Clinical Scenario RVU Simulator

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Scenario preset Cardiology new patient + transthoracic echo Primary care established visit panel GI endoscopy biopsy session GPCI locality Participant type Non-QPP QPP Monthly volume bundles Line quantities

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Data source CMS RVUinUSA scenario model · Verified 2026-08-31

Version

RVUinUSA scenario model

Last verified

2026-08-31

Source

CMS CPT/HCPCS RVU data and imported scenario preset assumptions.

Data path

Imported from the WordPress CPT and scenario datasets stored in options.

Scope

United States physician workflow planning.

Formula

Scenario presets combine CPT bundles, locality, conversion factor, and monthly volume into a planning worksheet.

A cardiology new-patient encounter paired with a transthoracic echocardiogram is one of the most common bundled scenarios in outpatient cardiology billing, and it’s a useful case study for understanding how Medicare actually prices a service. Two CPT codes drive the math: 99204 (office/outpatient visit, new patient, moderate complexity) and 93306 (complete transthoracic echocardiogram with 2D imaging, M-mode, spectral and color-flow Doppler). Each carries its own relative value units, and Medicare combines them through a locality adjustment and a conversion factor to arrive at a dollar amount.

What Drives the RVU Total

Every CPT/HCPCS code on the Medicare Physician Fee Schedule (MPFS) is built from three RVU components: physician work (wRVU), practice expense (PE RVU), and professional liability/malpractice (MP RVU). For CY 2026, CMS lists 99204 at 2.60 work RVUs and 5.31 total RVUs in the non-facility setting, reflecting the CY 2026 E/M revaluation that raised 99204’s total RVU from 5.05 to 5.31. CPT 93306, the complete TTE code, carries 1.42 work RVUs and 5.89 total RVUs nationally, with the bulk of the value sitting in practice expense (roughly 4.39 PE RVUs) because the code bundles the equipment, technician time, and overhead of running the ultrasound in-office.

Add the two codes together and you get exactly what the simulator reports for this scenario: 2.60 + 1.42 = 4.02 total work RVUs, and 5.31 + 5.89 = 11.20 total RVUs. This is the core logic behind “bundled scenario” presets — the tool sums the RVU components across every line in the bundle before applying any geographic or payment-policy adjustment, rather than pricing each code in isolation.

GPCI: Why Locality Matters

Medicare doesn’t pay a flat national rate for most localities. The formula is:

\(\text{Payment} = \left[ (\text{Work RVU} \times \text{Work GPCI}) + (\text{PE RVU} \times \text{PE GPCI}) + (\text{MP RVU} \times \text{MP GPCI}) \right] \times \text{Conversion Factor}\)

Each Geographic Practice Cost Index (GPCI) component reflects how a locality’s labor, rent, and liability-insurance costs compare to the national average, where 1.0 is the baseline. The “national” locality slug used in this scenario sets all three GPCIs — work, PE, and MP — to exactly 1.000, per the CMS 2026 localities dataset. That’s why the simulator’s result equals a simple RVU sum times the conversion factor with no geographic multiplier. If you swap the locality to, say, Manhattan or San Francisco, the work GPCI can climb toward 1.1–1.15 and PE GPCI even higher, which raises the payment for the same two codes without changing a single RVU value. Coders auditing multi-site groups should always confirm the exact CMS locality slug rather than assuming “national” applies, since even a few GPCI points shift monthly reconciliation totals meaningfully at volume.

Conversion Factor and Participant Type

CY 2026 introduced a genuine structural change: for the first time, Medicare set two separate conversion factors depending on whether a clinician qualifies as an Advanced Alternative Payment Model (APM) participant. The non-qualifying (non-QPP/non-QP) conversion factor is $33.4009, while the qualifying APM conversion factor is $33.5675 — a 3.26% and 3.77% increase respectively over the 2025 CF of $32.3465. This split stems from the One Big Beautiful Bill Act’s temporary 2.5% statutory increase plus a small budget-neutrality adjustment tied to the finalized work RVU changes.

Selecting “Non-QPP” in the simulator applies $33.4009 per RVU. Running the numbers: 11.20 total RVU × $33.4009 = $374.09, matching the tool’s output exactly. If the same clinician instead qualified as an APM participant, the payment would rise slightly to 11.20 × $33.5675 ≈ $375.96 — a small but real difference that compounds across a full month of volume. Practice managers tracking QPP status for a group should re-run scenarios under both conversion factors whenever a physician’s APM participation status changes mid-year, since it directly affects revenue projections, not just quality scoring.

Scaling to Monthly Volume

The “monthly volume” input treats the entire scenario — both CPT codes together — as a single repeatable unit, not a per-code multiplier. At 18 bundles per month, the simulator multiplies the per-encounter work RVU and payment by 18: 4.02 × 18 = 72.36 monthly work RVU, and $374.09 × 18 = $6,733.62 in projected monthly payment. This mirrors how practices actually forecast cardiology diagnostic-testing revenue: a new-patient echo workup rarely happens in isolation, so modeling it as a bundle gives a more realistic monthly projection than pricing 99204 and 93306 as unrelated line items with independent volumes.

This bundled-volume approach is particularly relevant for compensation modeling in wRVU-based physician contracts, where a cardiologist’s productivity bonus is calculated off total monthly work RVUs rather than dollar collections. A group tracking 18 new-patient-plus-echo encounters per month would credit the physician with 72.36 wRVUs from this scenario alone, before factoring in follow-up visits, stress tests, or other diagnostic codes.

Reading the “Missing Codes” Output

The simulator also reports a missing-codes count, which flags any line-item override entered manually that doesn’t resolve to a valid CPT/HCPCS code in the current MPFS relative value file. A count of zero, as in this scenario, confirms both 99204 and 93306 matched successfully against the loaded fee schedule data. This check matters operationally: CMS retires and revises codes annually, and RVU values shift with each Final Rule (as seen in the 99204/99205 increases and the 2.5% “efficiency adjustment” CMS applied to non-time-based procedure codes for 2026). Coders reusing saved scenarios from a prior year should always re-verify that every bundled code still carries current-year RVU data rather than assuming last year’s values carry forward unchanged.