GPCIs 1.000 · Participating physician · Before sequestration
Find the locality-adjusted allowed amount
Nationally priced under PFS, using the RVU formula.
CMS RVU13BApril 1 – June 30, 2013
( Work3.69 × 1.000 + Practice exp.12.45 × 1.000 + Malpractice0.48 × 1.000 ) × Conv. factor$34.0230 = $565.46
F Work RVU
3.69
G Non‑facility PE RVU
12.45
K MP RVU
0.48
Y Conversion factor
34.0230
( Work3.69 × 1.000 + Practice exp.1.36 × 1.000 + Malpractice0.48 × 1.000 ) × Conv. factor$34.0230 = $188.15
F Work RVU
3.69
I Facility PE RVU
1.36
K MP RVU
0.48
Y Conversion factor
34.0230
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Physician relative value file (PPRRVU) · PPRRVU13.V0215_04162013.csv row 4,871 in rvu13b.zip Download from CMS
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Physician relative value file (PPRRVU) · PPRRVU13.V0215_04162013.csv row 4,871 in rvu13b.zip Download from CMS
Loading rows 4,869–4,873 of PPRRVU13.V0215_04162013.csv…
The national PFS baseline was $565.46 for CPT 19103 in the Office (non-facility) setting and $188.15 in a facility under the Q2 2013 Physician Fee Schedule, effective April 2013. These are the national allowed amounts before locality (GPCI) adjustment; sequestration is excluded.
Why are the facility and non-facility amounts different?
Only the practice-expense RVU changes with the setting. For 19103 it's 12.45 RVUs in the Office (non-facility) setting versus 1.36 in a facility—the whole $377.31 gap between $565.46 and $188.15. In the Office (non-facility) setting the practice bears the overhead, so the allowed amount is higher; in a hospital or ASC the facility bills its own fee, so the professional amount is lower. See facility vs non-facility.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov).
What could change this amount? Copy link
Here are the inputs and payment rules that apply to this code. Each link takes you to the detail below.
Service location and setting · Participation and payment shares
Other payment indicators (6)
Why would a Medicare claim for 19103 be denied or paid less?
These come from CMS indicators on this page, not general billing advice.
- Assistant at surgery: never separately payable. See billing policy
- Co-surgeons: not permitted. See billing policy
- Team surgery: not permitted. See billing policy
- Multiple procedures: standard reduction applies. See billing policy
Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.
How location and RVUs set the amount Copy link
Rates by locality Copy link
The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.
19103 Office (non-facility) rate by metro area
Highest amount first. Each figure is that payment locality's own GPCI-adjusted allowed amount.
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19103 facility rate by metro area
Highest amount first. Each figure is that payment locality's own GPCI-adjusted allowed amount.
Show 33 more metros Show fewer metros
Q2 2013 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range—its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.
How this amount is computed Copy link
CPT 19103 has a work RVU of 3.69, a non-facility practice expense RVU of 12.45, a facility practice expense RVU of 1.36 and a malpractice RVU of 0.48—for total non-facility RVUs of 16.62 and total facility RVUs of 5.53 in the Q2 2013 release.
The formula is: (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.
| Component | RVU |
|---|---|
| Work RVU | 3.69 |
| Practice expense RVU (non-facility) | 12.45 |
| Practice expense RVU (facility) | 1.36 |
| Malpractice RVU | 0.48 |
Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead—higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, never as zero.
CMS RVU13BApril 1 – June 30, 2013 See file rows
Allowed amount, Medicare's share, and patient share Copy link
These figures use the same national baseline, with different participation and payment assumptions.
Computed from the Q2 2013 CMS release
- Allowed amount
- $565.46
- Medicare's share
- $452.37
- Sequestration
- -$9.05
- What Medicare pays
- $443.32
- Patient coinsurance
- $113.09
- Non-participating amount
- $537.19
- Limiting charge
- $617.77
The fee-schedule amount for 19103 in the Office (non-facility) setting. A participating provider accepts it as payment in full, and every figure below starts from it.
80% of the allowed amount, once the annual Part B deductible is met.
The 2% cut to Medicare’s share. It never reduces the allowed amount or the patient’s coinsurance.
Medicare’s share after sequestration.
The remaining 20%. Medigap or Medicaid often covers it.
