Search the Medicare Physician & Other Practitioners API by Provider and Service

Information on services and procedures provided to Original Medicare (fee-for-service) Part B (Medical Insurance) beneficiaries by physicians and other healthcare professionals; aggregated by provider and service.

Usage

physician_by_service(
  year,
  npi = NULL,
  last_name = NULL,
  first_name = NULL,
  credential = NULL,
  gender = NULL,
  entype = NULL,
  city = NULL,
  state = NULL,
  zipcode = NULL,
  fips = NULL,
  ruca = NULL,
  country = NULL,
  specialty = NULL,
  par = NULL,
  hcpcs_code = NULL,
  hcpcs_drug = NULL,
  place_of_srvc = NULL,
  tidy = TRUE
)

Source

Centers for Medicare & Medicaid Services

Arguments

year: int (required); Year in YYYY format. Run helper function provider:::physician_by_service_years() to return a vector of the years currently available.
npi: National Provider Identifier (NPI) for the rendering provider on the claim. The provider NPI is the numeric identifier registered in NPPES.
last_name: Last name/Organization name of the provider. When the provider is registered in NPPES as an individual (entity type code = I), this is the provider’s last name. When the provider is registered as an organization (entity type code = O), this is the organization name.
first_name: An individual provider's (entity type code = I) first name. An organization's (entity type code = O) will be blank.
credential: An individual provider's (entity type code=’I’) credentials. An organization's will be blank.
gender: An individual provider's gender. An organization's will be blank.
entype: Type of entity reported in NPPES. An entity code of ‘I’ identifies providers registered as individuals while an entity type code of ‘O’ identifies providers registered as organizations.
city: The city where the provider is located, as reported in NPPES.
state: The state where the provider is located, as reported in NPPES.
zipcode: The provider’s zip code, as reported in NPPES.
fips: FIPS code for the rendering provider's state.
ruca: Rural-Urban Commuting Area Code (RUCA); a Census tract-based classification scheme that utilizes the standard Bureau of Census Urbanized Area and Urban Cluster definitions in combination with work commuting information to characterize all of the nation's Census tracts regarding their rural and urban status and relationships. The Referring Provider ZIP code was cross walked to the United States Department of Agriculture (USDA) 2010 Rural-Urban Commuting Area Codes.
country: The country where the provider is located, as reported in NPPES.
specialty: Derived from the provider specialty code reported on the claim. For providers that reported more than one specialty code on their claims, this is the specialty code associated with the largest number of services.
par: Identifies whether the provider participates in Medicare and/or accepts assignment of Medicare allowed amounts. The value will be Y for any provider that had at least one claim identifying the provider as participating in Medicare or accepting assignment of Medicare allowed amounts within HCPCS code and place of service. A non-participating provider may elect to accept Medicare allowed amounts for some services and not accept Medicare allowed amounts for other services.
hcpcs_code: HCPCS code used to identify the specific medical service furnished by the provider. HCPCS codes include two levels. Level I codes are the Current Procedural Terminology (CPT) codes that are maintained by the American Medical Association and Level II codes are created by CMS to identify products, supplies and services not covered by the CPT codes (such as ambulance services).
hcpcs_drug: Identifies whether the HCPCS code for the specific service furnished by the provider is a HCPCS listed on the Medicare Part B Drug Average Sales Price (ASP) File. Please visit the ASP drug pricing page for additional information.
place_of_srvc: Identifies whether the place of service submitted on the claims is a facility (value of F) or non-facility (value of O). Non-facility is generally an office setting; however other entities are included in non-facility.
tidy: Tidy output; default is TRUE.

Value

A tibble containing 29 columns:

year: year
npi: year
entype: Entity/Enumeration Type of the Provider
first_name: year
middle_name: year
last_name: year
credential: year
gender: year
specialty: year
street: the provider’s street address
city: The city where the provider is located, as reported in NPPES.
state: State Abbreviation of the Provider
fips: State FIPS Code of the Provider
zipcode: Zip Code of the Provider
ruca: RUCA Code of the Provider
country: Country Code of the Provider
par: Medicare Participation Indicator
hcpcs_cd: HCPCS Code
hcpcs_desc: HCPCS Description
hcpcs_drug: HCPCS Drug Indicator
pos: Place of Service
tot_benes: Number of Medicare Beneficiaries
tot_srvcs: Number of Services
tot_day: Number of Distinct Medicare Beneficiary/Per Day Services
avg_charge: Average Submitted Charge Amount
avg_allowed: Average Medicare Allowed Amount
avg_payment: Average Medicare Payment Amount
avg_std_pymt: Average Medicare Standardized Payment Amount

Details

The Provider and Service dataset provides information on services and procedures provided to Medicare (fee-for-service) Part B beneficiaries by physicians and other healthcare professionals.

The data is based on information gathered from CMS administrative claims data for Part B beneficiaries available from the CMS Chronic Conditions Data Warehouse.

The spending and utilization data in the Physician and Other Practitioners by Provider and Service Dataset are aggregated to the following:

the NPI for the performing provider,
the Healthcare Common Procedure Coding System (HCPCS) code, and
the place of service (either facility or non-facility).

There can be multiple records for a given NPI based on the number of distinct HCPCS codes that were billed and where the services were provided. Data have been aggregated based on the place of service because separate fee schedules apply depending on whether the place of service submitted on the claim is facility or non-facility.

Note

Update Frequency: Annually

References

Medicare Physician & Other Practitioners: by Provider and Service API

Examples

if (FALSE) { # interactive()
physician_by_service(npi = 1003000126)
physician_by_service(year = 2019, last_name = "Enkeshafi")
c(1003026055, 1316405939, 1720392988) |>
  purrr::map(physician_by_service, year = 2020) |>
  purrr::list_rbind()
}