Medicare Resource-Based Relative Value Scale Research Articles

Nurse practitioner productivity measurement: An organizational focus and lessons learned.

Nurse practitioners (NPs) are valued members of the health care team, and their numbers are growing each year. The volume of literature demonstrating the impact on quality, safety, patient satisfaction, and access measures is substantial and growing. There is a significant lack of measurement methods and outcomes related to NP contributions to organizational productivity. The construction of strategy for measurement of NP productivity is a prerequisite for studies focusing on impact. Models that are being used to measure physician productivity are available to be examined in terms of their applicability to the NP work force. In 2005, the Deputy Under Secretary for Health for Operations and Management directed Veterans Healthcare Administration (VHA) to develop a productivity-based model for physicians using the Medicare Resource-Based Relative Value Scale, which was created in 1992 to provide guidance on determining payment for physician services. In 2015, the VHA set out to set standards for productivity measurements for NPs, physician assistants, and clinical nurse specialists, and in doing so, the physician productivity model was adapted for the NP workforce. The work of adapting the model will be presented in this article. The specific steps in the process of measurement, operational definitions for work activities, and calculations are provided. The article concludes with a discussion of lessons learned and next steps.

Modifier 25 and Minor Procedures

Modifier 25 and Minor Procedures

Application of the resource-based relative value scale system to pediatrics.

The majority of public and private payers in the United States currently use the Medicare Resource-Based Relative Value Scale as the basis for physician payment. Many large group and academic practices have adopted this objective system of physician work to benchmark physician productivity, including using it, wholly or in part, to determine compensation. The Resource-Based Relative Value Scale survey instrument, used to value physician services, was designed primarily for procedural services, leading to current concerns that American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) surveys may undervalue nonprocedural evaluation and management services. The American Academy of Pediatrics is represented on the RUC, the committee charged with maintaining accurate physician work values across specialties and age groups. The Academy, working closely with other primary care and subspecialty societies, actively pursues a balanced RUC membership and a survey instrument that will ensure appropriate work relative value unit assignments, thereby allowing pediatricians to receive appropriate payment for their services relative to other services.

Cost‐effectiveness analysis of tension‐free vaginal tape vs burch colposuspension for female stress urinary incontinence in the USA

To compare the cost-effectiveness (CE) of tension-free vaginal tape (TVT) with that of burch colposuspension (BC) for the treatment of female stress urinary incontinence (SUI). A Markov-chain decision model was created to simulate treatment of SUI with TVT or BC using Treeage Pro 2011 software (Treeage Software Inc., Williamstown, MA, USA). Costing data were obtained from the Medicare Resource-Based Relative Value Scale. Data regarding the success of TVT vs BC were obtained from the peer-reviewed literature, as were corresponding utilities for different continence states. The CE of each procedure was calculated and compared, and sensitivity analyses were performed. At 10-year follow-up, TVT was more cost-effective (CE = $1495/quality-adjusted life year [QALY]) than BC (CE = $1824/QALY). Sensitivity analysis showed that TVT was more cost-effective than BC if the cost of the TVT device was <$3220. If the probability of success after TVT was <42%, then BC became the more cost-effective strategy (CE = $1827/QALY). Our study showed that TVT was more cost-effective than BC as a treatment for female SUI. Both cost of TVT device and efficacy of the procedure affect the CE analysis.

2011 Medicare Resource-Based Relative Value Scale: Relative Value Units for Immunization Administration and Subsequent-Day Observation Care

Facility and non-facility RVUs/Medicare for CPT codes 90460, 90461, 99224, 99225, and 99226

Postoperative Acquired Coagulopathy: A Pilot Study to Determine the Impact on Clinical and Economic Outcomes

