Office-visit RVU payment estimates begin with the selected CPT code and end with a geographically adjusted Medicare calculation. The code level, practice expense setting, locality, conversion-factor status, and data year all matter. The result is an estimate under stated assumptions, not a guaranteed fee or a payer remittance.
This guide is for interpreting RVU data after the service has been coded through the applicable documentation and compliance process. For a code-level estimate, open the RVU Calculator for CPT 99213 or select another office-visit code in the calculator.
Which office-visit codes should be compared?
The established-patient office-visit family commonly reviewed in RVU workflows includes CPT 99211 through CPT 99215. The code descriptions and documentation requirements must be confirmed from current CPT and payer guidance. The links below are RVU reference pages, not coding instructions.
| Code | RVU reference | Calculator |
|---|---|---|
| 99211 | CPT 99211 RVU Guide | Calculate 99211 |
| 99212 | CPT 99212 RVU Guide | Calculate 99212 |
| 99213 | CPT 99213 RVU Guide | Calculate 99213 |
| 99214 | CPT 99214 RVU Guide | Calculate 99214 |
| 99215 | CPT 99215 RVU Guide | Calculate 99215 |
Use these pages to compare structured RVU inputs. Do not infer that a higher code is appropriate merely because it has a higher work RVU; code selection remains a documentation and compliance question.
What drives a Medicare office-visit estimate?
Medicare payment modeling uses three RVU components:
- Work RVU: the physician-work component often used in productivity reports.
- Practice expense RVU: the practice-resource component, which may use a different facility or non-facility value.
- Malpractice RVU: the professional-liability component adjusted by the MP GPCI.
Each component is adjusted with its corresponding locality factor. The payment estimate then applies the conversion factor for the selected year and payment status.
Adjusted total RVU =
(Work RVU x Work GPCI)
+ (Selected PE RVU x PE GPCI)
+ (MP RVU x MP GPCI)
Medicare payment estimate =
Adjusted total RVU x Conversion FactorThe formula should be read together with the code, setting, locality, and source year. A work RVU alone cannot reproduce the Medicare estimate.
Facility and non-facility setting
Office-visit comparisons often use the non-facility practice-expense column, but the applicable payment context must be selected from the current CMS data and claim setting. The same code can produce a different estimate when the selected practice-expense value changes.
When comparing two office-visit codes, hold the site of service constant. If the setting changes at the same time as the code, the difference no longer measures the code change alone.
Locality matters more than the state label
GPCI values are assigned to Medicare payment localities. A state name is useful for navigation, but it is not always the calculation unit. For a city, county, or practice market, identify the applicable locality and use the corresponding Work, PE, and MP GPCI values in the GPCI Calculator.
For a code-specific result, use the RVU Calculator with the selected locality and setting. Keep the locality name in the copied result so the estimate can be reviewed later.
Payment is different from compensation
A Medicare estimate answers a payment-schedule question. A physician compensation plan may credit work RVUs using a contract-defined schedule year, threshold, rate, modifier policy, exclusions, or reconciliation period. The employer’s dollars-per-wRVU rate should not be substituted for the Medicare conversion factor.
If the purpose is offer review, compare the office-visit work RVU with the written compensation terms. The CPT 99213 RVU Guide and the salary estimator can support that workflow, but neither replaces contract review.
A reproducible office-visit comparison
- Choose the code supported by the service documentation.
- Record the data year and the facility or non-facility setting.
- Identify the payment locality and its Work, PE, and MP GPCI values.
- Select the applicable conversion-factor status.
- Run each code with the same assumptions in the RVU Calculator.
- Compare work RVU, adjusted total RVU, and payment as separate outputs.
This method makes the source of a difference visible. A change in payment may come from the code, practice-expense setting, locality, conversion factor, or a combination of those inputs.
Source and limitations
The CMS CY 2026 Medicare Physician Fee Schedule final-rule summary provides policy context for the year. The structured calculator data supplies the code and locality inputs. Verify the current CMS source row when an estimate is used for billing, budgeting, or a contractual decision.
- Do not use this page to select a code without documentation and compliance review.
- Do not treat a Medicare estimate as a commercial payer allowed amount.
- Do not treat the conversion factor as a physician compensation rate.
FAQ
Which office-visit code should I use in the calculator?
Use the code that has already been selected through the applicable documentation and coding process. The calculator should model a selected code, not decide which code is correct.
Why can the same office-visit code produce different estimates?
The facility or non-facility setting, locality-specific GPCI values, conversion-factor status, and data year can change the estimate.
Can an office-visit Medicare estimate be used for compensation?
Not automatically. Compensation depends on the written agreement and may use credited work RVUs, thresholds, and negotiated dollars-per-wRVU terms.