Current Procedural Terminology (CPT) codes are the standardized language used by healthcare professionals to report medical, surgical, and diagnostic procedures to payers, including Medicare and commercial insurance companies. The financial value of a CPT code is measured by the Relative Value Unit (RVU), which forms the foundation of the Resource-Based Relative Value Scale (RBRVS) system. This system, adopted by Medicare and widely used across the healthcare industry, ensures that payment for a service reflects the resources expended to provide it. Understanding the total RVU for a specific code, such as the commonly used CPT code 99213, is essential for deciphering physician reimbursement.
Defining CPT Code 99213
CPT code 99213 is frequently utilized in outpatient medicine, representing a Level 3 office or other outpatient Evaluation and Management (E/M) visit for an established patient. To qualify for this level, the encounter must meet requirements based on medical decision-making (MDM) or the total time spent on the date of the encounter.
The medical decision-making component for CPT 99213 is defined as a low level of complexity. This involves managing one stable chronic illness, or two or more self-limited or minor problems, alongside a limited amount of data review and a low risk of complication from the treatment plan. It is commonly used for routine follow-up visits where a patient’s chronic condition is managed without significant changes to the treatment regimen.
If the provider codes based on time, CPT 99213 requires 20 to 29 minutes spent on the patient’s care on the date of the encounter. This total time includes both face-to-face interaction and non-face-to-face activities, such as preparing for the visit, reviewing test results, documenting the encounter, and coordinating care. This time requirement separates it from lower-level codes like 99212 and higher-level codes such as 99214.
An established patient is defined as one who has received professional services from the physician or another physician of the same specialty within the same group practice within the past three years. CPT 99213 is commonly billed for continuing follow-up care in primary care and specialty practices.
Understanding the Components of an RVU
The total RVU is a composite value built from three distinct components: Work RVU, Practice Expense RVU, and Malpractice RVU. These components are added together to form the total Relative Value Unit. The Centers for Medicare & Medicaid Services (CMS) sets these national values through the Medicare Physician Fee Schedule (MPFS).
Work RVU (W-RVU)
The Work RVU (W-RVU) represents the physician’s effort in performing the service. This component accounts for the time, technical skill, physical and mental effort, and stress associated with the service. For an E/M visit like 99213, the W-RVU reflects the cognitive labor involved in evaluating the patient, making a diagnosis, and formulating a treatment plan.
Practice Expense RVU (PE-RVU)
The Practice Expense RVU (PE-RVU) accounts for the non-physician costs of running a medical practice, including staff salaries, office rent, utilities, and equipment. The PE-RVU has two separate values: a higher non-facility rate for physician offices and a lower facility rate for services performed in a hospital outpatient department. This distinction recognizes that hospitals bear many of the overhead costs when the service is performed in their setting.
Malpractice RVU (MP-RVU)
The Malpractice RVU (MP-RVU) covers the cost of professional liability insurance. This value is determined by the estimated risk associated with the particular service and the cost of the insurance premium for the specialty performing it. Because Evaluation and Management services are lower risk than surgical procedures, the MP-RVU component is the smallest part of the total RVU for a code like 99213.
The Current RVU Value for 99213
For the current calendar year (2025), the national, unadjusted Relative Value Units for CPT code 99213 have been established by CMS. The total RVU for this Level 3 visit differs based on the setting: a physician’s private office (non-facility) or a hospital outpatient department (facility). These values are subject to annual review and change based on updates to the Medicare Physician Fee Schedule.
In the non-facility setting, the Total RVU for CPT 99213 is 2.75, derived from the sum of the three components. The Work RVU (W-RVU), which measures the physician’s effort and time, is approximately 1.30. This W-RVU reflects a moderate level of complexity, requiring more cognitive effort than a Level 2 visit but less than a Level 4 visit.
The largest variation between the two settings is in the Practice Expense RVU (PE-RVU). The non-facility PE-RVU is approximately 1.40, reflecting the significant overhead costs borne by the physician’s office. The Malpractice RVU (MP-RVU) contributes a small amount, around 0.05, to the total.
For a service provided in a hospital-owned facility, the Total RVU is approximately 1.92. This value is significantly lower because the facility PE-RVU is much smaller, as the hospital covers the practice’s overhead. The Work RVU and the Malpractice RVU remain constant in both settings.
Translating RVUs into Physician Reimbursement
The Total RVU of 2.75 for CPT 99213 is a unit value, not a dollar amount; it must be converted into an actual payment using additional factors. The Resource-Based Relative Value Scale system uses a specific formula to achieve this conversion and determine the final payment amount. The formula involves adjusting the three RVU components for geographic costs and then multiplying the result by a national dollar amount.
The first step in the payment calculation is applying the Geographic Practice Cost Index (GPCI). The GPCI is a set of adjustment factors that accounts for regional differences in the cost of practicing medicine, such as variations in rent and wages across different U.S. localities. There are separate GPCIs for each of the three RVU components: Work GPCI, Practice Expense GPCI, and Malpractice GPCI.
Each national RVU component is multiplied by its corresponding local GPCI to create an adjusted RVU total that reflects the specific economic area of the practice. For instance, a Work RVU of 1.30 for CPT 99213 would be multiplied by the Work GPCI for the specific city or region where the service was provided. This adjustment ensures that payment reflects regional cost differences.
The final step is to multiply the sum of the geographically-adjusted RVUs by the Conversion Factor (CF). The Conversion Factor is a fixed dollar amount, set annually by Congress and CMS, that converts the final RVU total into the payment amount. For 2025, the national Conversion Factor is set at $32.35.
The full formula for calculating the Medicare payment for CPT 99213 is: Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor. If a provider’s non-facility adjusted RVU total comes to 2.75, multiplying this by the 2025 Conversion Factor of $32.35 results in an unadjusted national payment of $88.96. The application of the GPCIs to the individual components of the RVU is what allows the system to regionalize this national value into a specific, final reimbursement amount.