To characterize the clinical factors associated with postoperative acquired coagulopathy, and to estimate the economic impact of resources used to treat postoperative patients with this coagulopathy compared with postoperative patients who did not develop the coagulopathy. Case-control study. Academically affiliated public hospital and level I trauma referral center. Twenty-six patients (mean age 53.9 yrs) who experienced acquired coagulopathy after undergoing an index surgery (cases), and 26 patients (mean age 50.8 yrs) matched to these case patients by index surgery, age, and sex (controls). Data were collected from a database of 5367 adult surgical admissions over 6 months during 2008, corresponding inpatient electronic health records, billing data, and Medicare Resource-Based Relative Value Scale payments. Case patients had a minimum of two postoperative consecutively drawn episodes of prothrombin time (PT) or activated partial thromboplastin time (aPTT) elevated to greater than 20% above the upper limit of normal. Patients with inherited clotting disorders or other identifiable causes of coagulopathy were excluded. Case patients underwent the following surgeries: 12 orthopedic (46%), six cardiovascular (23%), four gastrointestinal (15%), and four neurosurgical (15%). Mean values of the first elevated PT and aPTT were 19.7 and 50.8 seconds, respectively. Mean postoperative stay was 31.5 days for cases versus 9.8 days for controls (p<0.05). Mean cost (2008 U.S. dollars) of resources used was $112,280 for cases versus $38,357 for controls (p<0.001). Costs incurred between the onset of coagulopathy and discharge constituted 67% of postoperative costs. Physician reimbursement expenditures were minimal. Postoperative acquired coagulopathy was associated with stays that were 3 times longer and resource use costs that were 3 times higher than those of controls. This type of coagulopathy may be an under-recognized and underappreciated event. The case-control design is limited to exploring associations and does not establish causality. Prospective studies need to be conducted to establish the causes of acquired coagulopathy and methods for screening and diagnosing this condition.

Application of the Resource-Based Relative Value Scale System to Pediatrics

With an increased focus on payment and productivity measurement in health care, it is essential to understand the genesis and principles behind the Medicare Resource-Based Relative Value Scale (RBRVS) physician fee schedule. The majority of third-party payers, including a growing number of Medicaid programs and commercial payers, use variations of the Medicare RBRVS as their basis for physician payment. Many group practices have also adopted this system to benchmark physician productivity and determine variable compensation and bonus payments. Because pediatric care is underrepresented in any Medicare-based payment system analysis, unique aspects of physician work and practice expense may not be accurately reflected in the total relative value units (RVUs) for certain pediatric services. Despite this potential limitation, the American Academy of Pediatrics supports the use of Current Procedural Terminology (CPT) codes to report unique physician work and the RBRVS physician fee schedule as a uniform payment system. The American Academy of Pediatrics will continue to work to rectify perceived inequities of the RBRVS system as they pertain to pediatrics.

Pilot study comparing patients’ valuation of health‐care services with Medicare’s relative value units

Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties. Cross-sectional survey. Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. Data collection included the use of a visual analog 'value scale' wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the above-mentioned services. Comparisons of (i) the 'patient valuation RVUs' with actual Medicare RVUs, and (ii) patients' estimations of physician income with actual income were explored using t-tests. Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P<0.001) and the range in values assigned by participants was much smaller than Medicare's (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P<0.001) and the differential across specialties was thought to be much smaller (estimate: $88,225, actual: $146,769). In this pilot study, patients' estimations of the value health-care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients' valuation of services rendered by physicians may be warranted.

A decision analysis of treatments for nonobstructive azoospermia associated with varicocele

