Health Insurance and CPT Codes: Using the sample relative value units and GPCIs

Question

Health Insurance and CPT Codes:

Using the sample relative value units and GPCIs shown on page 129 and a conversion factor of $24.6712, calculate the expected charge for the following services:

A. CPT 33500 in Manhattan, NY

B. CPT 99203 in San Francisco, CA

C. CPT 33503 in Galveston, TX

Sample RVUs Work Practice CPT/HCPCS Description 33500 33502 33503 99203 99204 Malpractice Expense RVU 4.07 1.96 4.07 0.05 0.06 RVU Expense RVU Repair heart vessel fistula Coronary artery correction Coronary artery graft OV new detailed OV new comprehensive 25.55 21.04 21.78 1.34 2.00 30.51 15.35 26 0.64 0.96 Sample GPCIs Practice Malpractice Locality San Francisco, CA Manhattan, NY Columbus, Ohio Galveston, TX Work GPCI 1.067 1.093 0.990 0.988 Expense GPCI 1.299 1.353 0.939 0.970 Expense GPCI 0.667 1.654 1.074 1.386

Explanation / Answer

The formula is as follows

Total RVU = [(Work RVUs x Work GPCI) + (Practice Expense RVUs x Practice Expense GPCI) +
(Malpractice RVUs x Malpractice GPCI)]

Expected charge = Total RVU x Conversion Factor

A. CPT 33500 in Manhattan, NY

Total RVU = 25.55*1.093+ 30.51*1.353 + 4.07 * 1.654 = 75.937

Expected charge = 75.937*24.6712 = $1873.46

B. CPT 99203 in San Francisco, CA

Total RVU = 1.34*1.067 + 0.64 *1.299 + 0.05 * 0.667 = 2.2944

Expected charge = 2.2944*24.6712 = $1873.46 = $56.61

C. CPT 33503 in Galveston, TX

Total RVU = 21.78*0.988 + 26 *0.970 + 4.07 * 1.386 = 52.3796

Expected charge =52.3796*24.6712 = $1873.46 = $1292.269

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