QPP vs Non-QPP Conversion Factor Calculator

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CPT or HCPCS code GPCI locality Setting Non-facility Facility

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Data source CMS 2026 · Verified 2026-08-31

Data year

2026

Version

2026

Last verified

2026-08-31

Source

CMS 2026 source basis for the same CPT and locality inputs, with only the conversion factor changed.

Data path

Imported from the 2026 CMS-derived CPT and GPCI datasets stored in WordPress options.

Scope

United States Medicare payment assumptions.

Formula

The same CPT, setting, and locality are multiplied by the non-QPP and QPP conversion factors to isolate the payment delta.

Open source

Starting January 1, 2026, Medicare pays every CPT and HCPCS code twice — once under a conversion factor for clinicians participating in a Qualifying Advanced Alternative Payment Model (QP), and once under a separate, lower conversion factor for everyone else (non-QP). This is not a hypothetical policy detail; it is now baked into every Medicare Physician Fee Schedule (MPFS) allowable, and the gap between the two numbers determines whether a practice’s APM participation strategy is actually worth the administrative overhead. The QPP vs Non-QPP Conversion Factor Calculator isolates that gap for a specific code, locality, and site of service so coders and practice managers can see the real dollar impact instead of just the headline percentage.

The Two Conversion Factors Explained

Under the Medicare Access and CHIP Reauthorization Act (MACRA), the statute has required a bifurcated update path since the Quality Payment Program matured, but 2026 is the first year CMS is applying two fully separate dollar-value conversion factors rather than a single blended rate with a QP bonus layered on top. For calendar year 2026, CMS finalized a conversion factor of $33.57 for QPs and $33.40 for non-QPs, both up from the 2025 conversion factor of $32.35. That split comes from a 0.75% statutory update for QPs versus a 0.25% statutory update for non-QPs, layered with a 2.5% update mandated by recent budget legislation and a 0.49% positive budget-neutrality adjustment tied to updated work RVUs. The 0.49% figure is worth remembering — it’s the same percentage the calculator reports as the “Payment delta %,” because at the national level with GPCI held at 1.0, the QP/non-QP payment gap is almost entirely a function of that budget-neutrality-adjusted differential between the two statutory updates.

Practically, the distinction only matters for clinicians who meet CMS’s QP threshold through sufficient Medicare payment or patient volume flowing through an Advanced APM (e.g., certain ACO tracks, bundled payment models). If a practice bills fee-for-service Medicare without Advanced APM participation, every code on its fee schedule is reimbursed at the non-QP rate — $33.40 per RVU nationally in 2026, not $33.57.

How Total RVU Drives the Payment

Every MPFS allowable is built from three relative value unit (RVU) components defined under the Resource-Based Relative Value Scale (RBRVS):

• Work RVU — physician time, cognitive effort, and technical skill required for the service.
• Practice Expense (PE) RVU — overhead, staff time, equipment, and supplies; this component differs sharply between facility and non-facility settings.
• Malpractice (MP) RVU — the professional liability insurance cost allocated to the code.

For CPT 99214 (established patient office visit, moderate-complexity medical decision making, roughly 30 minutes total time), the 2026 national RVU components in the non-facility setting are: Work RVU 1.92, PE RVU approximately 2.00, and MP RVU approximately 0.14, summing to a Total RVU of 4.06. Note that the facility-setting PE RVU for 99214 dropped to roughly 0.47 in 2026 — down more than 40% from 2025 — because CMS applied a new “efficiency adjustment” to facility-based practice expense inputs across many codes, which is exactly why the calculator forces you to lock the site-of-service setting before comparing conversion factors; mixing facility and non-facility RVUs would distort the comparison entirely.

GPCI Locality Adjustment

Before any RVU sum is multiplied by the conversion factor, each of the three RVU components is separately adjusted by a Geographic Practice Cost Index (GPCI) value specific to the code’s locality — one GPCI for work, one for practice expense, and one for malpractice, reflecting that labor costs, rent, and liability insurance premiums vary independently by region. The full MPFS formula is:

Payment = [(Work RVU × Work GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI)] × Conversion Factor

When the locality is set to “National” (the CMS national average slug), all three GPCI values are fixed at 1.0, meaning the geographically adjusted RVU sum equals the raw Total RVU. This is why, in the national example, the calculator’s Total RVU of 4.06 flows straight into the conversion factor multiplication without any locality-specific scaling. If you switch the locality to an actual GPCI slug (e.g., Manhattan or rural Alaska), the adjusted RVU total — and therefore both QPP and non-QPP payments — will shift, sometimes significantly, because high-cost urban localities can carry GPCI values well above 1.0 while some rural localities sit below it.

Worked Example: CPT 99214, National, Non-Facility

Using the national GPCI (all components = 1.0) and the non-facility Total RVU of 4.06:

• Non-QPP payment = 4.06 × $33.40 = $135.60, rounding to the reported $135.61 (the small cent-level variance comes from CMS rounding each RVU component before summing, rather than rounding only the final total).
• QPP payment = 4.06 × $33.57 = $136.30, reported as $136.28 using the same component-level rounding convention.
• Payment delta = $136.28 − $135.61 = $0.67 per encounter.
• Payment delta % = $0.67 ÷ $135.61 ≈ 0.49%, matching the budget-neutrality adjustment baked into the 2026 conversion factor split.

Sixty-seven cents on a single 99214 looks negligible, but the calculation scales linearly with volume and RVU intensity. A practice billing 99214 as its modal E/M level across, say, 4,000 annual Medicare encounters would see roughly $2,680 in additional aggregate reimbursement purely from QP status on that one code — before accounting for higher-RVU procedural codes where the same 0.49% differential compounds against a larger base payment.

Applying This to Coding and Billing Workflows

For coders and billers, the practical takeaway is that CPT/HCPCS selection accuracy matters twice as much in 2026: an under-coded or over-coded E/M level not only misstates work RVU but also multiplies that error by the wrong conversion factor track if your entity’s QP status is being tracked incorrectly in claims systems. Practice managers evaluating whether pursuing Advanced APM participation is financially worthwhile should run their top 10–20 highest-volume CPT codes through this same locality-and-setting-adjusted comparison, since the 0.49% gap between conversion factors is a national constant but the RVU base — and therefore the dollar delta — varies by code family, facility versus non-facility site of service, and regional GPCI. Locking the setting field before comparing codes, as the calculator requires, prevents the common error of comparing a non-facility payment for one code against a facility payment for another, which would produce a meaningless conversion-factor comparison.