To examine the economic impact of initial treatments for varicocele-associated nonobstructive azoospermia, specifically varicocelectomy versus microsurgical testicular sperm extraction (TESE) with IVF/intracytoplasmic sperm injection (ICSI). Decision analytic model based on 1) outcomes data from Society for Assisted Reproductive Technology (SART) database and peer-reviewed literature and 2) costing data from Medicare Resource-Based Relative Value Scale and sampling of high volume US IVF centers. Academic medical center. Simulation with a decision analytic model. Variation of successful spontaneous live delivery after varicocelectomy versus rate of successful live delivery after IVF/ICSI. Cost-effectiveness. Microsurgical TESE was more cost effective than varicocelectomy. In 1999, initial treatment with microsurgical TESE was more cost effective ($65,515) than varicocelectomy ($76,878). Relative cost-effectiveness was unchanged in 2005: $69,731 versus $79,576. The cost-effectiveness of both treatments improved in relation to projections by inflation. Sensitivity analyses suggest that the relative cost-effectiveness of TESE versus varicocelectomy can only be changed with either substantial improvement in spontaneous live delivery rates after varicocelectomy or with deterioration in IVF success rates. Microsurgical TESE appears to be more cost effective than varicocelectomy for treatment of varicocele-associated nonobstructive azoospermia when indirect costs are considered. The cost-effectiveness of both treatments has improved with time. These results may be tailored with institution-specific data to allow more individualized results.

The Value of Using the Medicare Resource-Based Relative Value Scale in Your Practice

How to calculate your practice conversion factor when using RBRVS

Why Your State Medicaid Physician Fee Payment Schedule Differs From the Medicare Resource-Based Relative Value Scale

How RBRVS works and how it may affect your practice and payments

Detecting Occult Malignancy in Prophylactic Mastectomy: Preoperative MRI Versus Sentinel Lymph Node Biopsy

High-risk patients undergoing prophylactic mastectomy (PM) may have unsuspected cancers identified on pathology. The optimum way to identify and manage them is controversial. Magnetic resonance imaging (MRI) may identify occult cancer preoperatively. Sentinel lymph node biopsy (SLNB) allows intraoperative staging and axillary dissection during the same operation. We determined the efficacy and cost of MRI and/or SLNB in managing high-risk PM patients. We reviewed 192 PMs in 173 patients from 1999 to 2005. Costs were estimated for MRI and SLNB during PM by the 2005 Medicare Resource-Based Relative Value Scale. We also estimated costs and procedures for the four strategies in a larger hypothetical cohort. A total of 19 (10%) of 192 PMs contained occult cancers, 14 ductal carcinoma-in-situ (DCIS) and 5 invasive ductal carcinoma (IDC). In 59 patients, MRI detected an IDC but missed two DCIS and an IDC. Positive MRIs generated an additional average cost of $1,207 per patient. In 56 PMs with SLNB, 6 occult cancers were found, 5 DCIS and 1 IDC, all with negative SLNBs. Adding a SLNB costs an additional average of $644. A theoretical analysis demonstrated that PM alone costs $808 per patient, PM with SLNB costs $1,420, PM with MRI and selective SLNB costs $1,774, and PM with routine MRI and SLNB costs $2,379. MRI adds great cost and misses most occult cancers in PMs. SLNB allows the rare patient with occult IDC to avoid axillary dissection but adds cost. Given the low rate of unsuspected invasive cancers and the costs of MRI and SLNB, neither is recommended as standard practice for PM patients.

New Relative Value Unit for Hearing and Vision Screening and Care Plan Oversight

The Centers for Medicare & Medicaid Services (CMS) have finally assigned relative value units (RVUs) for hearing and vision screening (92551, 99173). RVUs have also been assigned to the codes for care plan oversight of patients residing in a home, domiciliary, or rest home (eg, assisted living facility) (99339, 99340). This is very good news because the majority of payers use the Medicare Resource-Based Relative Value Scale (RBRVS) as their basis for payment and the establishment of RVUs for these services may help you negotiate for coverage and payment.Be sure to check with your payers to determine their coverage of these services.

