ICD-10 / CPT Code Reimbursement Estimator
Estimate expected reimbursement for common CPT procedure codes using Medicare Physician Fee Schedule (MPFS) methodology, including work RVU, practice expense RVU, malpractice RVU, geographic adjustment factors (GPCI), and conversion factor.
Formula
Medicare Physician Fee Schedule (MPFS) Methodology:
Step 1 – Adjust RVUs by Geography (GPCI):
Adjusted RVU = (Work RVU × Work GPCI) + (Practice Expense RVU × PE GPCI) + (Malpractice RVU × MP GPCI)
Step 2 – Apply Conversion Factor:
Medicare Allowed Amount = Adjusted RVU × Conversion Factor (2024: $32.7442)
Step 3 – Apply Payer & Modifier:
Estimated Reimbursement = Medicare Allowed × Payer Rate Multiplier × Modifier Factor × Units
Medicare Split (Traditional Medicare only):
Medicare Pays = Allowed × 80% | Patient Coinsurance = Allowed × 20%
Assumptions & References
- RVU values are based on the 2024 Medicare Physician Fee Schedule (non-facility rates) published by CMS.
- The 2024 Conversion Factor is $32.7442 per RVU, as finalized by CMS in the 2024 MPFS Final Rule.
- Geographic Practice Cost Indices (GPCIs) vary by Medicare locality. Default values of 1.000 represent the national average. Actual GPCIs are published annually at cms.gov.
- Payer multipliers are approximate averages based on industry benchmarking data (MGMA, AMA). Actual contracted rates vary significantly by provider, specialty, and geography.
- Medicaid rates vary widely by state and are often significantly below Medicare rates.
- This tool does not account for: bundling rules, global surgery periods, place-of-service differentials, facility vs. non-facility rates, or payer-specific carve-outs.
- ICD-10 diagnosis codes affect medical necessity and coverage but do not directly alter the fee schedule calculation; they are used for claim adjudication.
- References: CMS MPFS Final Rule 2024; AMA CPT® 2024; CMS GPCI Files; MGMA 2023 Payer Benchmarking Report.