Georgia Medicare Physician Fee Schedule MPFS Guide 2026

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The Medicare Physician Fee Schedule (MPFS) is the formula by which Medicare Part B pays for more than 10,000 distinct services — every office visit, every consultation, every procedure, every diagnostic test, every surgical encounter, every therapy service delivered by Georgia physicians, advanced practice providers, therapists, and other Medicare-participating Part B clinicians. MPFS is the operational core of Medicare Part B physician payment — paying approximately $93 billion in professional services nationally each year.

MPFS rests on Section 1848 of the Social Security Act (42 U.S.C. § 1395w-4), enacted by the Omnibus Budget Reconciliation Act of 1989 (OBRA 1989, Public Law 101-239, December 19, 1989). Section 1848 directed CMS to develop and implement a Resource-Based Relative Value Scale (RBRVS) to replace the prior "reasonable charges" system that had been in place since Medicare's 1965 inception. RBRVS was developed under the direction of Harvard health economist William Hsiao through a multi-year multi-specialty research project funded by HHS. MPFS became operational on January 1, 1992 — phased in over five years.

For Georgia specifically:

• Georgia has multiple Medicare physician fee schedule localities — including Atlanta MSA and Rest of Georgia — each with distinct Geographic Practice Cost Indices (GPCIs) that adjust payment rates for geographic cost variation
• Major Georgia integrated systems (Wellstar Health System, Emory Healthcare Network, Piedmont Healthcare, Northside Hospital System) bill MPFS for thousands of clinicians
• Palmetto GBA Part A/B MAC Jurisdiction J processes Medicare Part B claims for Georgia (along with Alabama and Tennessee)
• MPFS interacts with the MACRA Quality Payment Program (QPP) — MIPS payment adjustments apply on top of MPFS, and the Qualifying APM Conversion Factor differential begins Payment Year 2026

The basic MPFS payment formula for any service is:

Payment = [(Work RVU × Work GPCI) + (Practice Expense RVU × PE GPCI) + (Malpractice RVU × MP GPCI)] × Conversion Factor

Where:

• Work RVU (wRVU) — measures physician work (time, skill, mental effort, technical skill, psychological stress)
• Practice Expense RVU (PE RVU) — measures direct and indirect practice costs (staff, supplies, equipment, rent)
• Malpractice RVU (MP RVU) — measures professional liability insurance costs
• GPCIs — Geographic Practice Cost Indices adjust each RVU component for the locality
• Conversion Factor (CF) — converts RVUs to dollars; updated annually

The CY 2025 final Conversion Factor is $32.3465 (slight decrease from CY 2024's $32.7442). The CF is updated through the MACRA Quality Payment Program framework with annual PFS Final Rulemaking.

This guide walks Georgia Medicare Part B clinicians, practices, and the beneficiaries who depend on them through the full MPFS framework: the statutory authority, the OBRA 1989 establishment, the RBRVS development under William Hsiao, the three RVU components, the GPCI methodology, the annual Conversion Factor, the site of service differential, the AMA RUC, the budget neutrality requirements, the 2021 E&M code reform, the MACRA QPP integration, and what it all means for Georgia clinicians and beneficiaries.

Key Takeaways (Callout)

