Medicare Reimbursement Fee Calculator

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

Medicare Payment:

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1. What is the Medicare Reimbursement Fee Formula?

The Medicare Reimbursement Fee formula calculates payment for physician services under the Medicare Physician Fee Schedule (MPFS). It accounts for three components: physician work, practice expenses, and malpractice insurance, each adjusted by geographic practice cost indices (GPCI).

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 Units
\( wGPCI \) — Work Geographic Practice Cost Index
\( peRVU \) — Practice Expense Relative Value Units
\( peGPCI \) — Practice Expense Geographic Practice Cost Index
\( mpRVU \) — Malpractice Relative Value Units
\( mpGPCI \) — Malpractice Geographic Practice Cost Index
32.35 — Conversion factor (2023 value, may change annually)

Explanation: The formula combines three weighted components adjusted for geographic cost differences, then multiplies by the annual conversion factor.

3. Importance of Medicare Payment Calculation

Details: Accurate payment calculation helps healthcare providers understand reimbursement rates, plan practice finances, and negotiate contracts with payers.

4. Using the Calculator

Tips: Enter all RVU and GPCI values. RVUs are typically available from the Medicare Physician Fee Schedule, while GPCIs are location-specific. All values must be non-negative.

5. Frequently Asked Questions (FAQ)

Q1: Where can I find the RVU values for specific CPT codes?
A: RVU values are published annually in the Medicare Physician Fee Schedule available on the CMS website.

Q2: How often do GPCI values change?
A: GPCI values are typically updated annually, though significant changes are infrequent.

Q3: Is the conversion factor always 32.35?
A: No, the conversion factor changes annually. Verify the current year's factor from CMS.

Q4: Does this calculator account for modifiers?
A: No, this calculates base payment. Modifiers like -25 or -59 may affect final payment.

Q5: Are there services not paid under this formula?
A: Yes, some services like vaccines or certain preventive services have different payment methodologies.