How Will the 2019 MPFS Affect Your Bottom Line?

Posted on 22 Feb, 2019 |comments_icon 0|By Elizabeth Debeasi

CMS estimates that some practices will see pay increases, some will see decreases, and others will see no pay adjustment from the 2019 MPFS changes, despite the conversion factor (CF) increase.

Take a look at the following specialties to see where your practice falls.

If your specialty isn’t listed, you can learn the estimated impact on your total allowable charges in Table 94 in the Federal Register publication of the final rule.

Caveat: The actual payment impact for your practice could vary from projections, depending on the procedures and the volume of procedures you perform. Remember, too, that local geographic factors can change your bottom line.

Check the Geographic Practice Indices for Your State

Location, location, location! The national CF doesn’t automatically apply when figuring your provider’s pay, in that conversion factors vary by state due to variation in Geographic Practice Cost Indices (GPCIs) for a given location with specific local economic and practice expense factors.

For example: Consider one of the more common urology procedures, code 51729 (Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique).

Medicare assigns Total Relative Value Units (RVUs) of 10.21 for both facility and non-facility sites with reimbursement based on the national CF, which is $367.96. This fee represents the standard unadjusted Physician Medicare fee schedule.

But when the GPCIs for each state or local area are factored in for Work RVUs, Practice Expense RVUs and Malpractice RVUs, the total RVUs can change. The final numbers often vary significantly, as you see in the example billing code 51729 for these three locations:

  • Mississippi: 9.09 adjusted RVUs for facility and non-facility; adjusted reimbursement of $327.60
  • Queens, NY: 12.09 adjusted RVUs for facility and non-facility; adjusted reimbursement of $435.72
  • Rest of New York: 9.74 adjusted RVUs for facility and non-facility; adjusted reimbursement of $351.03.

Adjust Your Reimbursement Expectations

As 2019 gets underway, be sure you’ve updated your billing systems to reflect the latest payment values to ensure you’re getting the most accurate reimbursement.

Additionally, you’ll find it helpful to know how to calculate the fee for a Medicare service. You simply multiply the conversion factor by the total RVUs for the procedure in question.

According to Medicare’s National Physician Fee Schedule Relative Value File, there are three separate RVU categories that, when totaled, determine payment.

  1. Work RVUs account for the provider’s work when performing a procedure or service. Work RVUs typically account for 52 percent of the RVU total for a given code.
  2. Practice expense (PE) RVUs reflect the cost of nonphysician labor, and expenses for building space, equipment, and office supplies. Practice expense RVUs typically account for 44 percent of the RVU total for a given service.

Because the expense of providing a service may differ depending on where the service is provided (facility vs. non-facility), the Fee Schedule lists separate columns to describe “facility” vs. “non-facility” PE RVUs.

  1. Malpractice (MP) RVUs reflect the cost of malpractice insurance for each procedure/service. Malpractice RVUs typically account for 4 percent of the RVU total for a given service.

You then determine the RVU total for a specific code by calculating the sum of work RVUs, MP RVUs, and either the facility or non-facility PE RVUs (as applicable to your place of service).

CMS applies separate GPCIs to each of the three relative values (work, MP, and PE) used to calculate payment since the cost of practicing medicine varies by geographic location. Use this formula to determine the true, total RVUs for a procedure or service in your area:

(work RVUs x work GPCI) + (PE RVUs x PE GPCI) + (MP RVUs x MP GPCI)

To calculate payment, you must multiply the place-of-service- and locality-specific RVU total by a dollar conversion factor.

Don’t Underestimate RVU Changes

RVU amount factors heavily into reimbursement, and changes in RVU assignments could drop your payment in 2019.

Example: E/M code 99204 had a total non-facility RVU of 4.65 for 2018, which calculated as a fee of approximately $167.35 when multiplied by the 2018 conversion factor of 35.99.

In 2019, code 99204 has a total non-facility RVU of 4.63. This calculates as a fee of approximately $166.86 when based on the national conversion factor of $36.0391. The decreased RVU (from 4.65 to 4.63) means lower reimbursement — despite the slightly higher CF.

Contributing Editors: Ellen Garver, Leigh DeLozier, Leesa Israel

Learn More

Stay on top of the MPFS CY 2019 final rule and get fast and effective answers to your Medicare questions with a subscription to Medicare Compliance & Reimbursement. Every issue of this monthly newsletter delivers coding and billing guidance, as well as high-impact tips to conquer the revenue-risking challenges that threaten your claims and compliance success.


Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

More from this author

View More

Leave a Reply

Newsletter Signup