• MPFS is the formula by which Medicare Part B pays for more than 10,000 services delivered by Georgia physicians, advanced practice providers, therapists, and other Part B clinicians.
• MPFS rests on Section 1848 of the Social Security Act (42 U.S.C. § 1395w-4), enacted by the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239, December 19, 1989). Operational since January 1, 1992.
• The Resource-Based Relative Value Scale (RBRVS) was developed under Harvard health economist William Hsiao, replacing the prior "reasonable charges" system.
• Every service has three Relative Value Units (RVUs): Work RVU, Practice Expense RVU, and Malpractice RVU.
• Geographic Practice Cost Indices (GPCIs) adjust each RVU component for geographic cost variation. Georgia has multiple Medicare localities.
• The Conversion Factor (CF) converts RVUs to dollars. CY 2025 CF: $32.3465 (slight decrease from CY 2024's $32.7442).
• Site of service differential: facility (hospital outpatient, ASC) rates differ from non-facility (office) rates.
• AMA Specialty Society Relative Value Scale Update Committee (RUC) recommends RVU values to CMS through an annual review process.
• Budget neutrality under Section 1848(c)(2)(B)(ii) limits net RVU changes to ±$20 million annually.
• CY 2021 PFS Final Rule (85 FR 84472, December 28, 2020) implemented major Evaluation and Management (E&M) code reform — eliminated documentation guidelines and moved to medical decision making or time-based coding for office/outpatient E&M visits.
• Multiple Procedure Payment Reduction (MPPR) reduces payment when multiple procedures are billed on the same date.
• Modifier 26 (professional component) and Modifier TC (technical component) allow split billing for services with both professional and technical components.
• MACRA QPP integration: MIPS payment adjustments apply on top of MPFS; the Qualifying APM Conversion Factor differential begins Payment Year 2026 for QPs in Advanced APMs.

Statutory Authority and Program History

Pre-RBRVS Era (1965-1991)

From Medicare's launch on July 1, 1966 through the end of 1991, Medicare Part B physician payment used the "reasonable charges" methodology — the lowest of the physician's actual charge, the physician's customary charge, or the prevailing community charge. The reasonable charges system was widely criticized for:

• Rewarding higher-priced specialties disproportionately
• Lacking transparent valuation methodology
• Failing to recognize differences in physician work intensity
• Embedding regional payment disparities

OBRA 1989 RBRVS Establishment

Section 6102 of the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239, signed by President George H.W. Bush on December 19, 1989) directed HHS to develop and implement a Resource-Based Relative Value Scale (RBRVS) as the basis for Medicare Part B physician payment. The new approach would:

• Value services based on the resources required to deliver them (physician work, practice expense, malpractice cost) rather than historical charges
• Address payment disparities between specialties
• Improve transparency in valuation methodology
• Adjust for geographic cost variation through GPCIs

William Hsiao and the Harvard RBRVS Study

The RBRVS was developed under the direction of William Hsiao, then Professor of Economics at Harvard School of Public Health. The Hsiao Harvard RBRVS Study (1985-1988) involved:

• More than 100 specialty societies
• Surveys of more than 6,000 physicians
• Direct observation of physician work
• Time-motion studies
• Cross-specialty calibration

The study produced initial Work RVU values for thousands of CPT codes. CMS adopted the RBRVS methodology through 42 CFR Part 414 rulemaking. MPFS launched on January 1, 1992 with a five-year phase-in.

Subsequent Major Reforms

• 1994-1996: RBRVS phase-in completion
• 1998: Resource-based Practice Expense methodology (replaced charge-based PE)
• 2010: Resource-based Malpractice methodology
• 2013: Resource-based Practice Expense recalibration
• CY 2021 PFS Final Rule (85 FR 84472, December 28, 2020): comprehensive Evaluation and Management (E&M) code reform — eliminated documentation guidelines, moved to medical decision making or time-based coding for office/outpatient E&M
• MACRA 2015 Conversion Factor framework: replaced SGR with annual update methodology tied to QPP

The MPFS Payment Formula

Basic Formula

For any service furnished in a Medicare locality:

Payment = [(Work RVU × Work GPCI) + (Practice Expense RVU × PE GPCI) + (Malpractice RVU × MP GPCI)] × Conversion Factor

Work RVU (wRVU)

The Work RVU measures physician work — time, skill, mental effort, technical skill required, and psychological stress. Higher complexity services have higher wRVUs. Work RVU is approximately 51% of the total RVU value on a national average.

