A Medicare payment estimate combines a CPT or HCPCS service’s RVU components, the applicable facility or non-facility setting, locality-specific GPCI values, and the annual conversion factor. This worked example uses the production database record for CPT 99213 from the 2026 CMS RVU dataset and the national GPCI baseline, so each step can be reproduced from a named code and stated assumptions.
Example Inputs
The example uses CPT 99213, a non-facility setting, the national GPCI baseline, and the 2026 conversion factors stored in the calculator database. The national baseline sets work, PE, and MP GPCI to 1.000; it is a comparison baseline, not a locality-specific estimate.
| Input | Value |
|---|---|
| CPT code | 99213 |
| Data year | 2026 |
| Setting | Non-facility |
| Work RVU | 1.30 |
| Non-facility PE RVU | 1.46 |
| MP RVU | 0.09 |
| Work GPCI | 1.000 |
| PE GPCI | 1.000 |
| MP GPCI | 1.000 |
The example uses the non-QP 2026 conversion factor of USD 33.4009. The QP comparison uses USD 33.5675. These are payment-modeling inputs only; they are not dollars-per-wRVU compensation rates. The RVU values are from the CMS 2026 RVU dataset.
Step 1: Confirm the Code
In a real workflow, code selection comes before payment calculation. Confirm the CPT or HCPCS code through the applicable coding and documentation process. The code determines which work, PE, and MP RVU values are retrieved from the current-year MPFS data.
Use the RVU Calculator after the code has been selected. A calculator should not be used to choose a code because one code appears to produce a higher payment.
Step 2: Select the Setting
Use one PE value for the calculation. The example uses the non-facility PE RVU of 1.46. If the applicable CMS payment context calls for the facility column, replace it with the facility PE RVU for CPT 99213 and keep the setting label with the result.
The Facility vs. Non-Facility RVU guide explains why the PE input can change while work RVU remains the same.
Step 3: Apply GPCI Values
GPCI is applied component by component, not as one blended multiplier:
Work component = 1.30 × 1.000 = 1.300
PE component = 1.46 × 1.000 = 1.460
MP component = 0.09 × 1.000 = 0.090Now add the adjusted components:
Adjusted total RVU =
1.300 + 1.460 + 0.090
= 2.850For a national baseline comparison, all three GPCI values are 1.000. A local estimate should use the exact CMS payment locality. The GPCI Calculator is designed for locality comparisons.
Step 4: Apply the Conversion Factor
Multiply the adjusted total RVU by the conversion factor that matches the participant-status assumption:
Non-QP Medicare payment estimate =
2.850 × $33.4009
= $95.192565
≈ $95.19
QP Medicare payment estimate =
2.850 × $33.5675
= $95.667375
≈ $95.67The two results differ only because the conversion factor changed. A clean QP comparison keeps the code, setting, locality, RVU values, and data year fixed.
For the official 2026 policy context, see the CY 2026 Medicare Physician Fee Schedule final rule.
Step 5: Interpret the Result
The result is a Medicare payment estimate under the stated assumptions. It is not a payer-specific allowed amount, a guarantee of collections, or an automatic physician compensation amount. Claim edits, modifiers, bundling, multiple-procedure rules, sequestration, secondary-payer rules, and other payer policies can affect the final remittance.
Compensation requires a separate model. A work-RVU agreement may use a base salary, credited wRVUs, a threshold, and a contract-defined dollars-per-wRVU rate. That contract rate should not be replaced with the Medicare conversion factor.
Use the Calculation in a Repeatable Workflow
- Confirm the code and record the current MPFS data year.
- Choose facility or non-facility PE and record the setting.
- Identify the exact CMS payment locality and its three GPCI values.
- Choose QP or non-QP status for the applicable conversion factor.
- Calculate adjusted total RVU before applying the conversion factor.
- Copy the assumptions with the result so another person can reproduce it.
Use the RVU Calculator for a single code, the CPT 99213 RVU Guide to review the code-level record, the GPCI Calculator for locality comparisons, and the QPP vs. non-QP Calculator when the only changing assumption is participant status. For multiple codes, use the Bulk CPT RVU Calculator. The Total RVU Formula guide explains the distinction between total RVU, adjusted total RVU, and payment.
Frequently Asked Questions
Can I skip GPCI for a local payment estimate?
No. GPCI can be set to 1.000 for a national baseline, but a locality-specific estimate should use the applicable work, PE, and MP values.
Do I use both facility and non-facility PE RVUs?
No. Select the PE column that matches the applicable payment context. The two PE values are alternative inputs, not values that are added together.
Does this estimate equal physician compensation?
No. Medicare payment modeling uses adjusted total RVU and a CMS conversion factor. Compensation depends on the written agreement and often uses credited work RVU.
Why should the assumptions be saved with the result?
Changing the code, setting, locality, participant status, or data year can change the estimate. Recording those inputs makes the result auditable.