Medicare RVU Reimbursement Calculator

How Medicare Actually Prices a CPT Code

Every CPT/HCPCS code carries three Relative Value Units: work (the clinician's time, skill, and intensity), practice expense (staff, rent, supplies — different values for facility vs non-facility settings), and malpractice. Each component is adjusted by your locality's Geographic Practice Cost Index (GPCI), summed, and multiplied by the annual conversion factor to produce the national allowable. Look up any code's RVUs in the CMS Physician Fee Schedule search tool, and find your GPCIs in the annual PFS locality files.

Two things practices routinely miss: the place of service changes the PE RVU — the same code pays less when performed in a facility because the facility bills separately (see our POS code guides) — and the check that arrives is reduced 2% by Medicare sequestration (CARC 253). If you're modeling contract rates, commercial payers often pay a percentage of the Medicare allowable, which makes this calculation the foundation of fee schedule negotiation.

Verify the current-year conversion factor before relying on any estimate — CMS updates it every January, and mid-year corrections happen. Enter your locality's actual GPCIs for a real-world number instead of the national 1.000 defaults.

Worked Example

A code with 1.92 work RVUs, 1.64 practice expense RVUs, and 0.14 malpractice RVUs, all at national GPCIs (1.000), with a $32.35 conversion factor:

Run the same code with a locality's real GPCIs (often 1.00–1.10 for work and PE in high-cost metro areas) and the allowable shifts — which is exactly why two practices billing the identical code in different cities get paid differently by the same payer.

Facility vs. Non-Facility: Where Practices Lose Money Without Noticing

The practice expense RVU has two published values for the same code: non-facility (your office, where you carry rent, staff, and equipment costs) and facility (hospital or ASC, where the facility bills its own separate fee). Billing a facility-setting code with the non-facility PE RVU — or vice versa — either overstates or understates the allowable, and payers' systems catch the mismatch based on the place of service code on the claim. POS 11 (office) uses non-facility PE; POS 19, 21, 22, 23, and 24 all use the lower facility PE. Confirm you're pulling the correct PE RVU for the setting before quoting or negotiating a rate.

How RVUs Get Set — and Why They Change Every Year

RVU values aren't arbitrary — they come from the AMA's RVS Update Committee (the "RUC"), a panel that reviews physician-submitted survey data on the time and intensity each service requires and recommends values to CMS. CMS reviews, sometimes adjusts, and finalizes them annually in the Physician Fee Schedule rule. The whole system operates under budget neutrality: when RVUs increase for some codes, the conversion factor or other codes' values typically shift to offset it, which is why a code's payment can change year to year even when nothing about how it's performed has changed at all. This is also why relying on last year's RVU table for this calculator's inputs can quietly produce a stale, incorrect estimate — always confirm you're pulling current-year values before using this for contract modeling.