How do RVUs work and affect my paycheck?

And now, after last week’s somewhat emotional cri de coeur , back to our regularly scheduled Ob/Gyn empowerment.

If you just want to skip to the work RVU reimbursement table, click here.

But for a deep dive into these RVUs, see below.

Relative Value Units, or RVUs, are the mathematical basis of how many Ob/Gyns are paid these days; however, they are a byzantine system that seems designed to make you very confused about how much money your employer actually owes you.

Every procedure you perform, from an office visit to a hysterectomy, is assigned a number of RVUs by the United States Government via the Centers for Medicare and Medicaid Services (CMS).

Here are a few examples:

Level 4 established patient visit (CPT code 99214) – 3.85 total RVUs (1.92 work RVUs + 1.79 practice expense RVUs + 0.14 malpractice RVUs – don’t worry, we’ll get to these categories below)

Colposcopy with endocervical and ectocervical biopsies (CPT code 57454) – 5.10 total RVUs (2.33 work RVUs + 2.38 practice expense RVUs + 0.39 malpractice RVUs)

CMS then assigns a “multiplier” to the CPT code in dollar amounts. It multiplies the total RVUs by that multiplier, and that is the base rate of how much your practice receives from Medicare for providing that service to one of its patients.

The multiplier as of September 9, 2024 in these United States of America is $33.29. (Side note: It was $32.74 and via a lot of lobbying by the AMA, ACOG, and other organizations, it was increased to our current amount, which is actually a decrease from 2023.)  

So, in theory, for the level 4 office visit with an established patient, my private practice would be reimbursed 3.85 RVUs x $33.29 = $128.17.

For the colposcopy as above, we would be reimbursed 5.10 RVUs x $33.29 = $169.78. Awesome, maybe we can make payroll after all!

It gets more complicated, though. CMS breaks down each procedure’s RVUs into the subcategories of “Work RVUs,” “Practice Expense RVUs,” and “Malpractice RVUs.”

The work RVUs basically take into account the relative amount of work that you, the physician, spend on the procedure. This includes time and emotional labor. Many employed physicians are reimbursed based on work RVUs. Let’s say your contract states you get $50 per work RVU by your health system. You would then earn 1.92 work RVUs x $50 = $96 for that level 4 visit and 2.33 work RVUs x $50 = $116.50 for that colposcopy. So buy your baby a new pair of shoes.

Practice Expense RVUs are CMS’s way of reimbursing non-physician practice costs. This is a way of estimating how much your practice paid to see this patient outside of paying you, including the cost of your support staff, supplies, rent, electricity, etc.  So your EMR, your front-desk staff, your exam paper, the pap smear brush, the colposcope you purchased, and your autoclaving are all covered in that 1.79 PE RVUs x $33.29 = $59.59 your practice received for the level 4 visit and the 2.38 PE RVUs x $33.29 = $79.23 for the colposcopy.

(Please note – as of early 2024, a new pelvic exam code was approved by CMS that has 0.68 RVUs, all of which are practice expenses. This is designed to reimburse practices for chaperone staff, purchasing & sterilizing speculums, and other expenses incurred by pelvic exams. This exam code can be used in addition to a well woman or problem visit code, but it these expenses are already built into colposcopy codes, so it cannot be used in addition to the 57454.)

Malpractice RVUs are just a special carve-out for practice expenses specific to malpractice insurance costs.

It gets more complicated.

Medicare pays a different amount based on where your practice is located. For that same colposcopy, it will reimburse much more to a practice in San Francisco, California, than anywhere in (sadly) Iowa. This involves three more multipliers, oh my God.  The multiplier is called the Geographic Practice Cost Index (GPCI) and there is a different GPCI for every region and every type of RVUs.

This is the actual CMS formula. It is insane:

Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU Malpractice x GPCI Malpractice)] x Conversion Factor

So, the physician work conversion factors don’t vary a ton by state / region.

The Physician Work GPCI for San Francsico is 1.088. The Physician Work GPCI for Iowa is 1.000. I don’t totally get why physicians are paid more for their work in San Francisco, where there is an MFM ready and waiting to do a Level 2 ultrasound on every low-risk patient, versus Iowa, where we are absolutely desperate for any doctors to come help us out. But there you have it.

