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April 24, 2013 - Revised: 03.06.15
Medicare Physician Fee Schedule (MPFS): How Are Fees Calculated?
Medicare contractors, including CGS, reimburse some services based on the CMS Medicare Physician Fee Schedule (MPFS). CMS calculates fee schedule amounts and provides these amounts directly to Medicare contractors, including CGS, and these amounts become the basis for payment for services that are paid based on the MPFS. This article explains how the fees are calculated based on a standard formula and the following variables:
The formula for calculating the MPFS, from the CMS website, uses the Fully Implemented Non-Facility PE RVU instead of the Transitioned Non-Facility PE RVU:
Examples: how does the math work?
Ohio example: CPT code 99213, non-facility setting
Work RVU: 0.97
[(0.97 * 1.00) + (1.01 * 0.918) + (0.06 * 0.993)] * .35.7547 = MPFS amount
Kentucky example: CPT code 96422, non-facility setting
Work RVU: 0.17
[(0.17 * 1.00) + (4.51 * 0.872) + (0.10 * 0.795)] * $35.7547 = MPFS amount
Ohio example: CPT code 45378 (no modifiers), facility setting
Work RVU: 3.69
[(3.69 * 1.00) + (1.94 * 0.918) + (0.56 * 0.993)] * $35.7547 = MPFS amount
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