Overview

What does the Procedure Price Lookup (PPL) API offer?

The Procedure Price Lookup (PPL) API lets licensed American Medical Association (AMA) users:

  • Search by procedure codes or terms describing medical procedures to find national averages for the amount Medicare pays hospitals or surgical centers, and the national average copay amounts beneficiaries with no Medicare Supplement Insurance (Medigap) would pay a provider.
  • Access the bulk cost data endpoint to get the AMA procedure descriptions and cost data associated with a subset of CPT/HCPCS codes.

The Centers for Medicare and Medicaid Services (CMS) Procedure Price Lookup (PPL), helps people with Medicare compare costs and copays for approximately 3,900 medical procedures in hospital outpatient departments and ambulatory surgical centers.

Getting started

To use the PPL API, you must have an AMA license and an API key.

How can I get an AMA License?

  • The AMA sells licenses to access their procedure descriptions associated with CPT/HCPCS codes on a yearly basis. Find information about purchasing an AMA license.

Who can use the PPL API?

  • Anyone who is an AMA license user and has requested an API key from CMS.

Once I have an AMA license, how can I start using the PPL API?

  • Request an API key. CMS will review your request and issue an API key after it’s approved. Once you have your API key, it’s ready to use.
  • You can find the PPL API documentation on Apiary: PPL API Documentation

Use cases

  • The PPL API powers CMS’ Procedure Price Lookup, which helps people with Medicare compare costs and copays for approximately 3,900 medical procedures in hospital outpatient departments and ambulatory surgical centers.

  • The AMA supports CMS in distributing content to its application development partners in accordance with current licensee and copyright requirements on data provided by CMS.

  • Third-party use cases may include any websites with users interested in healthcare pricing data for the 3,900 medical procedures set, or to compare costs and copays in hospital outpatients and ambulatory surgical centers.

Support

Questions and support requests can be submitted here.

FAQs

Q: What data is available?

A: Pricing data for procedures by CPT/HCPCS code

  • Codes (HCPCS or CPT) of medical procedures
  • Short, common-language descriptions of medical procedures
  • Flagged data indicating accounting for bundling of procedures depicting a comprehensive ambulatory payment classification
  • National average total payment amount approved/established by Medicare forhospital outpatient departments
  • National average total payment amount approved/established by Medicare for ambulatory surgical centers
  • National average payment made by Medicare for hospital outpatient departments
  • National average payment made by Medicare for ambulatory surgical centers
  • Flagged data indicating potential cap of inpatient deductible at $1340 instead of the beneficiary having to pay the copay for a hospital outpatient procedure
  • National average copay amount for a beneficiary with no Medicare Supplemental Insurance (Medigap) for hospital outpatient procedures
  • National average copay amount for a beneficiary with no Medicare Supplemental Insurance for an ambulatory surgical center procedure

Q: How is it determined which procedures are included?

A: Only procedures that can be performed at either hospital outpatient departments or ambulatory surgical centers under reasonable circumstances are included. (For example, emergency procedures aren’t included.)

Q: Which facility types are included? How is it determined?

A: The 2 main facility types currently included are ambulatory surgical centers and hospital outpatient departments. These were prioritized in our initial release by legislative mandate. More facility types may be added in future releases.

Q: How often is the data updated?

A: CMS updates the data each year.

Q: What do the prices include?

A: Prices reflect the “Medicare approved amount,” which is the total that the doctor or supplier is paid for the procedure. Usually, Original Medicare generally pays 80% of this amount and the patient pays 20%