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.
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:
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.
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.
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.
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
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