The three numbers that run your paycheck

Every procedure, visit, and consult you bill has a CPT code. Every CPT code maps to a Work RVU (wRVU) value. Your paycheck, in almost every employed model, is some version of this:

wRVUs produced × conversion factor ($/wRVU) = comp

The three levers are (1) how many wRVUs a given code is worth, (2) your conversion factor, and (3) any modifiers, quality bonuses, or threshold tiers layered on top. Every piece of physician comp confusion — quarterly reconciliation disputes, "why did my bonus drop" calls, missed billing — is a fight about one of those three.

wRVUs are assigned by CMS, not your employer

CMS publishes the Physician Fee Schedule every year. That document assigns a wRVU to every CPT code. A 99213 (level 3 established patient visit) is currently 1.3 wRVUs. A 99215 is 2.1. A colonoscopy with biopsy (45380) is around 4.57. These numbers move — sometimes by 10%+ year over year — and they're the reason your comp can shift even if your volume didn't.

Two practical implications: first, it's worth checking the annual update for your most-billed codes every January. Second, when a code's wRVU drops, your employer doesn't automatically adjust your conversion factor up — unless your contract says so.

The conversion factor is where contracts actually live

MGMA publishes median conversion factors by specialty every year. Family medicine lands near $50/wRVU. Cardiology sits north of $65/wRVU. Neurosurgery often clears $100/wRVU. Your employer's offer is almost always framed in salary terms, not $/wRVU terms — but the $/wRVU is what determines your upside.

A $280K salary with a $45/wRVU rate above threshold is a fundamentally different deal than a $260K salary with a $55/wRVU rate above threshold. At typical attending volume, the second one pays more and keeps paying more.

Why two docs doing the same work get different credit

A few things you may not have been told explicitly:

  • Modifiers change credit. Modifier 25 (a significant, separate E/M on the same day as a procedure), Modifier 59, and Modifier 51 all affect whether you get credit for both services or only one.
  • Billers code conservatively by default. When documentation supports a 99214, some billers drop it to a 99213 unless prompted. That's pure conversion factor leakage.
  • Incident-to and split/shared rules bury credit. Work done with an APP under your supervision may or may not appear on your RVU statement depending on how your group codes it.
  • Bundled codes suppress totals. Many procedure codes bundle pre- and post-op visits into the procedure wRVU. If you're seeing a post-op in clinic, it usually isn't separately credited.

Three checks to run this quarter

  1. Reconcile your top 10 CPT codes against the CMS Physician Fee Schedule. If any dropped this year, verify whether your contract's conversion factor moved.
  2. Audit one month of documentation against billed codes. If 10%+ of encounters were down-coded from what your note supports, that's a conversation with your billing team, not with your practice manager.
  3. Confirm your threshold math. Most contracts pay a base salary up to a wRVU threshold, then a different rate above it. Know both numbers. Track where you are relative to threshold each month, not at year-end reconciliation.

None of this is optional math anymore. With compensation reform across CMS and tighter margins at most employer systems, the physicians who actually understand their RVU statement are the ones who renegotiate cleanly.