The 2007 Resource-Based Relative Value Scale

The Centers for Medicare & Medicaid Services published the 2007 Medicare Resource-Based Relative Value Scale (RBRVS) in the Federal Register on December 1, 2006. You can access it on the CMS Web site at www.cms.hhs.gov/PhysicianFeeSched/.Why are these Medicare relative value units (RVUs) so important to your practice? Many state Medicaid programs and other third-party payers use the Medicare RVUs to establish their own payment policies. However, some payers do not use the Medicare RVUs and will establish their own relative values. It is extremely important that each practice understand the basis a payer uses to determine its payment rates.The total RVU for a given Current Procedural Terminology (CPT®) code is the total of all the associated work and expenses (practice and malpractice expenses) based on the national average relative costs. For most codes, practice expenses are established for both facility (eg, hospital) and non-facility (eg, office) settings.A geographic practice cost index (GPCI) is assigned by Medicare to reflect the relative costs associated with physician work, practice expenses, and malpractice expenses in each Medicare locality. A Medicare conversion factor (CF) is then established and used to convert the RVUs into payments for Medicare services. The 2007 Medicare CF is $37.8975, the same as last year.To calculate the Medicare payment rate, multiply the total geographically adjusted RVU (RVUs for physician work, facility or non-facility practice expense, and malpractice expense multiplied by the GPCI for your area or locality) by the Medicare CF.To calculate the non-Medicare payment rate, multiply the total RVU (physician work, facility or non-facility expense, malpractice expense) by a payer-specific or practice CF. (Most payers, including state Medicaid programs, will establish their own CF.)The Table provides you with the Medicare relative values for some of the new and revised 2007 CPT codes. As reported in the November 2006 (Vol 2, No. 2) issue of Pediatric Coding Companion™, revisions have been made to many of the physician work RVUs for 2007. Therefore, the revised relative values for some evaluation and management services have also been provided. You can access the complete list of RVUs and the GPCIs for your area at www.cms.hhs.gov/apps/pfslookup. You may also find an updated list of the most commonly performed pediatric procedures with the associated RVUs at www.aap.org/visit/RBRVSbrochure.pdf.

2006 Resource-Based Relative Value Scale

The Centers for Medicare and Medicaid Services (CMS) published the 2006 Medicare Resource-Based Relative Value Scale (RBRVS) on its Web site (http://www.cms.hhs.gov) on November 2 and in the Federal Register on November 21, 2005. These relative value units (RVUs) are important because many state Medicaid programs and other third-party payers use them as a basis for their reimbursement policies.The total RVUs for a code are made up of resource-based relative values for work, practice expenses (facility and non-facility), and malpractice expenses. Medicare assigns geographic practice cost indexes (GPCIs) that reflect the relative costs associated with physician work, practice expenses, and malpractice expenses in Medicare localities compared with national average relative costs. A Medicare conversion factor (CF) is then established to allow conversion of RVUs into the payments used to reimburse physicians for Medicare services. The 2006 Medicare CF is $36.1770, a decrease of 4.5% from last year’s CF of $37.8975.Total the physician work, practice expense (facility or non-facility), and malpractice RVUs. Multiply that total by the appropriate GPCIs for your area or locality. Multiply the total adjusted RVUs by the Medicare CF.Total the physician work, practice expense (facility or non-facility), and malpractice RVUs. Multiply that total by a payer-specific or practice CF.The new Current Procedural Terminology (CPT®) codes with assigned RVUs are listed in the Table. Note that RVUs have not yet been assigned to the new codes for moderate sedation, after-hours services, and domiciliary and home care plan oversight.Remember that some payers will apply their own relative value adjustments or use their own CFs. It is important tounderstand the basis they use to determine their payment rates. The importance of understanding RBRVS cannot be overemphasized. Every practice should be aware of its costs associated with each service or procedure and be able to calculate relative values.The American Academy of Pediatrics has developed a detailed summary of RBRVS and its effect on pediatrics that includes a table of the most common RVUs for your use. You can access this information at http://www.aap.org/visit/RBRVSbrochure.pdf.You can find the complete list of RVUs and GPCIs at http://www.cms.hhs.gov/apps/pfslookup.

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

New 2005 CPT Codes

New 2005 <i>CPT</i> Codes

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?

New 2004 CPT Codes

New 2004 <i>CPT</i> Codes

Why Should Pediatricians Use RBRVS-based Fee Schedules?

Why Should Pediatricians Use RBRVS-based Fee Schedules?