Ophthalmology and Optometry Coding Alert

Question: How do I determine which RVUs to use in the Medicare fee schedule so I can anticipate payment rates for our services?

Pennsylvania Subscriber

Answer: The Medicare Physician Fee Schedule establishes different values for codes depending on the setting/site (facility or non-facility) in which the provider performs the service or procedure. For some services, the total relative value units (RVUs) for a given procedure are the same in a facility or a non-facility. In some cases, however, the two totals may differ.

How it works: The facility and non-facility totals are made up of several constituent parts: physician work RVUs (to cover the cost of the provider’s work), practice expense RVUs (to cover the cost of supplies, equipment, etc.), and malpractice expense RVUs (to cover the cost of professional liability expenses).

Physician work RVUs and malpractice expense RVUs are the same, regardless of the setting (facility or non-facility). Practice expense RVUs may vary by site of service, however, which accounts for the difference in facility and non-facility RVU totals for a given code.

To figure out the national fee for a code, multiply the non-facility RVU total by the 2019 conversion factor ($36.0391).

Example: To calculate the unadjusted fee for E/M visit code 99213 (Office or other outpatient visit for the evaluation and management of an established patient …) multiply the non-facility total (2.09) by $36.0391. You can therefore figure out that the 2019 unadjusted fee for 99213 is $75.32.