CMS Rates

A Python tool for looking up Medicare Physician Fee Schedule reimbursement rates by CPT code and geographic region. Includes both a CLI and a web-based GUI.

Features

• Look up Medicare reimbursement rates by CPT/HCPCS code and state/locality
• Multi-code batch lookup with summary table and total payment
• Multi-payer rate comparison - Compare Medicare rates with commercial insurers and Medicaid
• Support for facility and non-facility rates
• Web-based GUI for easy lookups
• CLI with multiple output formats: table, JSON, CSV
• Verbose mode showing calculation breakdown
• Downloads official CMS RVU data files
• Covers all 50 states with 90+ locality-specific GPCI adjustments

Installation

Requirements

• Python 3.9+
• pip

Install dependencies

cd medical
pip install click rich httpx pydantic streamlit

Download CMS data

Before using the tool, download the fee schedule data:

PYTHONPATH=src python3 -m cms_rates update

This downloads ~18,000 CPT codes and GPCI data for all localities.

Web GUI

Launch the web-based graphical interface:

PYTHONPATH=src streamlit run src/cms_rates/app.py

Then open http://localhost:8501 in your browser.

The GUI provides:

• Single code lookup with detailed breakdown
• Multi-code batch lookup with summary table and total payment
• Search CPT codes by description
• Rate comparison across Medicare, commercial insurers, and Medicaid
• State/region dropdown selector
• Facility/non-facility toggle
• Calculation breakdown display
• View all localities in a state
• Add and manage payer rates directly in the UI

CLI Usage

Basic lookup

# Look up rate for CPT 99213 in California
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r CA

# Use full state name
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r California

# Look up facility rate
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r CA --facility

Multi-code lookup

# Look up multiple codes at once
PYTHONPATH=src python3 -m cms_rates lookup 99213 99214 99215 -r CA

# Get total payment for a procedure set
PYTHONPATH=src python3 -m cms_rates lookup 99213 99214 99215 -r TX --facility

# Output as JSON
PYTHONPATH=src python3 -m cms_rates lookup 99213 99214 -r NY --format json

Output formats

# JSON output
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r CA --format json

# CSV output
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r TX --format csv

# Verbose output with calculation breakdown
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r NY --verbose

View all localities in a state

# Show rates for all California localities
PYTHONPATH=src python3 -m cms_rates lookup 99213 -r CA --all-localities

List available localities

# List all localities
PYTHONPATH=src python3 -m cms_rates list-localities

# Filter by state
PYTHONPATH=src python3 -m cms_rates list-localities --state TX

Get CPT code information

PYTHONPATH=src python3 -m cms_rates info 99213

Search by description

# Search for CPT codes by description
PYTHONPATH=src python3 -m cms_rates search "office visit"

# Search with more results
PYTHONPATH=src python3 -m cms_rates search "x-ray" --limit 50

# Search with JSON output
PYTHONPATH=src python3 -m cms_rates search "MRI" --format json

Payer rate comparison

Compare Medicare rates with commercial insurers and Medicaid:

# Compare rates for a CPT code across all payers
PYTHONPATH=src python3 -m cms_rates compare 99213 -r CA

# Compare facility rates
PYTHONPATH=src python3 -m cms_rates compare 99213 -r CA --facility

# Output as JSON
PYTHONPATH=src python3 -m cms_rates compare 99213 -r TX --format json

Add payer rates

# Add a fixed rate for a payer
PYTHONPATH=src python3 -m cms_rates add-payer-rate 99213 "Blue Cross CA" --rate 115.50 --state CA

# Add rate as percentage of Medicare
PYTHONPATH=src python3 -m cms_rates add-payer-rate 99213 "Aetna" --percent-medicare 120 --type commercial

# Add Medicaid rate
PYTHONPATH=src python3 -m cms_rates add-payer-rate 99213 "Medi-Cal" --rate 72.00 --state CA --type medicaid

# Add with facility and non-facility rates
PYTHONPATH=src python3 -m cms_rates add-payer-rate 99213 "Cigna" --rate 110.00 --facility-rate 85.00 --state CA

Import payer rates from CSV

# Import rates from a CSV file
PYTHONPATH=src python3 -m cms_rates import-payer-rates medicaid_rates.csv --payer "Medi-Cal" --state CA --type medicaid

