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RUBRICWARD AI DOSSIER // TIER 2 AUTOPILOT (#01–#06, #11)
VA
VADOI-MRF-CPT-29881
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Virginia Bureau of Insurance (SCC) & Palmetto GBA JM MRF Index — Northern VA / Richmond MSA
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Henrico County, VA
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Filing / IDR Window: 2026-11-25
VA Commercial Payer TiC MRF & NSA IDR Cohort — CPT 29881 / 27447 Orthopedic & ASC
Commercial payer TiC MRF negotiated rate audit, CMS Medicare MPFS RVU/GPCI locality repricing, and ERISA 29 CFR § 2560.503-1 / Federal No Surprises Act (45 CFR § 149.510) IDR arbitration package for Orthopedic & ASC Surgery in VA (CPT 29881 Knee Arthroscopy & CPT 27447 Total Knee Arthroplasty).
Cohort MRF 75th-Pct Value
$1,485,000
Target % of Medicare
213.5% MPFS
Statutory Authority
VA-GPCI-2026-NOVA (Medicare Locality 00904-01 & VA Code § 38.2-3407.15 Prompt-Pay)
ERISA / Timely-Filing Window
120 Days
1. Commercial Payer TiC MRF Allowed-Amount Benchmarks (API #02)
| CPT / DRG Code | Clinical Procedure Description | Unit | Cohort Claims | MRF 25th Pct | MRF Median (QPA) | MRF 75th Pct |
|---|---|---|---|---|---|---|
| CPT-29881 | Orthopedic & ASC: Arthroscopy, Knee, Surgical; with Meniscectomy (Medial/Lateral) & CPT 27447 Total Knee | CLAIM | 420 | $640.00 | $1,185.00 | $1,495.00 |
| CPT-66984 | Extracapsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (1 Stage, ASC Facility + Pro) | CLAIM | 625 | $778.15 | $1,615.40 | $2,029.10 |
| CPT-66991 | Extracapsular Cataract Removal with Insertion of IOL and Aqueous Drainage Assist Device (MIGS) | CLAIM | 230 | $1,457.80 | $3,073.20 | $3,831.65 |
| CPT-66821 | Discission of Secondary Membranous Cataract (Opacified Posterior Lens Capsule), Laser Surgery (YAG) | CLAIM | 435 | $261.02 | $531.90 | $674.73 |
| CPT-65855 | Trabeculoplasty by Laser Surgery (SLT Glaucoma Therapy, Single or Multiple Sessions) | CLAIM | 320 | $290.57 | $600.85 | $763.38 |
| CPT-63030 | Neurosurgery & Spine: Lumbar Laminotomy/Discectomy (1 Interspace) & CPT 22551 Anterior Cervical ACDF | CLAIM | 185 | $1,480.00 | $2,190.00 | $2,940.00 |
| CPT-45380 | Gastroenterology & Endoscopy ASC: Flexible Colonoscopy with Biopsy & CPT 43239 Upper GI EGD | CLAIM | 610 | $520.00 | $795.00 | $1,140.00 |
| CPT-52356 | Urology & Lithotripsy: Cystourethroscopy with Ureteroscopy, Lithotripsy & Indwelling Stent Insertion | CLAIM | 230 | $810.00 | $1,240.00 | $1,745.00 |
| CPT-70553 | Diagnostic Radiology & Cardiology: Brain MRI w/ & w/o Contrast, CPT 74177 CT & CPT 93306 Echo | CLAIM | 480 | $410.00 | $685.00 | $995.00 |
| CPT-99285 | Emergency Medicine, Pathology & Anesthesia: Level-5 E/M, CPT 88305 Surgical Path & CPT 01402 QPA | CLAIM | 890 | $340.00 | $565.00 | $845.00 |
2. Regional Peer Specialty Groups & EIN/NPI MRF Comparables (API #11)
Advanced OrthopaedicsBethesda Chevy Chase Orthopaedic AssociatesPrivia Health Medical GroupQuality Medical Billing