Practice expense GPCIs are more variable. The PE GPCI for Long Island is 1.200. I have heard that in New York the rent is too damn high, so this makes sense to me. Ooh la la, a Long Island private practice will make a whopping $93.50 in practice expense reimbursements from that colposcopy! The PE GPCI for Nebraska is 0.917. Hopefully it is actually cheaper to run a practice in Nebraska.

The malpractice GPCIs are really crazy different by region. People must pay a lot for malpractice in Chicago, because the MP GPCI for Chicago is 2.018. The malpractice GPCIs for California are actually pretty low (0.445 for San Francsico) because California actually has common-sense malpractice reform. Although the California trial lawyers always have some bill cooking in the state legislature to revoke this. (See The Political Landscape for Ob/Gyns. )

Private payors and Medicaid

So all of this math determines how much Medicare pays us for Medicare patients. However, unless you’re a urogynecologist, you probably don’t have Medicare patients taking up a huge portion of your business. So why is the whole RVU thing important for the bulk of Ob/Gyn patients who are insured by private payors and Medicaid?

Well, in general, the other payors look to CMS to determine what their reimbursements will be. So if Medicare pays 30% more for a colposcopy than a Level 4 problem visit, them Blue Cross will likely do the same.  

RVUs and your paycheck

For most employed Ob/Gyns these days, the Work RVUs impact your paycheck most directly. The Practice Expense and Malpractice RVUs help keep your employer solvent, which is great, but many employers pay their doctors a certain dollar amount per Work RVU specifically that they generate. An extremely broad range is probably $40 - $70 per work RVU.

So, you should probably know how many work RVUs various visits and procedures are worth, so you know what you should be paid! However, this information is not as easy to find out as you may think.

There are a bunch of websites that want to sell you a subscription to provide this information. You will find them if you google, for example, “colposcopy RVUs.”

You can google the CPT code itself, which often works better. For example, if I google “57454 RVUs” it actually takes me to a website that will tell me the Work RVUs accurately for free. However, finding out the correct CPT code for a procedure can be a whole struggle. Even the AMA and ACOG want to charge you for their “coding bundles” and manuals just to tell you what CPT code you are supposed to bill for a dang colposcopy!

You can also go to the CMS website and download a somewhat daunting ZIP file full of Excel spreadsheets. I have actually done this for you, and you’re welcome. I went through the dang Excel files and Googled all the most common OB/Gyn CPT codes and made a document based on my very best educated guess on what all the codes mean.

Hopefully it helps you and should be valid as of September 9, 2024, which is when I downloaded the file. I take no responsibility for any incorrect information, although I did spend hours and hours going through this and I think it is all right. If anything in this document is incorrect, please let me know or mention in the comments!

Please note there are a number of codes I have used 0-5 times in my entire career that I have not included, such as 57010, drainage of pelvic abscess via colpotomy, 6.84 work RVUs.

I have also not included most urogynecology surgical codes, since billing of urogyn procedures is extremely complex and beyond me. I also excluded gyn onc codes for cancer staging, radical hysterectomy, etc for the same reasons.

I also found a number of absolutely insane codes from another era, such as CPT 59100, removal of hydatidiform mole abdominally via hysterotomy. Like you just make a laparotomy and then a hysterotomy and then scoop out the molar tissue with your hand?? Wow. But yeah, before the advent of suction D&C, that makes sense! I would love to talk to an obgyn who was around back then, sounds intense.

I also included global days in this document, since that is something I was always looking up.

If you want to order the official ACOG coding handbook, definitely do so!

 You will note that there are columns for “Office total RVUs” and “Non-office total RVUs”. The office total RVUs is how much your practice can bill for the procedure if performed in the office. The Non-office total RVUs is how much your practice can bill for the procedure if you perform it in the hospital. There is still considered to be some practice expense, mostly staff time, for hospital-based surgeries.

Link to Common OBGYN RVU Table PDF

Karla Solheim, MD, FACOG