Examples (CY 2025):

• CPT 99213 (Office visit, low-moderate complexity, established patient): wRVU 1.30
• CPT 99214 (Office visit, moderate complexity, established patient): wRVU 1.92
• CPT 99215 (Office visit, high complexity, established patient): wRVU 2.80
• CPT 47562 (Laparoscopic cholecystectomy): wRVU 10.47
• CPT 33533 (Coronary artery bypass, single graft): wRVU 32.71

Practice Expense RVU (PE RVU)

The PE RVU measures direct and indirect practice costs:

• Direct PE: clinical labor (medical assistants, nurses), supplies, equipment specific to the procedure
• Indirect PE: rent, utilities, administrative staff, general supplies, billing costs

PE RVU is approximately 45% of the total RVU value on a national average. PE RVU has two values for each service:

• Non-facility PE RVU: applies in office-based settings (physician absorbs practice costs)
• Facility PE RVU: applies in facility settings (facility absorbs most practice costs; lower PE RVU)

Malpractice RVU (MP RVU)

The MP RVU measures professional liability insurance costs. MP RVU is approximately 4% of the total RVU value on a national average. MP RVUs vary substantially across specialties — higher for surgical and obstetrics, lower for primary care and psychiatry.

Site of Service Differential — Facility vs. Non-Facility

When a service can be furnished in either an office (non-facility) or a hospital outpatient/ambulatory surgical center (facility), MPFS pays:

• Non-facility rate when furnished in office (physician bears all PE)
• Facility rate when furnished in facility (lower PE because facility absorbs some practice costs; facility separately bills for the technical component or facility fee)

For example, CPT 99214 (moderate complexity office visit) pays approximately $130 non-facility and approximately $100 facility in CY 2025 (varies by locality).

Geographic Practice Cost Indices (GPCIs)

Section 1848(e) of the SSA directs CMS to adjust each RVU component for geographic cost variation through Geographic Practice Cost Indices (GPCIs). CMS maintains three GPCIs for each Medicare locality:

• Work GPCI: adjusts physician work to local labor costs (statutory floor of 1.0 — protections for areas below national average)
• Practice Expense GPCI: adjusts PE for local practice costs (rent, staff, supplies)
• Malpractice GPCI: adjusts MP for local malpractice insurance costs

GPCIs are updated triennially.

Georgia Medicare Localities

Georgia has multiple Medicare localities (specific configuration may evolve):

• Atlanta MSA locality — covers Fulton, DeKalb, Cobb, Gwinnett, Clayton, Cherokee, Henry, Forsyth, Douglas, Fayette, Rockdale, Newton, Bartow, Carroll, Coweta, Paulding, Spalding, and adjacent counties
• Rest of Georgia locality — covers remaining Georgia counties

Atlanta MSA GPCIs are generally higher than Rest of Georgia GPCIs, reflecting higher labor costs and practice expenses in the metropolitan area.

Conversion Factor (CF)

The Conversion Factor converts RVUs to dollars. CF is updated annually through PFS rulemaking:

• CY 2024: $32.7442 (final)
• CY 2025: $32.3465 (final, slight decrease)
• CY 2026: TBD (typically set in CY 2026 PFS Final Rule, November 2025)

The CF is statutorily updated through the MACRA Quality Payment Program framework — annual updates are typically modest (0% to 0.5% in recent years), with rulemaking adjustments for budget neutrality and other factors.

For Qualifying APM Participants (QPs) in Advanced APMs beginning Payment Year 2026 (Performance Year 2024), CMS applies a Qualifying APM Conversion Factor that is higher than the standard CF — a structural payment differential replacing the prior 5% APM Incentive Payment.

The AMA Specialty Society RUC

The AMA Specialty Society Relative Value Scale Update Committee (RUC) is a specialty-society committee that recommends RVU values to CMS. Although nominally advisory, CMS adopts most RUC recommendations.

