What Is the Medicare Physician Fee Schedule (MPFS)? A Guide for Medical Coders

The Resource Based Relative Value Scale (RBRVS) is the payment methodology Medicare uses to reimburse physicians and other health care providers. The Medicare Physician Fee Schedule (MPFS) is the primary component used by the RBRVS to calculate payment for procedures/services provided by physicians enrolled in Medicare. Medicare payments for physician assistants, nurse practitioners and clinical nurse specialists are also linked to the physician fee schedule.

Medicare uses the Physician Fee Schedule (PFS) when paying for:

• Professional services of physicians and other health care providers in private practice
• Services covered incident to physicians’ services (other than certain drugs covered as incident to services)
• Diagnostic tests (other than clinical laboratory tests)
• Radiology services

The PFS is a complete listing of fees used to pay doctors or other providers/suppliers for the services they provide to Medicare beneficiaries.

The fees in the Physician Fee Schedule are calculated based on the values of factors called relative value units (RVUs). Each procedure or service covered by Medicare has an RVU value. RVUs are published in the PFS Relative Value Files | CMS which is a part of the Physician Fee Schedule.

The Relative Value File includes information on the specific services covered, the payment rates, and the calculation formulas used to determine those rates.

In addition to RVUs, the Relative Value File includes information on other billing factors, such as the specific services covered, the payment rates, and the calculation formulas used to determine those rates.

Example of other factors in the Relative Value File include:

Take Aways

• The Resource Based Relative Value Scale (RBRVS) is the reimbursement methodology for paying physicians and other qualified healthcare providers.
• The Medicare Physician Fee Schedule (MPFS) is the part of the RBRVS where the fee associated with each payable procedure is documented
• The RBRVS uses relative value units (RVUs) to calculate the fees that populate the MPFS
• RVUs are published in the Relative Value File
• The Relative Value File includes factors in addition to RVUs that have an impact on how payment is made to physicians or other qualified health care providers for procedures/services billed to Medicare.

For more information about the Medicare Physician Fee Schedule including, expanded instruction in relative value units (RVUs), calculation of anticipated reimbursement in the Medicare Physician Fee Schedule, discussion of the relationship between coding and RVUs and detailed explanations of the components of the Relative Value File see our companion course Medicare Physician Fee Schedule Overview, available on our premier learning platform HIAlearn.com.

References

• https://www.cms.gov/medicare/payment/fee-schedules/physician
• https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files/

For more than 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.

The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.