Relative Value Scale Update Committee Research Articles

Comparison of Work Relative Value Units Assigned to Urological and Gynecological Surgical Procedures.

We sought to determine if work relative value unit differences exist between analogous, sex-specific procedures. Representatives from the AUA and the American College of Obstetricians and Gynecologists independently reviewed the entire procedural code set and identified sex-specific procedures that had an analogous procedure in the opposite sex. These pairs were then evaluated and compared using current American Medical Association Relative Value Scale Update Committee methodology. Comparable code pair values were then examined to determine any systemic bias in the work relative value units assigned between the procedures. Mean differences and 95% confidence intervals were used to determine any differences in procedure or physician time values. The methodology used considered global period, intraservice time, total time, hospital days, postoperative office visits, and the date of the committee review. Of the 10 directly analogous code pairs reviewed, 7 of the female procedures had higher work relative value unit differences (range 0.29-6.47), and 3 of the male procedures had higher work relative value unit differences (range 1.23-2.34). There was no statistical difference between the code pair work relative value units. The work relative value unit per minute of intraservice time and total time were not statistically different. In this study, we compared operative procedures performed in women with clinically comparable operative procedures performed in men that had similar surgical approaches, global periods, and valuation methodologies. Overall, no statistical differences in work relative value units were demonstrated.

Abstract PO5-10-10: Disparities in Work RVUs for Breast and Prostate Cancer Operations

Abstract Introduction: In a vast array of different methods used to quantify healthcare processes, the Relative Value Unit (RVUs) has become the federal precedent set by the Centers for Medicare and Medicaid Services (CMS) to assign value to different procedures and processes. The current RVU conversion factor in 2023 is $33.06 per unit. Physician work RVUs, malpractice RVUs (MP RVUs) and practice expense RVUs (PE RVUs) were first implemented in 1992 as a system for assigning payment to physicians while providing administrative budgeting based on clinical and liability expenditures. These values are subject to reevaluation every 5 years at minimum, or as new services become available. The CMS updates it’s RVU model by consulting the American Medical Association’s Specialty Society Relative Value Scale Update Committee (RUC), which controversially sets higher values in certain fields of medicine than others. This article will objectively analyze the RVUs provided by the CMS to surgical oncologists treating breast cancer and compare them to the RVUs compensated to urologists treating prostate cancer, across multiple modalities. Methods: Work RVUs, practice expense RVUs, and malpractice RVUs were obtained from the CMS 2023 physician fee schedule, using the HCPCS codes to identify the services from their database. Estimated pre-evaluation times, intra-procedure times, immediate post service times, and total procedural times were gathered from the CY 2023 Final Rule Physician Work Time database provided by CMS. The HCPCS codes used for mastectomy variations were 19301 for partial mastectomy, 19302 for partial mastectomy with lymph node removal, 19303 for a simple complete mastectomy, 19305 for a radical mastectomy, 19306 for an urban type radical mastectomy, and 19307 for a modified radical mastectomy. The HCPCS codes used for armpit lymph nodes were 38740 and 38745 for axillary lymph node dissections. The HCPCS codes used for prostatectomy variations were 55810 and 55812 for a radical perineal prostatectomy, 55840 and 55845 for a radical retropubic prostatectomy, and 55866 for a laparoscopic retropubic radical prostatectomy. The HCPCS codes used for pelvic lymph nodes were 38571-38573 for laparoscopic lymphadenectomies. Work RVUs were compared between mastectomy and prostatectomy procedures, and axillary node procedures were compared to those of pelvic lymph nodes. To further asses any true disparities in the values assigned to the operations, a second analysis of work RVUs divided by total operation times were compared between their surgical counterparts. Conclusion: Values collected from CMS indicate 59% more RVUs are provided to urologists for prostatectomies than breast surgeons for mastectomies per procedure, and 12% more per hour of total procedure time. Additionally, the CMS indicates on average 29% more work RVUs are provided to urologists for pelvic lymph node removals than breast surgeons for axillary lymph node removals, and 3.4% more per hour of total procedure time (appendix 1). Breast cancer and prostate cancer have similar incidence and mortality rates, but one affects mostly women and the other only men. The decision by the Center of Medicare and Medicaid Services to place a higher value in prostate cancer management is unknown, and elicits future analysis with surveyed procedural data across the nation for statistical significance determination. Appendix 1 allocated work RVUs, practice expense RVUs, malpractice RVUs, and median operative times for prostate cancer and breast cancer operations. Citation Format: Noah Khosrowzadeh, Kyle Chambers, Matthew Gompels, Cyrus Washington, Jessica Meshman. Disparities in Work RVUs for Breast and Prostate Cancer Operations [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-10-10.

