Price a code in Puerto Rico Copy link
What common codes pay in Puerto Rico Copy link
99214 is $131.60 here, 0.3% above national. Across these 10 codes, local Office (non-facility) amounts run from 0.3% above to 0.5% above national, depending on each code's mix of work, practice-expense and malpractice RVUs.
| Code | National | Local | 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% |
Office (non-facility), Q3 2021, before sequestration; 2021 standard (non-QP) physician conversion factor $34.8931. 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 mixed GPCI components, so the net payment effect varies by code for the Q3 2021 release.
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.
Which ZIP codes are in Puerto Rico? Copy link
178 ZIP codes in PR, per the CMS ZIP-to-locality crosswalk (Q3 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
Show all 178 ZIP codes
- 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
Have a service address? Look up its ZIP and date of service to confirm the locality.
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.
Have its GPCIs changed? Copy link
These GPCIs took effect January 2021: MP 0.988 → 0.986.
| 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 2021 to October 2022 (this page) | 1.000 | 1.008 | 0.986 |
| January 2020 to October 2020 | 1.000 | 1.008 | 0.988 |
| January 2018 to October 2019 | 1.000 | 1.007 | 0.990 |
| January 2017 to October 2017 | 1.000 | 0.856 | 0.642 |
| January 2015 to October 2016 | 1.000 | 0.705 | 0.293 |
| April 2014 to October 2014 | 1.000 | 0.692 | 0.271 |
| January 2013 to April 2013 | 1.000 | 0.678 | 0.249 |
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
-
01 GPCI2021.csv · Q3 2021 (RVU21C) · row 94—the three GPCIs limits
- Effective
- Effective July 2021
- Locator
- GPCI2021.csv in rvu21c-updated-6302021.zip · row 94 of 112 · via CMS
- Fields read
-
MAC 09202 Locality 20 Work GPCI 1.000 PE GPCI 1.008 MP GPCI 0.986SHA-256 28f1a06af5324ac2…
- Doesn’t establish
- An amount for any code by itself: that needs the code’s RVUs and status from the same release.
-
02 ZIP5_JUL2021.txt · Q3 2021—178 ZIP codes limits
- Source
- ZIP code to carrier locality crosswalk
- Locator
- ZIP5_JUL2021.txt in Zip-Code-to-Carrier-Locality.zip · via CMS
- Fields read
-
SHA-256 1df7fdc16c83b0f9…
- Doesn’t establish
- Where a split ZIP’s service address falls: CMS places those by ZIP+4.
-
03 Example amounts · Q3 2021 · $34.8931—the common-code table limits
- Source
- Each code’s Office (non-facility) RVUs from the same release, × these GPCIs, × the 2021 standard (non-QP) physician conversion factor
- Effective
- Effective July 2021
- 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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