Payment calculation

Calculate expected Medicare reimbursement using the MPFS formula with GPCI-adjusted RVUs

The /v1/knowledge/payment-calc endpoint calculates expected Medicare payment for a CPT/HCPCS at a facility. It uses the same composer as GET /v1/codes/{code}/payment: physician (MPFS), outpatient facility (OPPS), lab (CLFS), and DMEPOS, populated from whichever fee schedules carry the code.

estimated_payment and components remain the physician (MPFS) view so existing clients keep working.

For a whole claim (many procedure lines + diagnoses), use POST /v1/knowledge/payment-calc/claim. That endpoint composes each line, then applies OPPS packaging (status indicators N/Q1/Q2/J1) and T-status 50% multiple-procedure reduction, plus NCCI PTP and LCD DX match.

The MPFS formula

Medicare payment is calculated as:

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

Each component represents a portion of the total cost:

Component	What it measures	RVU example (99213)
Work RVU	Physician time, skill, and judgment	1.30
PE RVU (facility)	Practice expense — staff, equipment, supplies	0.99
MP RVU	Malpractice insurance cost	0.10

The GPCI (Geographic Practice Cost Index) adjusts each component for local cost differences. The Conversion Factor for 2026 is $33.40.

Request

curl -X POST https://api-dev.rcintell.com/v1/knowledge/payment-calc \
  -H "X-API-Key: $RCI_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99213"
  }'

Parameters

Field	Type	Required	Description
ccn	string	Yes	6-digit Medicare Provider Number
cpt	string	Yes	CPT or HCPCS procedure code
payer	string	No	Payer name (defaults to Medicare)
modifier	string	No	CPT modifier
place_of_service	string	No	POS code to override facility/non-facility rate

Response

{
  "ccn": "170001",
  "cpt": "99213",
  "estimated_payment": 75.0,
  "components": {
    "work_rvu_adjusted": 1.3,
    "pe_rvu_adjusted": 0.895,
    "mp_rvu_adjusted": 0.0504,
    "total_adjusted_rvu": 2.2454,
    "conversion_factor": 33.40,
    "facility_rate": true
  },
  "methodology": "Medicare Physician Fee Schedule (MPFS) — (Work RVU × GPCI) + (PE RVU × GPCI) + (MP RVU × GPCI) × CF"
}

Worked example: 99213 at CCN 170001 (Kansas)

Step	Component	Base RVU	× GPCI	= Adjusted
1	Work	1.30	× 1.000	1.3000
2	Practice Expense (facility)	0.99	× 0.904	0.8950
3	Malpractice	0.10	× 0.504	0.0504
	Total adjusted RVU			2.2454
4	× Conversion Factor		× $33.40	$75.00

Kansas has a Work GPCI of 1.000 (floor applies), a relatively low PE GPCI of 0.904, and a low MP GPCI of 0.504. This means practice expense and malpractice costs are below the national average, resulting in a lower payment than coastal markets.

Facility vs. non-facility rates

The PE RVU has two values depending on where the service is performed:

Setting	PE RVU (99213)	Why
Facility (hospital, ASC)	0.99	Hospital covers overhead — lower PE
Non-facility (physician office)	1.81	Physician covers overhead — higher PE

The care setting is determined automatically from L3 (Care Setting). When the resolved care setting is office, the non-facility PE RVU is used. All other settings use the facility rate.

Comparing geographic impact

The same procedure pays differently depending on location:

Location	Work GPCI	PE GPCI	MP GPCI	99213 Payment
Kansas (170001)	1.000	0.904	0.504	$75.00
California (050001)	1.050	1.200	0.850	$87.93
New York (330001)	1.070	1.250	1.300	$93.59

Payment estimates are based on the Medicare Physician Fee Schedule and the current conversion factor ($33.40 for 2026). Actual reimbursement may differ based on sequestration adjustments, locality-specific GPCI subdivisions, and payer contract terms.