Paired Comparison Survey Analysis Utilizing Rasch Methodology of the Relative Difficulty and Estimated Work Relative Value Units of CPT Code 0202T.

In anticipation of Food and Drug Administration (FDA) approval of the Total Posterior Spine (TOPS) system, the International Society for the Advancement of Spine Surgery (ISASS) conducted a study to estimate the work relative value units (RVUs) for facet arthroplasty. The purpose of this study was to establish a valuation of work RVU for Current Procedural Terminology (CPT) Code 0202T in the interim until the Relative Value Scale Update Committee (RUC) can determine an appropriate value. The valuation established from this survey will assist surgeons to establish appropriate procedure reimbursement from third-party payers. A survey was created and sent to 52 surgeons who had experience implanting the TOPS system during the investigational device exemption clinical trial. The survey included a patient vignette, a description of CPT Code 0202T along with a video of the TOPS system, and a confirmation question about the illustration's effectiveness. Respondents were asked to compare the work involved in CPT Code 0202T to 8 lumbar spine procedures. A Rasch analysis was performed to estimate the relative difficulty of CPT 0202T using the work RVUs of the comparable procedures. Forty-one surgeons responded to the survey. Of all the procedures, CPT Code 0202T received the most responses for equal work compared with posterior osteotomy (46%) followed by transforaminal lumbar interbody fusion (41%). The results of the regression analysis indicate a work RVU for CPT 0202T of 39.47. The study found an estimated work RVU of 39.47 for CPT Code 0202T using Rasch analysis. As an alternative to this Rasch methodology, one may consider a crosswalk methodology to the work RVUs for transforaminal lumbar interbody fusion procedurally, not as an alternative code. These recommendations are not a substitute for RUC methodology but serve as a reference for physicians and third-party payers to understand work RVU similarities for charge and payment purposes temporarily until RUC methodology provides accurate RVUs for the procedure.

What Every Colorectal Surgeon Should Know About the American Medical Association/Specialty Society Relative Value Scale Update Committee.

What Every Colorectal Surgeon Should Know About the American Medical Association/Specialty Society Relative Value Scale Update Committee.

Fetal MRI: A Case Study in Valuation and the Role of the AMA Relative Value Scale Update Committee

Fetal MRI: A Case Study in Valuation and the Role of the AMA Relative Value Scale Update Committee

The NP's role in increasing RVU values.

The NP's role in increasing RVU values.

Determination of Work Related to Endoscopic Decompression of Lumbar Spinal Stenosis.

