Please note that this article contains information that is only relevant to American clinics.
The Centers for Medicare and Medicaid (CMS) are responsible for determining the payments attributed to each CPT code. They do this is through use of the Resource Based Relative Value Scale (RBRVS). And in this article, we’re going to pick apart the RBRVS so that you and your clinic can have a better understanding of why you’re only being paid a certain amount of money per treatment.
A recent article from Gawenda Seminars and Consulting stated that “The RBRVRS is a schema that assigns procedures performed by a therapist a relative value that is adjusted based on the providers’ geographic region.” To do this, they use something called the “geographic practice cost indices”—or the GPCI for short.
The article then goes on to explain that the CMS has divided America into a total of 112 different geographic regions. And if you do the math, you’ll quickly realize that some states can potentially have two, or even three, different GPCIs within them. For example, PTs in the northern part of the state can potentially get paid differently than PTs in the southern part of the state, despite providing virtually the same treatment.
The RBRVS considers three different factors when determining the price: 52% is based on physician work, 44% is based on practice expense, and 4% is determined by malpractice expense. And we’ll be delving into the meaning of each factor in Part 2 of How the CMS determines the dollar value of each CPT code with RBRVS.