Medicare CPT Reimbursement Calculator Tool

Medicare Payment Formula:

\[ Payment = [(wRVU \times wGPCI) + (peRVU \times peGPCI) + (mpRVU \times mpGPCI)] \times 32.35 \]

Work RVU (wRVU):

units

Work GPCI (wGPCI):

factor

Practice Expense RVU (peRVU):

units

Practice Expense GPCI (peGPCI):

factor

Malpractice RVU (mpRVU):

units

Malpractice GPCI (mpGPCI):

factor

Estimated Medicare Payment:

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1. What is Medicare CPT Reimbursement?

The Medicare Physician Fee Schedule (MPFS) determines payments for services based on Relative Value Units (RVUs) adjusted by Geographic Practice Cost Indices (GPCIs) and a conversion factor. This calculator helps estimate Medicare reimbursement for specific CPT codes.

2. How Does the Calculator Work?

The calculator uses the Medicare payment formula:

\[ Payment = [(wRVU \times wGPCI) + (peRVU \times peGPCI) + (mpRVU \times mpGPCI)] \times 32.35 \]

Where:

$ wRVU $ — Work Relative Value Unit
$ wGPCI $ — Work Geographic Practice Cost Index
$ peRVU $ — Practice Expense Relative Value Unit
$ peGPCI $ — Practice Expense Geographic Practice Cost Index
$ mpRVU $ — Malpractice Relative Value Unit
$ mpGPCI $ — Malpractice Geographic Practice Cost Index
32.35 — Conversion Factor (2023 value, subject to change)

Explanation: The formula combines three components (work, practice expense, malpractice) adjusted for geographic costs and converts to dollar amount.

3. Importance of Accurate Reimbursement Calculation

Details: Understanding Medicare reimbursement helps practices with financial planning, contract negotiations, and assessing the viability of services.

4. Using the Calculator

Tips: Enter all RVU values (available from CMS or coding resources) and corresponding GPCI values (specific to your location). Default GPCI values are 1.000 (national average).

5. Frequently Asked Questions (FAQ)

Q1: Where can I find RVU values for CPT codes?
A: The CMS Physician Fee Schedule Look-Up Tool provides current RVU values for all CPT codes.

Q2: How often do GPCI values change?
A: GPCI values are typically updated annually by CMS, effective January 1st each year.

Q3: What's the current conversion factor?
A: The 2023 conversion factor is $32.35, but this changes annually. Check CMS updates for current values.

Q4: Does this include Medicare sequestration adjustments?
A: No, this calculates the base payment. Medicare applies a 2% reduction under sequestration.

Q5: Can this be used for non-Medicare payers?
A: Some private payers use similar methodologies but may have different RVU weights or conversion factors.