The RUC reviews:

• New CPT codes (new services)
• Revaluation of existing codes (every 5 years; flagged codes more often)
• Practice expense values
• Survey results

The RUC is composed of representatives from medical specialty societies. The RUC process has been criticized for:

• Disproportionate representation of procedural specialties
• Embedding payment disparities favoring proceduralists over cognitive specialists
• Conflicts of interest in self-valuation

CMS has refined the RUC interaction over time, including independent CMS RVU reviews and "potentially misvalued code" identification.

Budget Neutrality

Section 1848(c)(2)(B)(ii) requires that revisions to RVU values, GPCIs, or other components be budget-neutral — meaning that aggregate changes within any year cannot increase or decrease MPFS spending by more than approximately ±$20 million. CMS implements budget neutrality through Conversion Factor adjustments — if RVU revisions would increase spending, the CF is reduced to keep aggregate payments neutral.

Budget neutrality is the reason the Conversion Factor can decline even without explicit policy reductions — RVU recalibrations (especially upward revisions to E&M codes) can necessitate downward CF adjustments to maintain budget neutrality.

The 2021 E&M Code Reform

The CY 2021 PFS Final Rule (85 Federal Register 84472, December 28, 2020) implemented the most significant Medicare E&M coding reform in decades. Key features:

• Eliminated documentation guidelines — the 1995/1997 E&M Documentation Guidelines that had governed how physicians documented history, examination, and medical decision making
• Two coding options for office/outpatient E&M (CPT 99202-99215):
  • Medical decision making (MDM) based — number/complexity of problems, data reviewed, risk of complications
  • Time-based — total time on the date of service including non-face-to-face activities
• CPT 99201 eliminated — Level 1 new patient visit removed
• Increased wRVUs for office E&M codes — recognized the cognitive complexity of primary care and E&M-heavy specialties
• Budget neutrality offset — the increased E&M wRVUs required downward CF adjustment to maintain budget neutrality, generating reductions for procedural specialties

The 2021 reform was widely viewed as a long-overdue revaluation of cognitive specialty work, but procedural specialties strongly opposed the offsetting CF reduction.

Subsequent E&M reforms extended the new framework to hospital inpatient/observation E&M (CPT 99221-99239) for CY 2023 and emergency department E&M (CPT 99281-99285) for CY 2024.

Other MPFS Mechanics

Multiple Procedure Payment Reduction (MPPR)

When multiple procedures are billed on the same date, MPFS applies the Multiple Procedure Payment Reduction (MPPR):

• Highest-paid procedure: 100%
• Second procedure: 50% of PE RVU (varying by procedure category)
• Subsequent procedures: 50% of PE RVU

MPPR recognizes economies of scale when multiple procedures are performed in the same encounter.

Modifiers — Professional and Technical Components

Many MPFS services (especially imaging and diagnostic) can be split between:

• Professional component (Modifier 26) — the physician interpretation
• Technical component (Modifier TC) — the equipment, supplies, and technical staff

The professional and technical components together equal the global service. Each component is paid separately when billed separately.

Therapy Services

Physical therapy, occupational therapy, and speech-language pathology services are paid under MPFS at separate practice expense rates. Therapy services are subject to the KX modifier threshold (CY 2026: $2,330 PT/SLP combined and $2,330 OT) and Targeted Medical Review threshold ($3,000) through CY 2027 (see Tick 447 Georgia Medicare Therapy Cap Repeal BBA 2018 article).

Reimbursement Rates and 80/20 Cost-Sharing

For Medicare-covered Part B services, after the annual Part B deductible (CY 2026: $257), Medicare pays 80% of the MPFS-allowed amount. The beneficiary owes the remaining 20% coinsurance (unless covered by Medigap, Medicaid, or other secondary insurance).

MACRA QPP Integration

MPFS interacts with the MACRA Quality Payment Program in two ways:

MIPS Payment Adjustments

MIPS payment adjustments (up to ±9%) apply on top of MPFS-paid amounts. Clinicians with high MIPS Final Scores receive positive adjustments; clinicians below the Performance Threshold receive negative adjustments.

