Medicare payment locality · Q2 2018 release

Virginia VA Medicare Locality 00

MAC 11302 · Locality 00

This locality's GPCIs are all at or below the national baseline, so services priced with the standard RVU formula usually come out below the national amount 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

1.000

Adjusts the physician-work component for professional labor costs

Practice expense GPCI

0.986

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

Malpractice GPCI

0.908

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 Virginia Copy link

National and Virginia 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	Virginia	Difference
99214	$109.44	$108.38	-1.0%
99213	$74.16	$73.41	-1.0%
99215	$147.60	$146.17	-1.0%
66984	$656.27	$649.69	-1.0%
99204	$167.40	$165.66	-1.0%
92014	$128.52	$127.27	-1.0%
97110	$31.32	$31.05	-0.9%
88305	$70.20	$69.51	-1.0%
97530	$41.40	$40.99	-1.0%
99203	$109.80	$108.56	-1.1%

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

Virginia covers 1,145 ZIP codes across VA, per the CMS ZIP-to-locality crosswalk (Q2 2018). 1 of them span more than one locality and need ZIP+4 for an exact match.

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

Common questions Copy link

Why do Medicare rates in Virginia 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. Virginia 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 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. About 1 ZIP codes in Virginia span more than one locality and need the 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 109)

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

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