Background: Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT®) code 62380. However, no work relative value units (wRVUs) are currently assigned to the procedure. A physician's payment needs to be updated to commensurate with the work involved in the modern version of the lumbar endoscopic decompression procedure with and without the use of any implants to stabilize the spine. In the United States, the American Medical Association (AMA) and its Specialty Society Relative Value Scale Update Committee (RUC) proposes to the Centers for Medicare and Medicaid Services (CMS) what wRVUs to assign for any endoscopic lumbar surgery codes. Methods: The authors conducted an independent survey between May and June 2022 which reached 210 spine surgeons using the TypeForm survey platform. The survey link was sent to them via email and social media. Surgeons were asked to assess the endoscopic procedure's technical and physical effort, risk, and overall intensity without focusing just on the time required to perform the surgery. Respondents were asked to compare the work involved in modern comprehensive endoscopic spine care with other commonly performed lumbar surgeries. For this purpose, respondents were provided with the verbatim descriptions of 12 other existing comparator CPT® codes and associated wRVUs of common spine surgeries, as well as a typical patient vignette describing an endoscopic lumbar decompression surgery scenario. Respondents were then asked to select the comparator CPT® code most reflective of the technical and physical effort, risk, intensity, and time spent on patient care during the pre-operative, peri- and intra-operative, and post-operative periods of a lumbar endoscopic surgery. Results: Of the 30 spine surgeons who completed the survey, 85.8%, 46.6%, and 14.3% valued the appropriate wRVU for the lumbar endoscopic decompression to be over 13, over 15, and over 20, respectively. Most surgeons (78.5%; <50th percentile) did not think they were adequately compensated. Regarding facility reimbursement, 77.3% of surgeons reported that their healthcare facility struggled to cover the cost with the received compensation. The majority (46.5%) said their facility received less than USD 2000, while another 10.7% reported less than USD 1500 and 17.9% reported less than USD 1000. The professional fee received by surgeons was <USD 1000 for 21.4%, <USD 2000 for 17.9%, and <USD 1500 for 10.7%, resulting in a fee less than USD 2000 for 50% of responding surgeons. Most responding surgeons (92.6%) recommended an endoscopic instrumentation carveout to pay for the added cost of the innovation. Discussion and Conclusions: The survey results indicate that most surgeons associate CPT® 62380 with the complexity and intensity of a laminectomy and interbody fusion preparation, considering the work in the epidural space using the contemporary outside-in and interlaminar technique and the work inside the interspace using the inside-out technique. Modern endoscopic spine surgery goes beyond the scope of a simple soft-tissue discectomy. The current iterations of the procedure must be considered to avoid undervaluing its complexity and intensity. Additional undervalued payment scenarios could be created if technological advances continue to replace traditional lumbar spinal fusion protocols with less burdensome, yet no less complex, endoscopic surgeries that necessitate a high surgeon effort in terms of time required to perform the operation and its intensity. These undervalued payment scenarios of physician practices, as well as the facility and malpractice expenses, should be further discussed to arrive at updated CPT® codes reflective of modern comprehensive endoscopic spine care.

Heart Rhythm Society's survey assessing the impact of reductions in Medicare reimbursement for cardiac ablation in the United States.

Following its regularly scheduled reassessment of reimbursement schedules, in 2021 the US Centers for Medicare and Medicaid Services (CMS) proposed reductions in reimbursement for commonly performed electrophysiology ablation procedures, including ablation procedures for atrial fibrillation and supraventricular tachycardia.1 Although modest reductions had been expected on the basis of gains in efficiency over time, the proposed cuts were drastic. During and after the public commentary period, there was strong objection from the Heart Rhythm Society (HRS), American College of Cardiology, American Medical Association’s Resource-Based Relative Value Scale Update Committee, other physician groups, and hundreds of patients, but CMS enacted these reductions on January 1, 2022.

Top Policy Issues: A Powerful, Passionate Journey

Top Policy Issues: A Powerful, Passionate Journey

Time-Driven Activity-Based Costing in Preoperative Tasks for Total Hip and Knee Arthroplasty.

Substantial work in the preoperative phase of total hip arthroplasty (THA) and total knee arthroplasty (TKA) is unaccounted for in current Relative Value Scale Update Committee methodology. A Time-Driven Activity-Based Costing (TDABC) analysis allows for an accurate assessment of the preoperative costs associated with total joint replacement surgery. The mean time that clinical staff members spent on preoperative tasks per patient was multiplied by the hourly salary. Clinical staff members included orthopedic surgeons, nurse practitioners or physician assistants, nurses, medical assistants, and surgical coordinators. Mean time spent on preoperative tasks was obtained from the most recent literature. Salaries were obtained from the nationwide database provided by Glassdoor Inc. Total time spent among clinical staff involved in preoperative tasks for each arthroplasty patient was 8.45hours (2.96-13.94). Total TDABC was calculated to be $348.17 (132.46-562.64). Accounting for preoperative tasks, the TDABC for TKA/THA increases from $13321.5 to $13669.67. Preoperative tasks are composed of 2.6% of total TKA/THA TDABC. In 2020, an estimated $544,189,710 of preoperative TKA/THA work was completed. Surgeons, providers, and ancillary staff involved in THA/TKA spend a cumulative preoperative work time of approximately 8.5hours per patient, which equates to $348.17 that is currently unaccounted for in Relative Value Scale Update Committee methodology.

