Medicare PFS data and coverage
Review the October 2026 source files, supported dates and settings, calculation method and limits of the installed reference dataset.
The installed snapshot combines CMS October 2026 RVU files, GPCI values and the October ZIP-to-locality crosswalk. It supports a base-reference calculation for one service, not complete claim adjudication.
Loading source status.
Three archives, three different jobs
| Source | What is actually in the supplied archive | How DueMD uses it |
|---|---|---|
| RVU26D | 19,453 non-QP rows; 11,978 QP rows; 109 GPCI localities. Counts include code/component combinations and non-priceable statuses. | RVUs, setting flags, conversion factors and locality adjustments. |
| PFREV26D | 654 revision records per rate class: six codes × 109 localities. This is not the full payment catalog. | Independent amount comparisons for these six codes, not a replacement for the RVU catalog. |
| October ZIP crosswalk | 42,957 ZIP5 records and 1,087,640 ZIP+4 records, with quarter marker 20264. | Exact service-location mapping to a MAC and locality. Split areas require ZIP+4. |
Supported reference scope
The current release supports service dates from October 1 to December 31, 2026. A priceable query needs status A, an applicable setting, an exact QP/non-QP record and a supported blank, 26 or TC component. Rows with OPPS-cap dependencies are stopped for separate review. Other modifiers are not applied.
There are 8,460 eligible code/component keys per rate class before the setting check: 4,447 have a supported non-facility setting and 7,151 have a supported facility setting. These groups overlap. They are not counts of unique services or verified final payments.
How a local reference is calculated
The engine uses exact integer arithmetic for the source decimals and rounds once to cents. The optional contract percentage is then applied to that rounded reference. QP and non-QP values stay in separate records.
The separate unadjusted mode sets each GPCI to 1. It is not a weighted national average and is not represented as a row retrieved from the complete PFALL payment catalog.
What has been checked
ZIP-member CRCs, source hashes, field layouts, row counts, duplicate keys, setting flags and RVU component totals were checked during import. The non-facility calculation matches all 1,308 supplied PFREV revision amounts across both rate classes. That independent amount check covers six codes—not every code supported by the tool.
The snapshot was imported from supplied archives. File hashes and source metadata are retained, but the files have not been independently matched against a fresh CMS download. This is an imported dataset, not a live CMS feed.
Updates are explicit
Each snapshot is immutable. A new version is prepared and tested before its pointer can change. A failed import leaves the old pointer untouched. The native adapter is for this exact October 2026 format; a later release needs its own schema, change and fixture review.
Code-set rights still need review
AMA and ADA rights notices apply to material in the source files. Procedure descriptions are omitted here; that does not by itself clear code-set rights. Public use and onward distribution remain subject to the applicable permissions.
What is not included
No anesthesia pricing, OPPS-dependent rates, complete modifier logic, multiple-procedure reductions, patient responsibility, sequestration, MIPS, coverage decisions or full claim adjudication. A setting marked NA is not priced even when another source column contains a number. Only records within the supported date range are used.