Qualifying APM Conversion Factor (Beginning PY 2026)

For Qualifying APM Participants (QPs) in Advanced APMs (such as MSSP BASIC Levels C/D/E, MSSP ENHANCED, and ACO REACH), CMS applies a Qualifying APM Conversion Factor that is higher than the standard CF. This structural differential began Payment Year 2026 (Performance Year 2024) and replaces the prior 5% APM Incentive Payment.

Georgia Provider Implications

Major Georgia Integrated Systems

Wellstar Health System, Emory Healthcare Network, Piedmont Healthcare, and Northside Hospital System bill MPFS for thousands of clinicians across multiple Georgia localities. These systems typically:

• Use centralized revenue cycle management
• Manage MIPS performance at the group level
• Coordinate Advanced APM participation through MSSP or ACO REACH ACOs
• Provide MPFS payment forecasting and budgeting infrastructure

Independent Practices

Independent physician practices in Georgia rely on Palmetto GBA for claims processing and must manage:

• MPFS code-level documentation
• E&M coding compliance with the post-2021 framework
• MPPR awareness
• Site of service billing rules
• Modifier 26/TC billing for imaging
• MIPS reporting (unless exempt)

Specialty Implications

• Primary care and cognitive specialties benefit from 2021 E&M reform
• Procedural specialties experienced wRVU recalibrations and CF reductions
• Anesthesia has separate base unit + time methodology
• Radiology heavily uses Modifier 26/TC splits
• Therapy subject to KX threshold and Targeted Medical Review

Worked Examples

Example 1: Fulton 70 — Office Visit 99214 Calculation

A 70-year-old Atlanta beneficiary visits her primary care physician for a moderate-complexity visit (CPT 99214). CY 2025 RVU components (approximate, non-facility):

• Work RVU: 1.92
• PE RVU (non-facility): 2.06
• MP RVU: 0.16

Applying CY 2025 CF ($32.3465) and approximate Atlanta GPCIs: Approximate Payment ≈ $130

Medicare pays 80% after deductible ($104), beneficiary owes 20% coinsurance ($26).

Example 2: DeKalb 75 — Cardiology Consultation

A 75-year-old DeKalb County beneficiary sees a cardiologist for a new patient consultation (CPT 99204 — moderate complexity new patient). RVU components (approximate, non-facility):

• Work RVU: 2.60
• PE RVU (non-facility): 2.65
• MP RVU: 0.21

Approximate Payment ≈ $175

Example 3: Cobb 68 — Facility vs. Non-Facility

A 68-year-old Cobb County beneficiary has an office visit (CPT 99214) that costs ~$130 non-facility but ~$100 facility (lower PE RVU when furnished in hospital outpatient or facility setting). The facility separately bills a facility fee.

Example 4: Worth County 72 — Rural GPCI Implications

A 72-year-old Worth County (rural south Georgia) beneficiary visits her PCP for a moderate-complexity visit (CPT 99214). Worth County is in the Rest of Georgia locality with slightly lower GPCIs than Atlanta MSA. The same service pays slightly less than in Atlanta — reflecting lower practice costs in rural Georgia.

Example 5: Bibb 80 — Therapy KX Threshold

An 80-year-old Bibb County beneficiary receives physical therapy. The therapist bills CPT 97110 (therapeutic exercise, 15 minutes) at the MPFS PT rate. Cumulative therapy spending crosses the CY 2026 KX threshold ($2,330). The therapist appends modifier KX to subsequent claims attesting to medical necessity, and services continue to be paid under MPFS.

Example 6: Hall 67 — MIPS Adjustment on MPFS

A 67-year-old Hall County beneficiary's PCP participates in MIPS. The PCP's MIPS Final Score for PY 2024 is 85, yielding a positive 2% MIPS payment adjustment in PY 2026. The PCP's MPFS payments in PY 2026 are increased by 2% — affecting practice revenue but not the beneficiary's coinsurance amount.