Variation in Estimated Surgical Procedure Times Across Patient Characteristics and Surgeon Specialty

The time involved in performing a procedure is a key factor in determining physician payments by Medicare. However, there are long-standing concerns regarding the accuracy of the time estimates generated by the American Medical Association/Specialty Society Relative Value Scale Update Committee surveys that are used in the valuation process, and there have been calls to use other data sources to estimate procedure times. To compare estimated procedure times that come from claims with the times used in Medicare's valuation process. Building off prior work using Medicare fee-for-service claims, procedure times were estimated from linked anesthesia claims data for 1349 different Current Procedure Terminology codes that are typically performed with anesthesia. All procedures in the nation performed in 2018 for Medicare fee-for-service beneficiaries were included in the analysis. These estimated times were compared with the times used in the valuation process. Analysis took place from February to November 2021. Estimated procedure times using anesthesia claims were compared with the procedure time used in valuation by calculating an estimated-to-valuation procedure time ratio for each code. The valuation procedure time is publicly reported by Medicare. The mean and median ratio are presented over all procedures and for select high-volume codes as well as by patient characteristics (age, sex, and risk score) and specialty of the physician performing the procedure. Across 4.9 million procedures in this analysis, the mean estimated procedure time was 27% lower than the time used in the valuation process. There were notable exceptions, for which the mean estimated procedure time equaled or exceeded the valuation time including total hip arthroplasty (5% longer) and total knee arthroplasty (equal duration). Within a given code, older patients and those with more illness had longer procedure times. There was substantial variation across specialties in the percent difference between mean estimated and valuation procedure times ranging from gastroenterology (36% shorter) and ophthalmology (35% shorter) to cardiac surgery (2% longer) and thoracic surgery (7% longer). Claims-based procedure times could be used to improve the accuracy of valuations for procedures.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Hip and Knee Arthroplasty Alternative Payment Model Successes and Challenges.

Procedures With Longer Intraoperative Times Undervalue Surgeon Work in Total Joint Arthroplasty: A Large, Nationwide Database Study.

Work relative value units (wRVUs) measure a surgeon's time and intensity required to perform the pre-service, intra-service, and post-service work of a surgical procedure and are commonly used to compare a physician's work between different procedures. Previous literature across multiple specialties report that longer, often revision, operations are undervalued when compared to primary procedures. Our study aims to analyze the differences in intra-operative time, and its corresponding wRVU/h between the Medicare benchmarks and real-world time-stamped data for total joint arthroplasty procedures. Thirteen primary and revision hip and knee arthroplasty procedures were identified, and intra-operative times were collected using the National Surgical Quality Improvement Program databases from 2014 to 2019. The Relative Value Scale Update Committee's (RUC) estimated median intra-operative times for each procedure was compared to the calculated median intra-operative times from National Surgical Quality Improvement Program, as were their corresponding wRVU/h. Procedures were additionally stratified by "long" (>110minutes) and "short" (≤110minutes) intra-operative times. The RUC over-estimated intra-operative time by 35.24% on average and this overestimation was more profound in longer operations than shorter operations (47.75% vs 15.22%, P= .011). The RUC intensity per unit time values (wRVU/h) between "long" and "short" procedures were significantly different (P<.001) and showed the undervaluation of intensity for the longer procedures by an average of 3.47 wRVU/h. Our study provides further evidence that physician work is undervalued in revision total hip and knee surgeries.

Perioperative work in shoulder arthroplasty is undervalued by Relative Value Scale Update Committee methodology: quantifying shoulder arthroplasty workload in a single surgeon’s practice

