Using the Data Contained in the Physician Fee Schedule Public Use Files
This brief document describes one example of how stakeholders might use the data contained within the public use files (PUF) available in the ?download? section of the Physician Fee Schedule (PFS) rule website. 
The CMS creates PFS rates by using established methodologies to develop Relative Value Units (RVUs) for each individual service and implement required adjustments to the PFS conversion factor (CF) to ensure that policy changes and changes to the RVUs are consistent with statutory budget neutrality requirements for the PFS.  
Several stakeholders have inquired with CMS about using these publicly available files to determine how much the proposed rates for individual services contribute to our estimates of overall payments, and consequently, the required budget neutrality adjustment.  In order to make these calculations, estimate (1) the total number of RVUs or anticipated total 2021 payments that would accrue to the individual service(s) and (2) the total number of RVUs or total 2021 payments under the PFS.
The total number of RVUs or anticipated total 2021 payments that would accrue to the individual service(s) can be calculated directly from two Notice of Proposed Rulemaking for Calendar Year 2021 (NPRM21) PUFs: ?Appendix B?, which provides the RVUs, and ?CY 2019 Utilization Crosswalk to CY 2021?, which provides the utilization needed for this calculation.  The total number of RVUs is simply the product of the RVUs reported in Appendix B and the utilization for the service of interest.  The utilization PUF reflects payment modifiers, such as MOD=50 for bilateral services, while RVUs only differ from the unmodified value for TC (technical component of a service) and 26 (professional component of a service) modifiers1. The unmodified RVU value is appropriate for all values except TC and 26.  Once the appropriate RVU value by facility is merged with the utilization for the service(s) of interest, take the product of each RVU (work, PE, MP) and its corresponding utilization and sum across the cases for the service by its HCPCS code.  This summation or ?pool? of RVUs multiplied by the NPRM21 CF of $32.2605 is then the value of total payments for the service(s) under the 2021 RVUs and CF.  
To identify the total number of RVUs or total 2021 payments under the PFS, the information described above must be aggregated for all codes, and must also be supplemented with the proposed payments for anesthesia services (HCPCS codes 00100-01999), which are not included in PFS Addendum B since they are paid under a different formula.  The total pool of RVUs and payments must include these services and they are included in totals reported below.
The total RVUs (or payment) associated with the service(s) of interest can be divided into the total RVUs (or payment) used in establishing budget neutrality in the table below to calculate its/their share of total RVUs (or payment).    
Please note that under the PFS, payment adjustments, including budget neutrality adjustments, are reflected through changes to both the RVUs assigned to each service and the CF.  While the effect on total payments of, for example, eliminating payment for particular services can be estimated by the methods described above, the actual effect on the CF and RVUs of such a change would likely differ slightly from this estimate.
Table 1 illustrates the estimated spending effects for proposals described in the A-F pages (F.  Refinements to Values for Certain Services to Reflect Revisions to Payment for Office/Outpatient Evaluation and Management (E/M) Visits and Promote Payment Stability during the PHE for COVID-19 Pandemic) of the NPRM21.  The first row of the table estimates total spending for all services included in budget neutrality.  The CF dropped 10.61 percent from $36.0896 to $32.2605 based on all policy changes reflected in the NPRM21.  If the CF did not change from 2020, overall spending would increase by $ 11,437,340,235 or 10.6 percent of the 2021 total.  



Table 1: Total 2021 RVUs and Total Payments for 2021 RVUs under Alternative CFs, Selected HCPCS Codes
Service (HCPCS Code)
Short Descriptor 
Setting
Total 2021 Service RVU (Work + Practice Expense + Malpractice)
Total Payments Under NPRM21 RVUs and CF ($32.2605) 
Proposed estimated payment as a percent of total
All Services Included in Budget Neutrality

All
N/A
$96,360,584,643 





(equals total payment under FR20 RVUs and CF)

