Medicare provides public reference fee schedules for all kinds of medical services: E&M codes, laboratory and radiology services, DME, and drugs and injectables.
Making your own Medicare fee schedule provides a ready reference for your practice payments. The Medicare fee schedule has four components that are useful references for a pediatrician:
- Part 1: the physician fee schedule (PFS), which contains fees for all RVU-containing CPT and HCPCS codes, like sick and well evaluation and management (E&M codes), immunization administration codes, and procedure codes.
- Part 2: laboratory schedule, which contains fees for lab work (like urinalysis, CBC, rapid strep, and other codes, generally in the 80000-89999 CPT range.)
- Part 3: immunization and injectable schedule, which contains Medicare payments for Medicare-approved immunizations and injectable drugs.
- Part 4: DME, which contains Medicare payments for DME and supply codes.
Medicare fee schedule part 1: Physician fee schedule (outpatient and inpatient professional services)
|1. Go to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html.|
|2. Select a time period. The latest data will have the most recent year and highest letter: for example, the first fee schedule for any calendar year is "A," with subsequent fee schedules for the same year being marked "B," "C," and so on.|
|3. Click to download the file (e.g. RVU18D.zip)|
|4. In the zip file, there are several Excel files. First open the LOCCO Excel file (e.g. 18LOCCO.xls.)|
|5. Find the carrier code and location code that correspond to your state and city/county region. In this example, let's look for Knoxville, Tennessee. Tennessee has a single carrier/location code pair: 10312 and 35.|
|6. Next, open the GPCI Excel file (e.g. GPCI2018.xls) in the zip file.|
|7. In the GPCI file, find your carrier and location code. Then make a note of the three Geographic Practice Cost Indicators for your location: physician work (PW GPCI), practice expense (PE GPCI), and malpractice (MP GPCI). In our example, the indicators for Tennessee’s sole locality are 1.000, 0.901, and 0.526, respectively.
You may close the GPCI file.
|8. Now, open the RVU file (e.g. PPRRVU18_OCT.xls.) I recommend that you make a Save As copy, e.g. “My Medicare Fee Schedule 2018 – D.xlsx.”|
|9. Add two new columns to the file. Hover over the Column F column header, right-click, and choose Insert. A new column will appear. Repeat for a second new column.|
|10. Label your two new columns Payment (nonfacility) and Payment (facility)|
|11. Optional: Hide rows that will not be valued on by this fee schedule. There are over 16,000 rows on this spreadsheet, many of which are zero-valued on this particular spreadsheet (indicating they are priced elsewhere.) The more useful data may get lost, so you can temporarily filter out the rows you don't think you need. For example, you can hide everything that has a practice expense factor of zero. To do this, first type Ctrl-A to select all rows. Then in the Data tab, under Sort & Filter, click Filter. Click the filtering arrow under the Column I header. In the dropdown, remove the check box next to 0.00, then click OK. You can always remove this filter later if you want to see everything again.|
|12. Now, create the non-facility formula. First find the row index for the first row of data. In this example, the first medical service listed is G0101, located in row 1366.|
|13. In that row, find the Excel coordinates of four cells: the first row's Work RVU, the first row's Non-Facility PE RVU, the first row's Malpractice (MP) RVU, and the first row's Conversion (Conv) Factor. In this example, these are found in cells H1366, I1366, M1366, and AA1366, respectively.|
|14. In the first Payment (nonfacility) cell (here, F1366), enter a formula based on the following construction:
=ROUND(((row's Work RVU cell * PW GPCI)+(row's Non Facility PE RVU cell * PE GPCI)+( row's Malpractice RVU cell * MP GPCI)) * row's Conversion Factor),2)
Or in this example:
|15. Press Enter, and a value should appear in F1366.|
|16. Now you can copy/paste this formula down all of column F. Click in cell F1366. Then type Ctrl-C to copy the formula in F1366. Then click and drag to the bottom of the column, and type Ctrl-V. You should now see the formula's result in every row.|
|17. Create the Payment (facility) formula in a similar manner. In the first Payment (facility) cell (here, G1366), enter a formula based on the following construction:
=ROUND(((row's Work RVU cell * PW GPCI)+(row's Facility PE RVU cell * PE GPCI)+( row's Malpractice RVU cell * MP GPCI)) * row's Conversion Factor),2)
Or in this example:
|18. Copy/paste the formula down through column G.|
|19. Be sure to save your work!|