Sleep Code Payment Explanation

Glossary of Terms

Conversion Factor (CF) – The conversion factor is the number that, when multiplied by the RVUs assigned for a service, determines the payment for that service.  

RVU – The RVU or relative value unit is the unit of measure assigned to aspects of the service performed.  A relative value unit is assigned for the physician work, the practice expense and the malpractice insurance for each service payable by Medicare.  These relative value units are multiplied by the conversion factor to determine payment for each service.

GPCI – The Geographic Practice Cost Index or GPCI is an index that reflects the differences in physician costs across geographic areas.  GPCIs for physician work (work GPCI), practice expense (PE GPCI) and professional liability insurance (PLI GPCI) are assigned to each geographic area.  GPCIs are multiplied by the RVUs to calculate the service’s total RVU for a particular area. 

Physician Work RVU – The physician work RVU is the unit of measure assigned to the physician’s portion of the service performed. 

Practice Expense RVU – The practice expense RVU is the unit of measure assigned to the technical component of the service performed.

Professional Liability Insurance (PLI) RVU – Also known as malpractice, professional liability insurance RVU is the unit of measure used to indicate the portion of reimbursement estimated to cover malpractice insurance for the particular service.  This unit is proportional to the amount of risk in the service.


How to Calculate National Payment
To calculate payment for a given service, you must first calculate the total RVUs for the service using the following formula:
Total RVU = work RVU + PE RVU + PLI RVU

The 2011 RVUs for sleep testing codes (95800-95811) can be found on page 73794 of the Monday November 29, 2010, Federal Register.

The total RVUs are then multiplied by the conversion factor to calculate the total payment:
Payment = Total RVU x Conversion Factor

Current National RVU and Payment Information

 

The following is a table of RVU and payment information for sleep codes 95803-95811.  This table reflects RVUs applicable for 2010.  The conversion factor used to calculate the payment information in this table is $36.87, which is the conversion factor today, November 29, 2010.  Please note that codes 95800 and 95801 are new codes in 2011 and are therefore not included in this table.

 

 

Code

Physician Work RVU

Physician Work Payment

Practice Expense RVU

Practice Expense Payment

PLI RVU

PLI Payment

Total RVU

Total National Payment = (work + PE + PLI) x Conversion Factor

95803

1.00

$36.87

2.37

$87.38

.04

$1.48

3.41

$125.73

95805

1.88

$69.32

8.74

$322.24

.08

$2.95

10.70

$394.51

95806

1.66

$61.20

3.79

$139.74

.07

$2.58

5.52

$203.52

95807

1.66

$61.20

11.18

$412.21

.12

$4.42

12.96

$477.83

95808

2.65

$97.70

15.28

$563.37

.15

$5.53

18.08

$666.60

95810

3.52

$129.78

17.08

$629.74

.18

$6.64

20.78

$766.16

95811

3.79

$139.74

18.94

$698.32

.21

$7.74

22.94

$845.80

 

January 1, 2011 National RVU and Payment Information with Conversion Factor Decrease

 

The following is a table of payment information for sleep codes 95800-95811.  This table reflects RVUs applicable starting January 1, 2011.  The conversion factor used to calculate the payment information in this table is $25.52, which is the conversion factor expected to take effect on January 1, 2011.

 

Code

Physician Work RVU

Physician Work Payment

Practice Expense RVU

Practice Expense Payment

PLI RVU

PLI Payment

Total RVU

Total National Payment = (work + PE + PLI) x Conversion Factor

95800

1.05

$26.80

37.51

$957.26

.05

$1.27

38.61

$985.33

95801

1.00

$25.52

64.32

$1641.45

.05

$1.27

65.37

$1668.24

95803

.90

$22.97

3.84

$98.00

.04

$1.02

4.78

$121.99

95805

1.20

$30.62

10.84

$276.64

.08

$2.04

12.12

$309.30

95806

1.25

$31.90

4.05

$103.36

.08

$2.04

5.38

$137.30

95807

1.28

$32.67

12.45

$317.72

.15

$3.83

13.88

$354.22

95808

1.74

$44.40

17.28

$440.99

.17

$4.34

19.19

$489.73

95810

2.50

$63.80

17.80

$454.26

.21

$5.36

20.51

$523.42

95811

2.60

$66.35

19.30

$492.54

.23

$5.87

22.13

$564.76

 

January 1, 2011 National RVU and Payment Information without Conversion Factor Decrease

 

The following is a table of payment information for sleep codes 95800-95811.  This table reflects RVUs applicable starting January 1, 2011.  The conversion factor used to calculate the payment information in this table is $36.87, which reflects the current conversion factor freeze. 

 

Code

Physician Work RVU

Physician Work Payment

Practice Expense RVU

Practice Expense Payment

PLI RVU

PLI Payment

Total RVU

Total National Payment = (work + PE + PLI) x Conversion Factor

95800

1.05

$38.71

37.51

$1382.99

.05

$1.85

38.61

$1423.55

95801

1.00

$36.87

64.32

$2371.47

.05

$1.85

65.37

$2410.19

95803

.90

$33.18

3.84

$141.58

.04

$1.48

4.78

$176.24

95805

1.20

$44.24

10.84

$399.67

.08

$2.95

12.12

$446.86

95806

1.25

$46.09

4.05

$149.32

.08

$2.95

5.38

$198.36

95807

1.28

$47.19

12.45

$459.03

.15

$5.53

13.88

$511.75

95808

1.74

$64.15

17.28

$637.11

.17

$6.27

19.19

$707.53

95810

2.50

$92.18

17.80

$656.28

.21

$7.74

20.51

$756.20

95811

2.60

$95.86

19.30

$711.59

.23

$8.48

22.13

$815.93

 

Local Payment Calculation

 

The RVUs and payment calculations in the Final Rule are based on national information.  Payments for all services vary based on locality.  In order to calculate the payment for your locality, you will need to find the Geographic Practice Cost Index (GPCI) RVUs for your locality.  GPCI RVUs can be found in the Monday November 29, 2010, Federal Register on page 73817. 

2010-11-29T00:00:00+00:00 November 29th, 2010|Professional Development|