99202
Office/outpatient visit new
Non-Facility
2.14
$160,304,277 
0.17%
99202
Office/outpatient visit new
Facility
1.43
$14,155,664 
0.01%
99203
Office/outpatient visit new
Non-Facility
3.29
$1,067,920,683 
1.11%
99203
Office/outpatient visit new
Facility
2.42
$93,664,790 
0.10%
99204
Office/outpatient visit new
Non-Facility
4.94
$1,431,418,970 
1.49%
99204
Office/outpatient visit new
Facility
3.96
$197,173,880 
0.20%
99205
Office/outpatient visit new
Non-Facility
6.53
$444,509,145 
0.46%
99205
Office/outpatient visit new
Facility
5.39
$137,910,132 
0.14%
99211
Office/outpatient visit est
Non-Facility
0.69
$55,626,802 
0.06%
99211
Office/outpatient visit est
Facility
0.27
$1,165,888 
0.00%
99212
Office/outpatient visit est
Non-Facility
1.68
$466,814,894 
0.48%
99212
Office/outpatient visit est
Facility
1.06
$40,489,445 
0.04%
99213
Office/outpatient visit est
Non-Facility
2.69
$7,000,127,462 
7.26%
99213
Office/outpatient visit est
Facility
1.96
$652,744,034 
0.68%
99214
Office/outpatient visit est
Non-Facility
3.81
$11,195,864,834 
11.62%
99214
Office/outpatient visit est
Facility
2.89
$1,282,244,202 
1.33%
99215
Office/outpatient visit est
Non-Facility
5.34
$1,338,492,759 
1.39%
99215
Office/outpatient visit est
Facility
4.27
$355,701,171 
0.37%
99XXX
Prolng off/op e/m ea 15 min
Non-Facility
0.97
$27,554,285 
0.03%
99XXX
Prolng off/op e/m ea 15 min
Facility
0.94
$9,031,377 
0.01%
GPC1X
Complex visit w med care svs
Non-Facility
0.49
$2,533,780,963 
2.63%
GPC1X
Complex visit w med care svs
Facility
0.49
$401,256,868 
0.42%
59400
Obstetrical care
Facility
72.01
$6,265,867 
0.01%
59410
Obstetrical care
Facility
31.8
$817,623 
0.00%
59425
Antepartum care only
Non-Facility
16.88
$346,060 
0.00%
59425
Antepartum care only
Facility
13.08
$76,539 
0.00%
59426
Antepartum care only
Non-Facility
30.82
$825,483 
0.00%
59426
Antepartum care only
Facility
23.9
$147,206 
0.00%
59430
Care after delivery
Non-Facility
7.89
$216,235 
0.00%
59430
Care after delivery
Facility
5.41
$45,287 
0.00%
59510
Cesarean delivery
Facility
79.55
$5,871,571 
0.01%
59515
Cesarean delivery
Facility
39.18
$956,963 
0.00%
59610
Vbac delivery
Facility
75.3
$205,333 
0.00%
59614
Vbac care after delivery
Facility
34.4
$35,752 
0.00%
59618
Attempted vbac delivery
Facility
80.41
$60,028 
0.00%
59622
Attempted vbac after care
Facility
40.62
$8,696 
0.00%
90791
Psych diagnostic evaluation
Non-Facility
5.2
$106,765,687 
0.11%
90791
Psych diagnostic evaluation
Facility
4.46
$38,304,096 
0.04%
90792
Psych diag eval w/med srvcs
Non-Facility
5.82
$55,005,554 
0.06%
90792
Psych diag eval w/med srvcs
Facility
5.08
$48,352,196 
0.05%
90832
Psytx w pt 30 minutes
Non-Facility
2.26
$124,324,743 
0.13%
90832
Psytx w pt 30 minutes
Facility
1.98
$35,524,019 
0.04%
90834
Psytx w pt 45 minutes
Non-Facility
2.98
$421,385,239 
0.44%
90834
Psytx w pt 45 minutes
Facility
2.61
$48,069,651 
0.05%
90837
Psytx w pt 60 minutes
Non-Facility
4.38
$797,691,828 
0.83%
90837
Psytx w pt 60 minutes
Facility
3.85
$37,472,848 
0.04%
90951
Esrd serv 4 visits p mo <2yr
Non-Facility
34.69
$3,252 
0.00%
90951
Esrd serv 4 visits p mo <2yr
Facility
34.69
$13,532 
0.00%
90954
Esrd serv 4 vsts p mo 2-11
Non-Facility
22.76
$82,090 
0.00%
90954
Esrd serv 4 vsts p mo 2-11
Facility
22.76
$380,953 
0.00%
90955
Esrd srv 2-3 vsts p mo 2-11
Non-Facility
15.34
$2,369 
0.00%
90955
Esrd srv 2-3 vsts p mo 2-11
Facility
15.34
