RVU & Physician Fee Schedule

What is an RVU?

The Relative Value Unit (RVU) is a system established by CMS (Centers for Medicare & Medicaid Services) to simplify updating service fees each year. Think of it as the medical currency: instead of changing the fee of every service annually, CMS changes a single number — how much it pays per RVU.

How much is one RVU worth?

The dollars-per-RVU figure is the conversion factor, which CMS declares at the start of each year. For 2026, and as required by statute, there are now two conversion factors: $33.40 per RVU for most physicians (non–qualifying-APM) and $33.57 per RVU for qualifying alternative-payment-model (APM) participants — both up from $32.35 in 2025.

wRVU vs RVU

Each RVU is composed of three parts:

• wRVU (work RVU) — the physician-compensation component.
• Practice-expense RVU — the facility / practice component.
• Malpractice RVU — the liability component.

How is the total service fee calculated?

Total fee = conversion factor × (work RVU + practice-expense RVU + malpractice RVU)

How are the fees updated?

• Every year, CMS declares a new conversion factor (dollars per RVU).
• Every few years, CMS updates the number of RVUs assigned to each service.

What should you bill? — E/M visit levels

For most clinical encounters you bill an Evaluation & Management (E/M) code. The level you pick is what mostly drives your wRVU — and under-coding leaves real work uncounted. Since the 2021 (office) and 2023 (hospital) reforms, the visit level is chosen by either the Medical Decision Making (MDM) level OR the total time you spend on the date of service — history and exam no longer determine the level (a medically appropriate history/exam is still required).

Work RVUs reflect the 2021 RUC-adopted values currently in the CMS Physician Fee Schedule; verify against the current-year PFS before relying on exact figures.

Inpatient examples — Level 2 vs Level 3 follow-up

The daily hospital follow-up is where neurohospitalists most often under-bill. The jump from 99232 (1.59 wRVU) to 99233 (2.40 wRVU) is roughly a 50% increase in work credit for the same visit when the patient genuinely warrants it.

• 99232 (moderate) — e.g. an ischemic-stroke patient, neurologically stable, continuing secondary-prevention work-up; reviewing labs/telemetry; adjusting antihypertensives. One or more chronic illnesses, stable or with mild exacerbation; prescription drug management.
• 99233 (high) — e.g. the same patient now with neurologic worsening, new weakness, or a condition posing a threat to life or bodily function (large-vessel infarct with edema risk, status post-tPA monitored for hemorrhage, status epilepticus being titrated). Severe exacerbation, drug therapy requiring intensive monitoring for toxicity, or a decision about escalation/de-escalation of care.

Outpatient examples — Level 3, 4, 5

• 99213 / Level 3 (low) — stable established patient: well-controlled epilepsy, no medication change, routine follow-up.
• 99214 / Level 4 (moderate) — the bread-and-butter neurology visit: one chronic disease with progression, or two stable chronic problems, plus prescription drug management (e.g. titrating an anti-seizure medication, starting a DMT, adjusting a migraine preventive). Most return neurology visits meet Level 4.
• 99215 / Level 5 (high) — a chronic illness with severe exacerbation or a problem posing a threat to life/function (e.g. breakthrough seizures with injury, rapidly progressive weakness, a new diagnosis of MS or a brain tumor discussed that day), or drug therapy requiring intensive monitoring for toxicity.

Documentation tips to support a higher level

Code by MDM or by time — whichever favors you on a given day — and document accordingly. MDM is met when 2 of these 3 elements reach the level:

1. Problems addressed — state the number and severity. "Stable" ≠ "with progression" ≠ "severe exacerbation / threat to life." Spell out the trajectory.
2. Data reviewed — document each unique lab/study ordered or reviewed, your independent interpretation of imaging/EEG, and any discussion with another clinician.
3. Risk — the phrases that raise risk to moderate or high: "prescription drug management," "drug therapy requiring intensive monitoring for toxicity," "decision regarding hospitalization," "decision to escalate/de-escalate care," and DNR/comfort-care discussions.

RVU targets & benchmarks

Most employed neurologists have an annual wRVU target, often set near the specialty median, with productivity bonuses above it. The best neurology-specific benchmark is the AAN Neurology Compensation & Productivity (NCP) Report. For quick orientation: general neurology runs a median of ~5,377 wRVU and ~$300,000, while a neurohospitalist runs ~3,939 wRVU and ~$321,886 — note the neurohospitalist earns more on fewer wRVUs, reflecting shift-based and call pay.

Full breakdown by subspecialty (per 1.0 clinical FTE; shown as median with the 25th–75th percentile range):

Ahmed Koriesh, MD