> ## Documentation Index
> Fetch the complete documentation index at: https://docs.rcintell.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Payment calculation

> Calculate expected Medicare reimbursement using the MPFS formula with GPCI-adjusted RVUs

The `/v1/knowledge/payment-calc` endpoint calculates expected Medicare payment for a CPT/HCPCS at a facility. It uses the same composer as `GET /v1/codes/{code}/payment`: physician (MPFS), outpatient facility (OPPS), lab (CLFS), and DMEPOS, populated from whichever fee schedules carry the code.

`estimated_payment` and `components` remain the **physician (MPFS)** view so existing clients keep working.

For a whole claim (many procedure lines + diagnoses), use `POST /v1/knowledge/payment-calc/claim`. That endpoint composes each line, then applies OPPS packaging (status indicators N/Q1/Q2/J1) and T-status 50% multiple-procedure reduction, plus NCCI PTP and LCD DX match.

## The MPFS formula

Medicare payment is calculated as:

```
Payment = (Work RVU × Work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × Conversion Factor
```

Each component represents a portion of the total cost:

| Component             | What it measures                              | RVU example (99213) |
| --------------------- | --------------------------------------------- | ------------------- |
| **Work RVU**          | Physician time, skill, and judgment           | 1.30                |
| **PE RVU** (facility) | Practice expense — staff, equipment, supplies | 0.99                |
| **MP RVU**            | Malpractice insurance cost                    | 0.10                |

The **GPCI** (Geographic Practice Cost Index) adjusts each component for local cost differences. The **Conversion Factor** for 2026 is **\$33.40**.

## Request

```bash theme={null}
curl -X POST https://api-dev.rcintell.com/v1/knowledge/payment-calc \
  -H "X-API-Key: $RCI_API_KEY" \
  -H "Content-Type: application/json" \
  -d '{
    "ccn": "170001",
    "cpt": "99213"
  }'
```

### Parameters

| Field              | Type   | Required | Description                                     |
| ------------------ | ------ | -------- | ----------------------------------------------- |
| `ccn`              | string | Yes      | 6-digit Medicare Provider Number                |
| `cpt`              | string | Yes      | CPT or HCPCS procedure code                     |
| `payer`            | string | No       | Payer name (defaults to Medicare)               |
| `modifier`         | string | No       | CPT modifier                                    |
| `place_of_service` | string | No       | POS code to override facility/non-facility rate |

## Response

```json theme={null}
{
  "ccn": "170001",
  "cpt": "99213",
  "estimated_payment": 75.0,
  "components": {
    "work_rvu_adjusted": 1.3,
    "pe_rvu_adjusted": 0.895,
    "mp_rvu_adjusted": 0.0504,
    "total_adjusted_rvu": 2.2454,
    "conversion_factor": 33.40,
    "facility_rate": true
  },
  "methodology": "Medicare Physician Fee Schedule (MPFS) — (Work RVU × GPCI) + (PE RVU × GPCI) + (MP RVU × GPCI) × CF"
}
```

## Worked example: 99213 at CCN 170001 (Kansas)

| Step | Component                   | Base RVU | × GPCI    | = Adjusted  |
| ---- | --------------------------- | -------- | --------- | ----------- |
| 1    | Work                        | 1.30     | × 1.000   | 1.3000      |
| 2    | Practice Expense (facility) | 0.99     | × 0.904   | 0.8950      |
| 3    | Malpractice                 | 0.10     | × 0.504   | 0.0504      |
|      | **Total adjusted RVU**      |          |           | **2.2454**  |
| 4    | × Conversion Factor         |          | × \$33.40 | **\$75.00** |

<Note>
  Kansas has a Work GPCI of 1.000 (floor applies), a relatively low PE GPCI of 0.904, and a low MP GPCI of 0.504. This means practice expense and malpractice costs are below the national average, resulting in a lower payment than coastal markets.
</Note>

## Facility vs. non-facility rates

The PE RVU has two values depending on where the service is performed:

| Setting                             | PE RVU (99213) | Why                                   |
| ----------------------------------- | -------------- | ------------------------------------- |
| **Facility** (hospital, ASC)        | 0.99           | Hospital covers overhead — lower PE   |
| **Non-facility** (physician office) | 1.81           | Physician covers overhead — higher PE |

The care setting is determined automatically from L3 (Care Setting). When the resolved care setting is `office`, the non-facility PE RVU is used. All other settings use the facility rate.

## Comparing geographic impact

The same procedure pays differently depending on location:

| Location            | Work GPCI | PE GPCI | MP GPCI | 99213 Payment |
| ------------------- | --------- | ------- | ------- | ------------- |
| Kansas (170001)     | 1.000     | 0.904   | 0.504   | \$75.00       |
| California (050001) | 1.050     | 1.200   | 0.850   | \$87.93       |
| New York (330001)   | 1.070     | 1.250   | 1.300   | \$93.59       |

<Warning>
  Payment estimates are based on the Medicare Physician Fee Schedule and the current conversion factor (\$33.40 for 2026). Actual reimbursement may differ based on sequestration adjustments, locality-specific GPCI subdivisions, and payer contract terms.
</Warning>