88305	$71.53	$71.88	+0.5%
97530	$39.43	$39.61	+0.5%
99203	$113.75	$114.10	+0.3%

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

Puerto Rico covers 178 ZIP codes across PR, per the CMS ZIP-to-locality crosswalk (Q2 2021).

00601 00602 00603 00604 00605 00606 00610 00611 00612 00613 00614 00616 00617 00622 00623 00624 00627 00631 00636 00637 00638 00641 00646 00647 00650 00652 00653 00656 00659 00660 00662 00664 00667 00669 00670 00674 00676 00677 00678 00680 00681 00682 00683 00685 00687 00688 00690 00692 00693 00694 00698 00703 00704 00705 00707 00714 00715 00716 00717 00718 00719 00720 00721 00723 00725 00726 00727 00728 00729 00730 00731 00732 00733 00734 00735 00736 00737 00738 00739 00740 00741 00742 00744 00745 00751 00754 00757 00765 00766 00767 00769 00771 00772 00773 00775 00777 00778 00780 00782 00783 00784 00785 00786 00791 00792 00794 00795 00901 00902 00905 00906 00907 00908 00909 00910 00911 00912 00913 00914 00915 00916 00917 00918 00919 00920 00921 00922 00923 00924 00925 00926 00927 00928 00929 00930 00931 00933 00934 00935 00936 00937 00938 00939 00940 00949 00950 00951 00952 00953 00954 00955 00956 00957 00958 00959 00960 00961 00962 00963 00965 00966 00968 00969 00970 00971 00975 00976 00977 00978 00979 00981 00982 00983 00984 00985 00986 00987 00988

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

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 costs for physician work, running an office, and liability insurance therefore move the final amount up or down. Puerto Rico currently has mixed GPCI components, so the net payment effect varies by code for the Q2 2021 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.

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 2021 release (effective April 2021). ZIP coverage from the CMS ZIP-to-locality crosswalk, Q2 2021 release. Example amounts use the standard (non-QP) physician conversion factor ($34.8931) 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 2021) · rvu21b-updated-03022021.zip (GPCI2021.csv row 94)

ZIP code to carrier locality crosswalk (Q2 2021) · Zip-Code-to-Carrier-Locality.zip (ZIP5_APR2021.txt)

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