BackgroundThe Center for Medicare and Medicaid Services (CMS) quantifies the total work associated with procedures based on recommendations from the Relative Value Scale Update Committee (RUC). To determine the amount of work for a procedure, the RUC relies on data gathered via surveys from practicing physicians. Investigation of the accuracy of the RUC’s estimates of physician work has shown that there are discrepancies between the RUC times used to calculate work and times determined objectively. The purpose of this study was to determine the accuracy of the RUC and CMS’s current times and work relative value units (wRVUs) for the perioperative work involved regarding shoulder arthroplasty. MethodsThe RUC was contacted to obtain a list of perioperative tasks for shoulder arthroplasty surgeries. The tasks that occurred outside of the operating room were timed as the event occurred, whereas times for tasks performed inside the operating room were determined from the electronic medical record. Each task’s time was then multiplied by its respective CMS-assigned intensity coefficient to calculate the wRVU. ResultsThe tasks timed in this study were allotted 105 minutes by the RUC and a total wRVU of 2.1. Our study found that these same tasks took 119.5 minutes and had a total wRVU of 2.4. The overall time it takes to perform perioperative tasks in shoulder arthroplasty surgeries is underestimated by 14.5 minutes, resulting in an undervaluation of the wRVU by 0.3. ConclusionThe perioperative work associated with shoulder arthroplasty surgeries is underestimated by the RUC and CMS’s. The RUC and CMS should consider using prospective, empiric times when calculating physician work as it is a more accurate measurement than the current method used. This discrepancy is expected to be amplified with increased preoperative templating and utilization of technological advancements in arthroplasty. Further study is needed on a broader national or international level to determine if this discrepancy exists systemically.

Decreasing physician Medicare reimbursement for dermatology services

Decreasing physician Medicare reimbursement for dermatology services

Determination of Work Relative Value Units for Management of Lumbar Spinal Stenosis by Open Decompression and Interlaminar Stabilization.

Effective January 1, 2017, open surgical decompression and interlaminar stabilization (ILS) received a Category I Current Procedural Terminology (CPT®) code 22867. The current work relative value units (wRVUs) assigned to the procedure of 13.5 are not reflective of the amount of work involved. During the survey process, CPT® 22867 was erroneously assessed with a percutaneous "sister" code (CPT® 22869), which is performed with no decompression (but within the same new "family") and primarily by nonsurgeons. However, similar CPT® code descriptors assigned to each of these new codes undermined their procedural differences during the survey process and generated confusion among physician survey responders, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), and ultimately the Centers for Medicare and Medicaid Services (CMS) regarding the value of ILS. The resulting physician payment determination for the ILS procedure has had severe deleterious effects on this procedure being offered to lumbar spinal stenosis (LSS) patients. Our independent society-driven survey presents new data that assess the accuracy of the assigned wRVUs for CPT® 22867. An independent survey was driven by the International Society for the Advancement of Spine Surgery (ISASS) in November 2018 and sent to 58 US surgeons with experience performing open decompression with ILS (CPT® 22867) and without financial conflicts of interest as analogous to RUC survey financial disclosure requests. Respondents were asked to compare CPT® 22867 with a list of 10 other comparator CPT® codes reflective of common spine surgeries. The survey presented each comparator CPT® code with its code descriptor and corresponding wRVUs alongside the code descriptor for CPT® 22867. A patient vignette was also provided that describes a typical clinical scenario for the surveyed procedure. Respondents were then asked to indicate which comparator CPT® code on the reference list is most similar to the survey code descriptor and typical patient/service vignette provided, as well as specify estimated wRVUs for CPT® 22867 relative to their selected comparator CPT® code. The surgeons' responses were analyzed to determine comparator CPT® codes and estimated wRVUs. Among the 28 surgeons who responded to the survey, both open decompression codes (57.1%) and fusion codes (42.9%) were chosen as most similar to the typical patient/service for CPT® 22867. Furthermore, the laminectomy procedure (CPT® 63047) was chosen as the surveyed surgeons' model response for a reference procedure in terms of similar work intensity and time for CPT® 22867. After calculating the difference between the selected comparator codes and estimated wRVUs, nearly all respondents had a positive calculated difference, indicating that surgeons selected wRVUs lower than they deemed appropriate as a result of the listed CPT® codes they were required to use. In the spirit of the Rasch analysis, the regression analysis estimated wRVUs for CPT® 22867 that are greater than its assigned wRVUs (13.5) and its most comparable procedure (CPT® 63047; reference wRVUs: 15.37). The survey results indicate that the wRVUs assigned to CPT® 22867 are significantly undervalued at 13.50 and have directly resulted in the underreimbursement for surgeons performing the ILS procedure. This misvaluation of the code has created a supply-and-demand anomaly in which the rate of ILS procedures has flatlined despite increasing rates of fusion procedures and an increasing older population. This anomaly is a cause of concern for policy makers and the health care community for the future of safeguarding patient welfare and procedural innovation. Therefore, understanding the clinical economic impact and appropriately addressing potential misvalued codes, such as the ILS procedure, are critical to protecting the future of patient care.

