Medicare PFS glossary

Work RVU

A work RVU measures the relative time, skill, effort, and intensity a physician spends providing a service. It is the first of the three RVU components Medicare...

Practice expense RVU

The practice expense RVU reflects the overhead cost of providing a service — clinical staff time, supplies, equipment, and facility costs. Medicare publishes tw...

Malpractice RVU

The malpractice RVU reflects the relative cost of professional liability insurance for a given service. It is the smallest of the three RVU components but is st...

GPCI

A GPCI is a geographic adjustment factor that scales each RVU component up or down to reflect local cost differences. Medicare publishes three GPCIs per localit...

Payment locality

A payment locality is the geographic area Medicare uses to set the local cost adjustment for the Physician Fee Schedule. Each locality is identified by a Medica...

Conversion factor

The conversion factor is the dollar amount Medicare multiplies by total geographically-adjusted RVUs to produce a payment, updated at least annually. Starting w...

Status indicator

A status indicator is a single-letter code that tells you how Medicare treats a service under the Physician Fee Schedule — whether it is separately payable, bun...

HCPCS

HCPCS is the code set Medicare uses to identify procedures, services, supplies, and drugs. It has two levels: Level I is the CPT code set, and Level II is a set...

CPT

CPT is the numeric code set used to report medical procedures and services. It forms Level I of HCPCS and is maintained by the American Medical Association. Und...

NCCI PTP edit

An NCCI Procedure-to-Procedure (PTP) edit is a CMS rule identifying pairs of HCPCS/CPT codes that generally cannot both be billed for the same patient on the sa...

MUE

A Medically Unlikely Edit (MUE) is the maximum number of units of a HCPCS/CPT code that CMS considers plausible for one patient on one date of service. It is a...

OPPS cap

The OPPS cap limits the Physician Fee Schedule non-facility payment for certain procedures to what Medicare's Hospital Outpatient Prospective Payment System (OP...

Anesthesia base units

Anesthesia services (status J) are not priced with the standard work/practice-expense/malpractice RVU formula. Instead, Medicare pays base units plus time units...

Limiting charge

The limiting charge is the most a non-participating provider can bill a Medicare patient for a service when not accepting assignment: 115% of the non-participat...

Bilateral surgery indicator

The bilateral surgery indicator tells you how Medicare adjusts payment when a procedure is performed on both sides of the body — most often billed with modifier...

Assistant surgery indicator

The assistant surgery indicator tells you whether an assistant at surgery — billed with modifier 80, 82, or AS for a non-physician assistant — can be separately...

Co-surgeon indicator

The co-surgeon indicator tells you whether two surgeons of different skills can each be separately paid for jointly performing distinct parts of the same proced...

Team surgery indicator

The team surgery indicator tells you whether a surgical team — multiple surgeons of different specialties, billed with modifier 66 — can be paid for a procedure...

Multiple procedure indicator

The multiple procedure indicator tells you how Medicare reduces payment when a procedure is billed alongside other procedures for the same patient on the same d...

PC/TC indicator

The PC/TC indicator tells you whether a code splits into a professional component (the physician's interpretation, modifier 26) and a technical component (the e...