medicare_allowed

Medicare Allowed

What it answers

Returns the Medicare allowed amount for ONE billing code (CPT/HCPCS, or an MS-DRG for inpatient) from every Medicare fee schedule that prices it: PFS (professional, national non-facility), OPPS Addendum B (hospital outpatient APC), ASC, CLFS (lab), and IPPS (national DRG amount). Inputs: billing_code (required); optional care_class to pick the setting that fits a site (02_asc, 03_outpatient, 04_urgent_care, 05_imaging, 06_lab, 07_dialysis — the same preference table care_site_price uses for its Medicare floor); optional setting to return one schedule only (PFS_non_facility | OPPS_APC | ASC | CLFS | IPPS_MSDRG_national); optional medicare_year to PIN a schedule vintage (4-digit year; omit it and the LATEST edition held for the chosen schedule is served — an older vintage is never returned unless you pin it); optional limit.

RETURNS a detail payload: value.medicare_year and value.setting state the vintage and schedule actually served; value.summary carries the PREFERRED row for the requested care_class (medicare_allowed, medicare_source, medicare_year, billing_class), the latest year held per schedule (latest_year_by_schedule) and whether the year was pinned or resolved (medicare_year_selection), plus the count of schedules that price the code; value.settings lists EVERY schedule row for the code with what it is (fee_schedule, professional vs facility component, site, national basis, locality_adjusted=false, source_table, medicare_year vintage). Every number is NATIONAL — no GPCI / wage-index localisation is applied, and PFS is the NON-FACILITY (office) professional rate. A code priced on no schedule returns found=false ('not priced on these Medicare schedules', never $0). Reads the latest available edition per schedule (vlada_curated.vw_medicare_benchmark; the underlying M-2 fact tables are read WHERE is_current).

SOURCE: CMS PFS RVU + conversion factor, OPPS Addendum B, ASC addendum, CLFS, IPPS Table 5 + base rates.

Inputs

billing_code

string · required

care_class

string · optional

limit

integer · optional

medicare_year

integer · optional

setting

string · optional

Call it

From an agent: connect the Vlada MCP once (one click for Claude, ChatGPT, Cursor, VS Code) and ask in plain English; the agent selects medicare_allowed when the question fits. From code: the same tool over REST with an API key. The schema endpoint needs no key.

curl -X POST https://api.vladahealth.com/v1/tools/medicare_allowed \
  -H "Authorization: Bearer $VLADA_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{"billing_code":"<billing_code>"}'

curl https://api.vladahealth.com/v1/tools/medicare_allowed/schema      # the JSON schema, no auth
# MCP endpoint (Streamable HTTP): https://mcp.vladahealth.com/mcp

What comes back

Typed rows plus provenance on every answer: the public source file, its vintage, the methodology, and a response_hash you can replay. Prove and replay tools turn any number into a re-runnable receipt. A number the data cannot support comes back as “not in the data”, never as zero.

Sources behind it

vlada_curated.vw_medicare_benchmark
medicare_silver.fact_pfs_rvu
medicare_silver.fact_opps_addendum_b
medicare_silver.fact_asc_addendum
medicare_silver.fact_clfs_national_rate

tables: vlada_curated.vw_medicare_benchmark · medicare_silver.fact_pfs_rvu · medicare_silver.fact_opps_addendum_b · medicare_silver.fact_asc_addendum · medicare_silver.fact_clfs_national_rate

Known limits

National amounts only: no GPCI (PFS) or wage-index (OPPS/ASC/IPPS) localisation.
PFS is the non-facility (office) professional rate; the facility-setting professional rate is not served.
DMEPOS / anesthesia / ESRD schedules are not loaded; a code absent from every served schedule is 'not priced here', not $0.

As of the 2026-09-19 build of the served surface · machine-readable catalog · the live server may run a different version; the schema endpoint above is authoritative for what is deployed.