Some Insurers Working to Encourage Psychiatrists to Join Their Networks

Some Insurers Working to Encourage Psychiatrists to Join Their Networks

Substantial Preoperative Work Is Unaccounted for in Total Hip and Knee Arthroplasty

BackgroundThe Centers for Medicare and Medicaid Services has recently designated the codes for total hip and knee arthroplasty as misvalued and has asked the Relative Value Scale Update Committee (RUC) to review the work required to perform these procedures. Although other studies have reported time spent on perioperative and postoperative care, time spent on coordinating and performing preoperative care is not included in current RUC methodology and has yet to be addressed in literature. MethodsWe prospectively tracked a consecutive series of 438 primary total hip arthroplasty and total knee arthroplasty patients by one of the 5 surgeons over a 3-month period. Each clinical staff member tracked the amount of time to perform each preoperative care task from the last clinic visit until day of surgery. Data were analyzed separately between providers and ancillary medical staff. ResultsAlthough the current RUC review includes 40 minutes of preservice time on the day of surgery, surgeons spent an average of an additional 43.2 minutes while physician assistants and nurse practitioners spent an additional 97.9 minutes per patient on preoperative care prior to that time. Ancillary medical staff spent a mean of 110.2 minutes per patient. The most common tasks include preoperative phone calls, templating and surgical planning, and preoperative patient education classes. ConclusionSurgeons and advanced practice providers spend nearly 2 hours per arthroplasty patient on preoperative care not accounted for in current RUC methodology. As readmissions, hospital stay, and complication rates continue to decline, Centers for Medicare and Medicaid Services should consider the substantial work required during the preoperative phase to allow for these improved outcomes.

4:03 PM Abstract No. 124 Stop the bleeding: What interventional radiologists need to know about the Medicare physician fee schedule cut

Health care reimbursement occurs through private insurance or government programs such as Medicare and Medicaid (CMS). We evaluate the models of physician payments and discuss current policies affecting interventional radiology (IR) practices. We evaluated CMS Physician Fee Schedule (PFS) proposed rules for 2020-2021. CMS accepted the American Medical Association (AMA) procedural terminology (CPT) codes and AMA Relative Value Scale Update Committee recommendations. The terms included re-direction and increased reimbursement for primary care and nonprocedural specialties, while negatively impacting procedure-based specialties. IR outpatient clinic data was collected from Jan to Sept 2019 and used to estimate the economic impact of the proposed changes to health policy rules were to be implemented. Following implementation of the CMS 2020 ruling, IR PFS rates will decrease by 4% for bone biopsy, lumbar spine puncture, abdominal aortography, angiography, and duplex ultrasound. In addition, proposed changes to E/M code payment are predicted to result in additional 2% cuts, with an overall 6% reduction in Medicare payments by 2021. Total allowable Medicare charges for IR are $432,000,000, therefore, this reduction may equate to approximately $26,000,000 lost reimbursement. In our institution’s outpatient IR practice with 1,559 clinic visits over nine months and $251,964 in billings (mean, $162 per visit), this estimates to potential payment reductions of $20,000 per year or $10 per visit in E/M reimbursement only. This reduction can be compounded by ineffective E/M documentation. Advocacy efforts to mitigate this reduction include communication with legislators through Comment Letters to CMS and Grassroots Programs, as well as educational resources for IR physicians to optimize documentation. The proposed 2020-2021 Physician Fee Schedule rate reduction is predicted to decrease reimbursement for IR services by at least 6%. Support of SIR Advocacy efforts is needed to mitigate the undervaluing of IR services.

Pathway to endosurgery and third-space endoscopy reimbursement: understanding the past to get payment in the future

By the 1960s the proliferation of physician services after decades of accelerating innovation required development of a common language to describe medical services for modern health care.1 The American Medical Association (AMA) in partnership with medical specialties developed Current Procedural Terminology (CPT) to specify nomenclature describing physician procedures and services to facilitate documentation and third-party billing. In 1991 the Relative Value Scale Update Committee (RUC) was established to develop a standard method to advise the Centers for Medicare & Medicaid (CMS), which sets service payments for physician services within the Resource-Based Relative Value Scale (RBRVS).