Best Practices

1. For clinicians: understand the RVU components of your most commonly billed services — use Medicare Physician Fee Schedule Database (MPFSDB).
2. For clinicians: document E&M visits using the post-2021 framework — MDM-based or time-based.
3. For clinicians: bill the correct site of service — facility vs. non-facility is determined by where the service is furnished.
4. For clinicians: use modifiers 26/TC appropriately for split-component services.
5. For practices: monitor annual PFS Final Rule changes — released November of preceding year.
6. For practices: forecast Conversion Factor changes for budget planning.
7. For practices: track local Medicare locality and GPCIs for accurate payment expectations.
8. For practices: integrate MIPS payment adjustment into revenue forecasting.
9. For ACO participants: leverage Qualifying APM Conversion Factor differential beginning PY 2026.
10. For all clinicians: maintain Medicare enrollment and revalidation compliance.
11. For all clinicians: respond to MAC (Palmetto GBA) inquiries promptly.
12. For beneficiaries: review MSNs to verify MPFS-billed services.
13. For beneficiaries: understand 20% coinsurance is calculated from MPFS-allowed amount.
14. For Medigap holders: verify Medigap coverage of the 20% coinsurance.

Common Issues

1. E&M coding disputes — Was the visit Level 3, 4, or 5?
2. Site of service errors — billing non-facility rates for facility-rendered services creates audit risk.
3. MPPR disputes — order of procedures affects payment.
4. Modifier misuse — Modifier 26 or TC misapplied.
5. GPCI confusion — clinicians may not recognize their locality.
6. Conversion Factor expectation gaps — clinicians may not realize annual CF changes apply.
7. MIPS adjustment surprise — clinicians may not understand MIPS-driven payment adjustments.
8. Therapy KX threshold tracking — therapists must track cumulative spending.
9. AMA RUC recommendations — clinicians may dispute specific RVU values.
10. Budget neutrality offsets — RVU increases for some codes drive CF reductions affecting all codes.
11. Specialty distribution disparities — historical RUC dynamics favor procedural specialties.
12. Anesthesia base unit + time methodology — distinct from standard RVU framework.
13. Multiple Medicare locality coverage in metro Atlanta — boundary disputes.
14. MPFS interaction with private payer fee schedules — many commercial payers use MPFS as benchmark.

Frequently Asked Questions

Q1: What is the Medicare Physician Fee Schedule (MPFS)?

A: MPFS is the formula by which Medicare Part B pays for more than 10,000 distinct professional services. It rests on Section 1848 of the Social Security Act (42 U.S.C. § 1395w-4) and uses the Resource-Based Relative Value Scale (RBRVS).

Q2: When did MPFS take effect?

A: MPFS was established by the Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239, December 19, 1989) and became operational on January 1, 1992, replacing the prior "reasonable charges" system.

Q3: Who developed RBRVS?

A: RBRVS was developed under the direction of Harvard health economist William Hsiao through a multi-year multi-specialty research project (the Harvard RBRVS Study, 1985-1988).

Q4: What are the three RVU components?

A: Every MPFS-covered service has three Relative Value Units:

• Work RVU (wRVU) — physician work
• Practice Expense RVU (PE RVU) — practice costs (with separate facility and non-facility values)
• Malpractice RVU (MP RVU) — professional liability cost

Q5: What are Geographic Practice Cost Indices (GPCIs)?

A: GPCIs are geographic adjustment factors required by Section 1848(e) SSA. CMS maintains three GPCIs for each Medicare locality (Work, PE, MP) that adjust RVU components for local cost variation. GPCIs are updated triennially.

Q6: How many Medicare localities does Georgia have?

A: Georgia has multiple Medicare localities, including Atlanta MSA and Rest of Georgia. Atlanta MSA GPCIs are generally higher than Rest of Georgia, reflecting higher labor and practice costs.