$29,083 
0.00%
90956
Esrd srv 1 visit p mo 2-11
Non-Facility
10.23
$12,983 
0.00%
90956
Esrd srv 1 visit p mo 2-11
Facility
10.23
$34,008 
0.00%
90957
Esrd srv 4 vsts p mo 12-19
Non-Facility
22.74
$562,539 
0.00%
90957
Esrd srv 4 vsts p mo 12-19
Facility
22.74
$655,163 
0.00%
90958
Esrd srv 2-3 vsts p mo 12-19
Non-Facility
14.8
$107,516 
0.00%
90958
Esrd srv 2-3 vsts p mo 12-19
Facility
14.8
$91,989 
0.00%
90959
Esrd serv 1 vst p mo 12-19
Non-Facility
9.59
$45,540 
0.00%
90959
Esrd serv 1 vst p mo 12-19
Facility
9.59
$55,491 
0.00%
90960
Esrd srv 4 visits p mo 20+
Non-Facility
10.44
$707,449,644 
0.73%
90960
Esrd srv 4 visits p mo 20+
Facility
10.44
$29,308,633 
0.03%
90961
Esrd srv 2-3 vsts p mo 20+
Non-Facility
8.64
$191,310,606 
0.20%
90961
Esrd srv 2-3 vsts p mo 20+
Facility
8.64
$9,106,282 
0.01%
90962
Esrd serv 1 visit p mo 20+
Non-Facility
5.93
$38,737,541 
0.04%
90962
Esrd serv 1 visit p mo 20+
Facility
5.93
$2,548,953 
0.00%
90963
Esrd home pt serv p mo <2yrs
Non-Facility
17.89
$62,826 
0.00%
90963
Esrd home pt serv p mo <2yrs
Facility
17.89
$77,399 
0.00%
90964
Esrd home pt serv p mo 2-11
Non-Facility
15.36
$172,057 
0.00%
90964
Esrd home pt serv p mo 2-11
Facility
15.36
$305,694 
0.00%
90965
Esrd home pt serv p mo 12-19
Non-Facility
14.75
$431,451 
0.00%
90965
Esrd home pt serv p mo 12-19
Facility
14.75
$208,816 
0.00%
90966
Esrd home pt serv p mo 20+
Non-Facility
8.64
$96,228,015 
0.10%
90966
Esrd home pt serv p mo 20+
Facility
8.64
$4,149,895 
0.00%
90968
Esrd svc pr day pt 2-11
Non-Facility
0.51
$27,591 
0.00%
90968
Esrd svc pr day pt 2-11
Facility
0.51
$36,073 
0.00%
90969
Esrd svc pr day pt 12-19
Non-Facility
0.49
$31,999 
0.00%
90969
Esrd svc pr day pt 12-19
Facility
0.49
$30,707 
0.00%
90970
Esrd svc pr day pt 20+
Non-Facility
0.28
$8,145,999 
0.01%
90970
Esrd svc pr day pt 20+
Facility
0.28
$317,322 
0.00%
92521
Evaluation of speech fluency
Non-Facility
3.92
$26,189 
0.00%
92522
Evaluate speech production
Non-Facility
3.3
$358,738 
0.00%
92523
Speech sound lang comprehen
Non-Facility
6.71
$4,417,787 
0.00%
92524
Behavral qualit analys voice
Non-Facility
3.22
$1,881,361 
0.00%
97161
Pt eval low complex 20 min
Non-Facility
2.95
$144,507,473 
0.15%
97162
Pt eval mod complex 30 min
Non-Facility
2.94
$131,067,207 
0.14%
97163
Pt eval high complex 45 min
Non-Facility
2.94
$30,279,752 
0.03%
97164
Pt re-eval est plan care
Non-Facility
2
$38,590,643 
0.04%
97165
Ot eval low complex 30 min
Non-Facility
3.02
$14,383,001 
0.01%
97166
Ot eval mod complex 45 min
Non-Facility
3.01
$10,182,209 
0.01%
97167
Ot eval high complex 60 min
Non-Facility
3
$2,264,014 
0.00%
97168
Ot re-eval est plan care
Non-Facility
2.04
$2,333,894 
0.00%
99283
Emergency dept visit
Facility
2.09
$180,600,375 
0.19%
99284
Emergency dept visit
Facility
3.57
$607,925,026 
0.63%
99285
Emergency dept visit
Facility
5.18
$1,879,723,315 
1.95%
99483
Assmt & care pln pt cog imp
Non-Facility
8.3
$10,199,394 
0.01%
99483
Assmt & care pln pt cog imp
Facility
5.75
$1,025,556 
0.00%
99495
Trans care mgmt 14 day disch
Non-Facility
6.12
$129,108,527 
0.13%
99495
Trans care mgmt 14 day disch
Facility
4.21
$11,372,539 
0.01%
99496
Trans care mgmt 7 day disch
Non-Facility
8.28
$164,319,575 
0.17%
99496
Trans care mgmt 7 day disch
Facility
5.73
$10,624,884 
0.01%

1 Except for the 4 codes with MOD 53 reported in Addendum B
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