Orthopedic Coding Alert

Question: How do I determine which RVUs to use in the Medicare fee schedule for reimbursement rates?

Texas Subscriber

Answer: The 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 RVUs for a given procedure are the same regardless of whether the physician performs the procedure in a 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 providers 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 nonfacility). Practice expense RVUs, however, may vary by site of service (which accounts for a given codes difference in facility and non-facility RVU totals ).

Non-facility calculations: Add together the physician work RVUs (the column titled Work RVU), the nonfacility practice expense RVUs (Transitioned Non-Fac PE RVU column), and the malpractice RVUs (column labeled MP RVU) for the total non-facility RVUs for a given code. This total will also appear in the column labeled Transitioned Non-Fac Total.

Then, multiply the transitioned non-facility RVU total by the 2009 conversion factor ($36.0666).

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 transitioned non-facility total (1.70) by $36.0666. You can therefore figure out that the 2009 unadjusted fee for 99213 is $61.31.

Keep in mind: Your geographic practice cost index(ices) (GPCIs) are also part of your equation.