Medicare Physician Fee Schedule - Find-A-Code

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DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Medicare & Medicaid ServicesMedicare Physician Fee SchedulePAYMENT SYSTEM FACT SHEET SERIESICN 006814 May 2014

Please note: The information in this publicationapplies only to the Medicare Fee-For-ServiceProgram (also known as Original Medicare).This publication provides the followinginformation about the Medicare Physician FeeSchedule (PFS): Physicians’ offices; Hospitals; Ambulatory Surgical Centers; Skilled Nursing Facilities and other post-acutecare settings; Physician services; Hospices; Medicare PFS payment rates; Outpatient dialysis facilities; Medicare PFS payment rates formula; and Clinical laboratories; and Resources. Beneficiaries’ homes.Physician ServicesMedicare Part B pays for physician services based onthe Medicare PFS, which lists the more than 7,400unique covered services and their payment rates.Physicians’ services include the following: Office visits; Surgical procedures; Anesthesia services; and A range of other diagnostic and therapeuticservices.2Physicians’ services are furnished in all settingsincluding:Medicare Physician Fee ScheduleMedicare PFS Payment RatesPayment rates for an individual service are based onthe following components as shown in the MedicarePFS payment rates formula on page 3:1) Relative Value Units (RVU); Work RVU; Practice expense (PE) RVU; and Malpractice (MP) RVU;2) Conversion Factor (CF); and3) Geographic Practice Cost Indices (GPCI).

Medicare PFS Payment Rates FormulaPaymentWork RVU xWork GPCIPE RVU xPE GPCIEach component of the Medicare PFS payment ratesformula is discussed in more detail below.1) Relative Value Units (RVU)Three separate RVUs are associated with thecalculation of a payment under the Medicare PFS: Work RVUs reflect the relative time andintensity associated with furnishing a MedicarePFS service and account for approximately 50percent of the total payment associated with aservice; PE RVUs reflect the costs of maintaining apractice (such as renting office space, buyingsupplies and equipment, and staff costs); and MP RVUs reflect the costs of malpracticeinsurance.2) Conversion Factor (CF)To determine the payment rate for a particular service,each of the three separate RVUs is adjusted by thecorresponding GPCI. The sum of the geographicallyadjusted RVUs is multiplied by a dollar CF. The statutespecifies the formula by which the CF is updated onan annual basis.The formula specifies that the update for a year isequal to the Medicare Economic Index (MEI) adjustedup or down depending on how actual expenditurescompare to a target rate called the Sustainable GrowthRate (SGR). The MEI is a measure of inflation facedby physicians with respect to their practice costs andgeneral wage levels.3Medicare Physician Fee ScheduleMP RVU xMP GPCICFThe SGR is calculated based on: Medical inflation; Projected growth in the domestic economy; Projected growth in the number of beneficiariesin Fee-For-Service Medicare; and Changes in law or regulation.However, in recent years Congress has taken actionto establish a specific update amount.3) Geographic Practice Cost Indices (GPCI)GPCIs are adjustments that are applied to each of thethree relative values used in calculating a physicianpayment, as described above. The purpose of theseadjustments is to account for geographic variations inthe costs of practicing medicine in different areaswithin the country.

ResourcesThe chart below provides Medicare PFS resource information.Medicare Physician Fee Schedule ResourcesFor More Information About ResourceMedicare Physician Fee or-Service-Payment/PhysicianFeeSched on the Centers for Medicare & MedicaidServices (CMS) websiteMedicare Learning Network (MLN)publication titled “How to Use TheSearchable Medicare Physician FeeSchedule s/How to MPFS BookletICN901344.pdf on the CMS websitePhysician Fee Schedule Search Tool on the CMSwebsiteAll Available MLN Products“Medicare Learning Network Catalog ofProducts” located at log.pdf on the CMS website or scan theQuick Response (QR) code on the rightProvider-Specific Medicare InformationMLN publication titled “MLN Guided Pathways: Provider SpecificMedicare Resources” booklet located at ed Pathways Provider SpecificBooklet.pdf on the CMS websiteMedicare Information for Beneficiaries on the CMS website4Medicare Physician Fee Schedule

This fact sheet was current at the time it was published or uploaded onto the web. Medicare policy changes frequently solinks to the source documents have been provided within the document for your reference.This fact sheet was prepared as a service to the public and is not intended to grant rights or impose obligations. This factsheet may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement oftheir contents.Your feedback is important to us and we use your suggestions to help us improve our educational products, services andactivities and to develop products, services and activities that better meet your educational needs. To evaluate MedicareLearning Network (MLN) products, services and activities you have participated in, received, or downloaded, please go to and in the left-hand menu click on the link called ‘MLN Opinion Page’ and follow theinstructions. Please send your suggestions related to MLN product topics or formats to Medicare Learning Network (MLN), a registered trademark of CMS, is the brand name for official information healthcare professionals can trust. For additional information, visit the MLN’s web page at on theCMS website.Check out CMS on:Twitter5LinkedIn YouTubeMedicare Physician Fee Schedule

Medicare Physician Fee Schedule Author: CMS/CM/PCG/DPIPD Subject: Medicare Physician Fee Schedule Keywords: Medicare Physician Fee Schedule, PFS, payment rates, formula, relative value units, RVU, conversion factor, CF, geographic practice cost index, GPCI Created Date: 6/12/2014 3:45:35 PM

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