Q7: What is the Conversion Factor?

A: The Conversion Factor (CF) converts RVUs to dollars. CY 2024 CF was $32.7442 (final); CY 2025 CF is $32.3465 (slight decrease). CF is updated annually through PFS rulemaking under the MACRA QPP framework.

Q8: How does the basic payment formula work?

A: Payment = [(Work RVU × Work GPCI) + (Practice Expense RVU × PE GPCI) + (Malpractice RVU × MP GPCI)] × Conversion Factor

Q9: What is the facility vs. non-facility differential?

A: Many services have two PE RVU values — non-facility (applies in office, where physician bears all practice costs) and facility (applies in hospital outpatient/ASC, where facility absorbs some costs). Facility rates are typically lower because facilities separately bill facility fees.

Q10: Who is the AMA RUC and what do they do?

A: The AMA Specialty Society Relative Value Scale Update Committee (RUC) is a specialty-society committee that recommends RVU values to CMS. Although advisory, CMS adopts most RUC recommendations. The RUC reviews new CPT codes, revalues existing codes, and addresses practice expense values.

Q11: What is budget neutrality?

A: Section 1848(c)(2)(B)(ii) SSA requires that revisions to RVU values, GPCIs, or other components be budget-neutral — meaning aggregate annual changes cannot increase or decrease MPFS spending by more than approximately ±$20 million. CMS implements budget neutrality through Conversion Factor adjustments.

Q12: What was the 2021 E&M code reform?

A: The CY 2021 PFS Final Rule (85 Federal Register 84472, December 28, 2020) implemented the most significant E&M coding reform in decades. It eliminated documentation guidelines for office/outpatient E&M and moved to medical decision making (MDM) or time-based coding for CPT 99202-99215. It also increased wRVUs for E&M codes, with a budget-neutral offset through Conversion Factor reduction.

Q13: Has the E&M reform been extended to other E&M code categories?

A: Yes. Hospital inpatient/observation E&M (CPT 99221-99239) was reformed for CY 2023, and emergency department E&M (CPT 99281-99285) was reformed for CY 2024.

Q14: What is the Multiple Procedure Payment Reduction (MPPR)?

A: When multiple procedures are billed on the same date, MPFS applies the MPPR: highest-paid procedure pays 100%; second procedure pays 50% of PE RVU; subsequent procedures pay 50% of PE RVU. MPPR recognizes economies of scale.

Q15: What are Modifier 26 and Modifier TC?

A: Many MPFS services (especially imaging and diagnostic) can be split:

• Modifier 26 (Professional Component) — the physician interpretation
• Modifier TC (Technical Component) — the equipment, supplies, and technical staff Together they equal the global service. Each component is paid separately when billed separately.

Q16: How does MIPS affect MPFS payment?

A: MIPS payment adjustments (up to ±9% beginning PY 2022) apply on top of MPFS-paid amounts. Clinicians with high MIPS Final Scores receive positive adjustments; those below Performance Threshold receive negative adjustments.

Q17: What is the Qualifying APM Conversion Factor differential?

A: Beginning Payment Year 2026 (Performance Year 2024), Qualifying APM Participants (QPs) in Advanced APMs receive a Qualifying APM Conversion Factor that is higher than the standard CF — a structural payment differential replacing the prior 5% APM Incentive Payment.

Q18: What is the Medicare Part B coinsurance for MPFS services?

A: After the annual Part B deductible (CY 2026: $257), Medicare pays 80% of the MPFS-allowed amount; the beneficiary owes the remaining 20% coinsurance (unless covered by Medigap, Medicaid, or other secondary insurance).

Q19: How can I look up MPFS payment for a specific service?

A: Use the Medicare Physician Fee Schedule Database (MPFSDB) at CMS.gov. Filter by HCPCS/CPT code, locality, and year. The database shows Work/PE/MP RVUs, GPCIs, facility/non-facility rates.

