Medicare payment locality · Q2 2018 release

Rhode Island RI Medicare Locality 01

MAC 14412 · Locality 01

This locality's GPCIs are mixed, so the net payment effect varies by code for the Q2 2018 Physician Fee Schedule. For nationally priced services, Medicare adjusts each code's work, practice-expense, and malpractice RVUs using these indexes.

Work GPCI

1.027

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

1.050

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

Malpractice GPCI

0.999

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 Rhode Island Copy link

National and Rhode Island Office (non-facility) amounts for frequently reviewed codes in the Q2 2018 release (before sequestration). Conversion factor: 2018 standard (non-QP) physician conversion factor · $35.9996.

Code	National	Rhode Island	Difference
99214	$109.44	$113.49	+3.7%
99213	$74.16	$76.94	+3.7%
99215	$147.60	$152.96	+3.6%
66984	$656.27	$680.93	+3.8%
99204	$167.40	$173.35	+3.6%
92014	$128.52	$133.66	+4.0%
97110	$31.32	$32.48	+3.7%
88305	$70.20	$73.03	+4.0%
97530	$41.40	$43.07	+4.0%
99203	$109.80	$113.84	+3.7%

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

Rhode Island covers 91 ZIP codes across RI, per the CMS ZIP-to-locality crosswalk (Q2 2018).

02801 02802 02804 02806 02807 02808 02809 02812 02813 02814 02815 02816 02817 02818 02822 02823 02824 02825 02826 02827 02828 02829 02830 02831 02832 02833 02835 02836 02837 02838 02839 02840 02841 02842 02852 02854 02857 02858 02859 02860 02861 02862 02863 02864 02865 02871 02872 02873 02874 02875 02876 02877 02878 02879 02880 02881 02882 02883 02885 02886 02887 02888 02889 02891 02892 02893 02894 02895 02896 02898 02901 02902 02903 02904 02905 02906 02907 02908 02909 02910 02911 02912 02914 02915 02916 02917 02918 02919 02920 02921 02940

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

Common questions Copy link

Why do Medicare rates in Rhode Island 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. Rhode Island currently has mixed GPCI components, so the net payment effect varies by code for the Q2 2018 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 2018 release (effective April 2018). ZIP coverage from the CMS ZIP-to-locality crosswalk, Q2 2018 release. Example amounts use the standard (non-QP) physician conversion factor ($35.9996) 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 2018) · rvu18b.zip (GPCI2018.csv row 95)

ZIP code to carrier locality crosswalk (Q2 2018) · Zip-Code-to-Carrier-Locality.zip (ZIP5_APR18.txt)

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