# Preview import without saving (dry run)
PYTHONPATH=src python3 -m cms_rates import-payer-rates rates.csv --payer "BCBS" --dry-run

# Custom column names
PYTHONPATH=src python3 -m cms_rates import-payer-rates data.csv --payer "Aetna" --code-column "CPT" --rate-column "Amount"

Manage payers

# List all payers in the database
PYTHONPATH=src python3 -m cms_rates list-payers

# List payers as JSON
PYTHONPATH=src python3 -m cms_rates list-payers --format json

# Delete payer rates
PYTHONPATH=src python3 -m cms_rates delete-payer "Old Payer" --confirm

Example Output

$ PYTHONPATH=src python3 -m cms_rates lookup 99213 -r CA --verbose

╭──────────────────────────────────────────────────────────────────╮
│ Medicare Physician Fee Schedule - CPT 99213                      │
╰──────────────────────────────────────────────────────────────────╯
  Code:           99213
  Description:    Office o/p est low 20 min
  Year:           2025
  Setting:        Non-Facility
  Locality:       Rest of California (01182-99)
  Payment:        $90.16

           Calculation Breakdown
 Component            RVU   GPCI  Adjusted
 Work                1.30  1.014    1.3182
 Practice Expense    1.35  1.035    1.3973
 Malpractice         0.10  0.718    0.0718
                                  ────────
 Total Adjusted RVU                 2.7873

Conversion Factor: $32.3465
Final Payment: $2.7873 × $32.3465 = $90.16

Rate Comparison Example

$ PYTHONPATH=src python3 -m cms_rates compare 99213 -r CA

╭──────────────────────────────────────────────────────────────────────────────╮
│ Rate Comparison - CPT 99213 (Non-Facility)                                   │
│ Region: Anaheim/Santa Ana, CA (CA)                                           │
╰──────────────────────────────────────────────────────────────────────────────╯
┏━━━━━━━━━━━━━━━━━━┳━━━━━━━━━━━━┳━━━━━━━━━┳━━━━━━━━━━━━━━━┓
┃ Payer            ┃ Type       ┃    Rate ┃ % of Medicare ┃
┡━━━━━━━━━━━━━━━━━━╇━━━━━━━━━━━━╇━━━━━━━━━╇━━━━━━━━━━━━━━━┩
│ Medicare (CMS)   │ government │  $99.65 │        100.0% │
│ Aetna            │ commercial │ $109.61 │        110.0% │
│ Blue Shield CA   │ commercial │ $114.60 │        115.0% │
│ Medi-Cal         │ medicaid   │  $72.00 │         72.3% │
│ UnitedHealthcare │ commercial │ $105.50 │        105.9% │
└──────────────────┴────────────┴─────────┴───────────────┘

Commands

Command	Description
lookup <CPT...> -r <REGION>	Look up reimbursement rate (supports multiple codes)
search <QUERY>	Search CPT codes by description
compare <CPT> -r <REGION>	Compare Medicare rate with other payers
add-payer-rate <CPT> <PAYER>	Add a payer-specific rate
import-payer-rates <CSV>	Import payer rates from CSV file
list-payers	List all payers in the database
delete-payer <PAYER>	Delete rates for a payer
update	Download/update CMS fee schedule data
list-localities	List all available localities
info <CPT>	Show CPT code details without pricing

Options

lookup command

Option	Description
--region, -r	State name, abbreviation, or locality code (required)
--year, -y	Fee schedule year (default: 2025)
--facility, -f	Show facility rate (default: non-facility)
--modifier, -m	Modifier code (TC, 26, etc.)
--format, -o	Output format: table, json, csv
--all-localities	Show rates for all localities in region
--verbose, -v	Show calculation breakdown

Note: Multiple CPT codes can be provided as arguments for batch lookup.

Data Sources

• RVU Data: CMS Physician Fee Schedule Relative Value Files
• GPCI Data: Geographic Practice Cost Indices by locality

Payment Calculation

Medicare payment is calculated using the formula:

Payment = [(Work_RVU × Work_GPCI) + (PE_RVU × PE_GPCI) + (MP_RVU × MP_GPCI)] × Conversion_Factor

Where:

• Work RVU: Physician work component
• PE RVU: Practice expense (facility or non-facility)
• MP RVU: Malpractice component
• GPCI: Geographic Practice Cost Index for the locality
• Conversion Factor: $32.3465 (2025)

License

MIT