Q20: How does MPFS interact with private payer fee schedules?

A: Many commercial payers use MPFS as a benchmark for their fee schedules, often paying a percentage of Medicare. This makes MPFS the de facto reference point for U.S. physician payment beyond Medicare itself.

Q21: Who processes Medicare Part B claims for Georgia?

A: Palmetto GBA Part A/B MAC Jurisdiction J processes Medicare Part B claims for Georgia (along with Alabama and Tennessee).

Q22: How does MPFS apply to therapy services?

A: Physical therapy, occupational therapy, and speech-language pathology services are paid under MPFS at separate practice expense rates. Therapy is subject to the KX modifier threshold (CY 2026: $2,330 PT/SLP combined and $2,330 OT) and Targeted Medical Review threshold ($3,000) through CY 2027.

Q23: Are there separate methodologies for anesthesia and certain specialties?

A: Anesthesia uses a separate base unit + time methodology distinct from standard RVU framework. Radiology heavily uses Modifier 26/TC splits. Some other services have specialty-specific methodologies.

Q24: How are RVUs revised over time?

A: RVUs are revised through:

• 5-year reviews — every 5 years, all codes are eligible for revaluation
• Annual updates for new CPT codes or flagged codes
• AMA RUC recommendations
• Potentially Misvalued Code identification by CMS or stakeholders
• Notice-and-comment rulemaking in annual PFS Final Rules

Q25: Why does MPFS matter for Georgia Medicare beneficiaries?

A: MPFS determines payment for virtually every Part B service Georgia beneficiaries receive — every office visit, every consultation, every procedure, every diagnostic test. Beneficiaries' 20% coinsurance is calculated from MPFS-allowed amounts. MPFS also affects clinician participation patterns, practice viability, and care delivery investments. The annual Conversion Factor and ongoing RVU recalibrations shape how Medicare Part B operates in Georgia.

Call to Action — Contacts and Resources

If you have questions about Medicare Part B payment, MPFS, or how it affects your practice or your provider:

1. Medicare: 1-800-MEDICARE (1-800-633-4227) — Medicare.gov
2. QPP Service Center: 1-866-288-8292 — QPP technical questions
3. Palmetto GBA Part A/B MAC: 1-866-238-9650 — Georgia Part B claims processing
4. GeorgiaCares SHIP: 1-866-552-4464 — free Medicare counseling
5. CMS MPFSDB — Medicare Physician Fee Schedule Database at cms.gov
6. CMS Medicare Learning Network (MLN) — educational materials
7. Medical Association of Georgia (MAG)
8. AMA RUC — for RVU recommendations (provider-side)
9. Georgia Composite Medical Board — provider licensure
10. Medicare Rights Center: 1-800-333-4114
11. Acentra Health QIO: 1-844-455-8708
12. Atlanta Legal Aid: 404-377-0701
13. Georgia Legal Services: 1-800-498-9469
14. Eldercare Locator: 1-800-677-1116
15. 211 Georgia — 211
16. SSA: 1-800-772-1213
17. HHS OIG Hotline (for suspected fraud): 1-800-HHS-TIPS

The Medicare Physician Fee Schedule is the technical backbone of Medicare Part B physician payment in the United States — a formula that translates physician work, practice expenses, and malpractice costs into the dollars that flow to every Georgia office visit, procedure, and consultation. From the OBRA 1989 establishment of RBRVS to the William Hsiao Harvard study to the CY 2021 E&M reform to the MACRA QPP integration, MPFS has evolved continuously since 1992.

For Georgia clinicians, MPFS is the operational reality of daily practice — every claim submitted to Palmetto GBA is paid against MPFS-derived amounts. For Georgia Medicare beneficiaries, MPFS underlies every 20% Part B coinsurance bill they pay. Understanding MPFS — its components, its mechanics, its evolution — is essential context for navigating Medicare Part B in 2026 and beyond.