What a provider who doesn’t participate in Medicare is allowed on an assigned claim: 95% of the allowed amount.
The most a non-participating provider can bill the patient on an unassigned claim: 115% of the non-participating amount.
National Q2 2013 figures at GPCI 1.000. Adjust for your locality and sequestration, or open the explanations below for each figure in full.
Is $565.46 what a practice actually receives?
It's the national allowed amount—the starting point. Medicare pays 80% of it ($452.37) and the patient owes 20% coinsurance ($113.09). Sequestration trims Medicare's share by about 2%, your locality's GPCIs scale the total up or down, and the expected-payment calculator applies all three. That payment is practice revenue that covers staff, space, equipment, and billing. It isn't the clinician's take-home pay. The practice-expense RVU above is CMS's estimate of that overhead share.
Sources: Budget Control Act sequestration provisions; CMS Medicare Fee-for-Service payment guidance; CMS Geographic Practice Cost Index (GPCI) files; CMS Physician Fee Schedule overview (cms.gov).
What's the non-participating amount for 19103?
$537.19 in the Office (non-facility) setting—95% of the $565.46 participating fee schedule amount above. A participating provider takes the fee schedule amount as payment in full on every claim. A non-participating provider is paid this reduced amount, but chooses claim by claim whether to accept assignment. See participating vs non-participating.
Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.
What's the limiting charge for 19103?
$617.77 in the Office (non-facility) setting—the ceiling on what a non-participating provider can bill the patient on an unassigned claim. That's 109.25% of the $565.46 amount above. The non-participating amount is 95% of the fee schedule rate ($537.19), and the statutory cap is 115% of that. See limiting charge.
Sources: CMS Physician Fee Schedule overview (cms.gov); CMS Medicare Fee-for-Service payment guidance.
Who’s billing it Copy link
The allowed amount depends on who bills the service: NPs and PAs get 85% of the fee schedule amount, social workers and counselors 75%. These are national Q2 2013 figures at GPCI 1.000.
| Billed by | Office (non-facility) | Facility |
|---|---|---|
| Physician (MD/DO) The full fee schedule amount. Open in calculator | $565.46 | $188.15 |
| Physician assisting at surgery (-80, -81, -82) Medicare doesn’t pay for an assistant at surgery on this code. Source: Pub. 100-04 ch. 12 §20.4.3 Open in calculator | Not payable | Not payable |
There’s no CMS utilization data on file for 19103, so only the physician amounts are shown. Each percentage applies before the 80/20 split and sequestration.
CMS RVU13BApril 1 – June 30, 2013 See file rows
Which billing rules and modifiers apply? Copy link
Global period: what 19103's fee already covers Copy link
The fee covers pre-operative and post-operative work on the day of the procedure only—there is no follow-up window afterward. A visit the next day is separately payable.
| Modifier | Reports |
|---|---|
| -25 | A significant, separately identifiable E/M on the same day as the procedure, beyond its usual pre- and post-operative care. |
A modifier reports what happened; it does not by itself make a service payable. Documentation has to support it.
Billing policy Copy link
These billing-policy indicators explain how 19103 is treated. They apply whether the code is nationally priced or carrier-priced: a restriction like "bilateral not allowed" still matters on a carrier-priced code. See modifier amounts below for the dollar figures these support.
| Policy | Value | What it means |
|---|---|---|
| Bilateral surgery | 1 | 150% bilateral adjustment applies. Billed bilaterally (modifier 50, or on both sides), Medicare pays 150% of the single-side fee schedule amount. |
| Assistant at surgery | 1 | Never separately payable. An assistant at surgery may never be separately paid for this procedure—a statutory restriction. |
| Co-surgeons | 0 | Not permitted. Medicare does not recognize co-surgeons (modifier 62) for this procedure. |
| Team surgery | 0 | Not permitted. Medicare does not recognize a surgical team (modifier 66) for this procedure. |
| Multiple procedures | 2 | Standard reduction applies. When billed with other procedures on the same date, the highest-valued one is paid at 100% and the next four at 50% each. |
| Professional/technical split | 0 | No PC/TC split. This is a physician service code; the professional/technical split does not apply, and the code is billed as a single service. |
Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link
National Office (non-facility) amounts for the modifiers this code's indicators support. These are single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.
| Modifier | What it means | Amount |
|---|---|---|
| -50 | Bilateral procedure · 150% | $848.19 |
Not payable with 19103: -26/TC (professional/technical split); -80/81/82 (assistant surgeon (physician)); -AS (assistant at surgery (PA, NP, or CNS)); -62 (co-surgeons, each); -66 (team surgery).
Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment.
CMS RVU13BApril 1 – June 30, 2013 See file rows
Can you bill it with another code? Copy link
Check a pair of codes Copy link
Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit for the pair.
Payment review for 19103 Copy link
Four published payment rules can change what 19103 allows on a claim: the office/facility differential, the same-day global package, the standard multiple-procedure reduction and the 150% bilateral adjustment. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.
What to check
- Check the place-of-service code before attributing the gap to the payer: office and facility pricing differ by $377.31 nationally at GPCI 1.000, before any locality adjustment.
- Check the visit date: this code carries no follow-up window, so a related visit the day after the procedure is separately payable and should not have bundled.
- Rank the claim’s procedure lines before calling this one short-paid: billed with a higher-valued procedure on the same date, its allowed amount is $282.73 instead of $565.46 (national, GPCI 1.000). That is the rule, not a payer error.
- Look for modifier 50 or a second-side line before comparing: billed for both sides, this procedure should price at 150% of the single-side amount.
- Reprice the line against the release, locality, setting, modifier and participation status that applied to the date of service before treating any difference as an underpayment.
Compare against 19101, 19120 and 19100: their amounts are in Related codes.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04).
How has it changed? Copy link
Rate history by release Copy link
National Office (non-facility) amount for 19103 across quarterly releases. Unchanged since Q1 2013 · peak $565.46 in Q1 2013
| Release | Status | Office | Facility |
|---|---|---|---|
| Q2 2013 Apr 1, 2013 – present | A | $565.46 (0.0% no change) | $188.15 (0.0% no change) |
| Q1 2013 Jan 1, 2013 – Mar 31, 2013 | A | $565.46 | $188.15 |
When does this rate change?
CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. See what changed each release, or get an email when a new release moves rates.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files.
What it means outside Medicare Copy link
Contracted rate: % of Medicare Copy link
Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for 19103. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $565.46 national baseline; the calculator finds that amount from your service ZIP.
Usage and related codes Copy link
How 19103 compares with other codes Copy link
Against every code with a national PFS amount in Q2 2013 · National baseline · Before sequestration
- +200.5% Office over facility
- 19103's Office amount is $377.31 more than its facility amount, because a facility bills its own overhead separately. Of the 6,886 codes priced in both settings, 1,774 have a higher Office amount. 19103's gap is larger than 86% of theirs; the median gap is +51.2%.
- 72.5% Highest vs. lowest locality
- 19103's Office amount is 72.5% higher in its highest-paid payment locality than in its lowest. That spread is wider than 81% of the 6,886 codes compared; the median spread is 56.3%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.
- 0.0% Since Q1 2013
- 19103's Office amount didn't change from Q1 2013 to Q2 2013. Over the same period, the median code's amount didn't change. That's higher than the change for 0% of the 6,884 codes priced in both releases.
These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.
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Source & method
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This page uses CMS's Medicare Physician Fee Schedule Q2 2013 release (effective April 2013). National baselines use GPCI 1.000 and exclude sequestration. Whether a national amount exists depends on the status and CMS’s payment instructions; blank RVUs are never treated as zero. Past releases are never edited, so these sources stay valid after CMS publishes a newer one. Modifier amounts apply standard MPFS percentages to this code's billing indicators. We derive them here rather than read them from CMS, so confirm them against the current Claims Processing Manual before relying on them for payment. Our methodology explains sourcing, parsing, versioning, and how we cross-check claims before we publish them.
Conversion factor $34.0230 read from the same file, row 4,871, column 25.
The price card’s citations show the exact row, columns, and file lines behind each amount.
Cite this rate
The citation names the release, so anyone can check it even after CMS publishes a newer one.
CPT 19103 National PFS baseline: Office (non-facility) $565.46; Facility $188.15 (Q2 2013; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU13B, PPRRVU13.V0215_04162013.csv row 4,871. Localis. https://localishealth.com/cpt/19103/2013/B