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Documentation and Files

NATIONAL PHYSICIAN FEE SCHEDULE AND RELATIVE VALUE FILES

This file contains information on services covered by the Medicare Physician Fee Schedule (MPFS). For more than 10,000 physician services, the file contains the associated relative value units, a fee schedule status indicator, and various payment policy indicators needed for payment adjustment (i.e., payment of assistant at surgery, team surgery, bilateral surgery, etc.).

The Medicare physician fee schedule amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure's relative value unit (i.e., the RVUs for work, practice expense, and malpractice). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.

The payment formula is as follows:

  • Budget Neutrality Adjustor Values
    • Year 2006 & Earlier: N/A
    • Year 2007: 0.8994
    • Year 2008: 0.8806
    • Years 2009 - 2014: N/A
  • Non-Facility Pricing Amount =
    • [(Work RVU * Work GPCI) +
    • (Non-Facility PE RVU * PE GPCI) +
    • (MP RVU * MP GPCI)] * Conversion Factor
  • Facility Pricing Amount =
    • [(Work RVU * Work GPCI) +
    • (Facility PE RVU * PE GPCI) +
    • (MP RVU * MP GPCI)] * Conversion Factor

The Medicare limiting charge is set by law at 115 percent of the payment amount for the service furnished by the nonparticipating physician. However, the law sets the payment amount for nonparticipating physicians at 95 percent of the payment amount for participating physicians (i.e., the fee schedule amount). Calculating 95 percent of 115 percent of an amount is equivalent to multiplying the amount by a factor of 1.0925 (or 109.25 percent). Therefore, to calculate the Medicare limiting charge for a physician service for a locality, multiply the fee schedule amount by a factor of 1.0925. The result is the Medicare limiting charge for that service for that locality to which the fee schedule amount applies.

NOTE: CPT Codes and descriptions only are copyright 2009 American Medical Association all rights reserved.

To obtain a copy of all field definitions and downloadable payment or RVU files, visit the pages listed in the "Related Links Inside CMS" section at the bottom of this page.

PFALLyyA.ZIP
(yy = Year)This file contains the facility and non-facility fee schedule amount for all services paid for under the Medicare Physician Fee Schedule Medicare carriers use the Physician Fee Schedule to price claims for physician services under Medicare.

RVUyy A.ZIP
(yy = Year)This file contains the relative value units, status indicators, and payment policy indicators for procedure codes and procedure/modifier code combinations subject to the Medicare Physician Fee Schedule. A separate file containing the geographic practice cost indices (GPCIs) is also provided.


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