Difference between rural and urban Medicare reimbursement

June 4, 2007 2:26 PM

What is the difference between urban and rural Medicare physician reimbursements?

Medicare/HCFA classifies service areas into "urban" and "rural." Rural services are reimbursed at a lower rate, but I am having trouble discovering how much lower that lower rate actually is, either as a percent or as an absolute value to compare. I'm most interested in neurologist services (new consultation, EEG/EMG, LP), but would be interested in learning about other medical and surgical specialties too.

Non-physician services such as rehab, hospital days, radiology tests, etc., are not the numbers I'm looking for. In fact, they seem to be the chaff that is preventing me from getting anywhere when Googling this topic.

posted by ikkyu2 to health & fitness (9 comments total)

OK, here we go...

Physicians are reimbursed according to the RBRVS system. Under this system, there isn't a specific urban/rural classification - it's factored into the 6 variables used in the RBRVS payment.

The urban/rural classification you're referring to is used in facility payments, specifically payments to inpatient hospitals for procedures performed (called the DRG system).

The firm I work for has calculators to crunch RBRVS payments (mostly ones I built in fact). If have specific procedures (even better if you have the ICD-9 or HCPCS codes), I can calculate specific payment amounts for you.
posted by junesix at 2:55 PM on June 4, 2007

You might try playing with this, from CMS. I can't get anywhere with it, myself. CMS is not in the business of being enormously clear, though, as you've no doubt discovered. Any chance that your practice has a billing person/department and that they have a nice reference somewhere?
posted by dilettante at 2:56 PM on June 4, 2007

This question has nothing to do with my own practice.
posted by ikkyu2 at 3:06 PM on June 4, 2007

CMS also has an overview of the Physician Fee Schedule. Medpac has a brief report that explains how the Geographic practice cost indexes are calculated and provides an example or two.
posted by RichardP at 3:09 PM on June 4, 2007

Junesix, some CPT codes of interest are 99214, 99215, 99223, 99244, 99245, 95816, and 95819. For a DRG, let's try ICD-9 345; if you need more specific, then 345.41, 345.40, and 345.10 are of interest.
posted by ikkyu2 at 3:17 PM on June 4, 2007

It wouldn't need to have anything to do with your practice - the references can be fairly broad and general.
posted by dilettante at 3:35 PM on June 4, 2007

Location? Use the GPCI localities here for 2007.

BTW these GPCI localities are the geographic component of RBRVS physician reimbursement. That's really as specific as it gets for rural vs. urban. Thus with the exception of states with major metropolitan areas, all physicians within a state are pretty much reimbursed at the same amount.

As dilettante and RichardP pointed out, you can also do the RBRVS calculation yourself using the standard formulas and files.

2007 Non-Facility =
[(Work RVU * 0.8994 * Work GPCI) +
(Non-Facility PE RVU * PE GPCI) +
(MP RVU * MP GPCI)] * Conversion Factor

2007 Facility =
[(Work RVU * 0.8994 * Work GPCI) +
(Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor

For 2007, the conversion factor is $37.8975. For the RVU and GPCI variable values, download and unzip the RVU07B.zip file here. RVUs are in the PPRRVU07.xls file and the GPCIs are in the GPCI07.xls file.

Facility payments are to physicians working in hospitals, clinics, institutions. Non-Facility are freestanding centers, ie. private practice office.

I'll try to get you the payment figures soon.
posted by junesix at 3:47 PM on June 4, 2007

Wow, I'm so glad I'm Canadian. This entire thread is less intelligible to me than Chinese.
posted by blacklite at 12:11 AM on June 5, 2007

Thanks for the answers, folks. Junesix emailed me a useful Excel calculator that was able to answer my question.
posted by ikkyu2 at 12:55 AM on June 5, 2007