Resource-based Relative Value Scale Research Articles

A Review of Learner Impact on Faculty Productivity

A Review of Learner Impact on Faculty Productivity

New AAP Policy Statement: “Application of the Resource-Based Relative Value Scale System to Pediatrics”

The newly published AAP policy dealing with RBRVS is reviewed and explained.

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.

Development of a Resource-Based Relative Value Scale and Fee of Advanced Nursing Practices by Nurse Anesthetists in South Korea

Purpose: This study was aimed to develop fee and a resource-based relative value scale (RBRVS) advanced nursing practices done by nurse anesthetists under the national health insurance. Methods: The classification of practices in Nurse Anesthetists was performed by clinical panel and then the RBRVS of nurse anesthetists for 16 advanced nursing practices was calculated by magnitude estimation method, based on their workload and working time survey in the context of the national health insurance. A cost analysis including direct labor cost and indirect cost for advanced nursing practice was performed to estimate the conversion factor (unit price) for the RBRVS of nurse anesthetists. The share of nurse anesthetists’ contribution to the feefor-service was also analyzed. Results: Calculation of the RBRVS for the 16 advanced nursing practices showed a range of points from 100 to 305.2 with an average of 175.3 points. The relevant conversion factor for advanced nursing practices of nurse anesthetists was estimated at 14.9∼19.4 Korean won. The nursing fee for 16 advanced nursing practice was calculated by multiplying the RBRVS of the each practice and the conversion factor. The contribution rate for advanced nursing practices of nurse anesthetists using the relative value scale of the national health insurance was estimated at 9.3%∼100.0% (indirect cost 10%) with the rate varying widely. Conclusion: In order to address the shortage of anesthetic staffs, the employment of nurses specializing in anesthesia is thought to bring the national interests. In addition, we believe the Nurse Anesthetist system is an effective way to prevent a shortage of anesthetic care providers in South Korea.

How Radiologists Get Paid: Resource-Based Relative Value Scale and the Revenue Cycle

To learn the impact of health care reform, it is important for radiologists to first understand basic administrative aspects of medicine. This article describes the processes of radiology billing, reimbursement, and the revenue cycle, which includes the importance of proper coding, the resource-based relative value scale, and accounts receivable. An understanding of the basics of medical practice management can help radiologists effectively provide optimal patient care. This article provides an overview of one component of this topic--the current radiology reimbursement system.

Medicare Reform and Primary Care Concerns for Future Physicians

The widening income gap between specialists and primary care physicians (PCPs) has spurred many physician associations to reform the current Resource-Based Relative Value Scale fee schedule and sustainable growth rate expenditure target system. Hoping to better represent primary care, the American Association of Family Physicians formed a task force in 2011 to suggest supplements to the Relative Value Update Committee's procedural code recommendations to the Centers for Medicare and Medicaid Services. In addition, the predicted shortage of PCPs has caused many medical schools to increase class sizes; the scarcity of PCPs has also spurred the founding of new medical schools. Such measures, however, have not been met with more residency program sites or graduate medical education funding. The present article highlights major Medicare reform strategies and explores several issues affecting the field of primary care, including reimbursement, representation, and residency training.

The Undervaluation of Evaluation and Management Professional Services: The Lasting Impact of Current Procedural Terminology Code Deficiencies on Physician Payment

The Resource-Based Relative Value Scale (RBRVS) is fundamentally undermined by the following foundational errors: (1) The full range of office-based evaluation and management (E/M) activities are not captured by the Current Procedural Terminology (CPT) code choices, (2) it places relatively high values on procedural services, (3) there is no measure of intensity for complex outpatient E/M care, and (4) its maintenance and update have been delegated to select professional societies. Limitations imposed on the development of the RBRVS dating back to the early 1980s have not been corrected. The repertoire of codes for physician office-based E/M work must be expanded to create a new topology of choices with new outpatient code families with discrete service code levels, such as comprehensive outpatient consultation care, comprehensive outpatient primary care, and limited outpatient consultation care. Service code relative values must be based on representative samples and reliable survey data, draw from the broader literature on work intensity, and be developed with accountable and representative professional engagement.

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.

Assessing the Productivity of Advanced Practice Providers Using a Time and Motion Study

The Resource-Based Relative Value Scale is widely used to measure healthcare provider productivity and to set payment standards. The scale, however, is limited in its assessment of pre- and postservice work and other potentially non-revenue-generating healthcare services, what we have termed service-valued activity (SVA). In an attempt to quantify SVA, we conducted a time and motion study of providers to assess their productivity in inpatient and outpatient settings. Using the Standard Time and Motion Procedures checklist as a methodological guide, we provided personal digital assistants (PDAs) that were prepopulated with 2010 Current Procedural Terminology codes to 19 advanced practice providers (APPs). The APPs were instructed to identify their location and activity each time the PDA randomly alarmed. The providers collected data for 3 to 5 workdays, and those data were separated into revenue-generating services (RGSs) and SVAs. Multiple inpatient and outpatient departments were assessed. The inpatient APPs spent 61.6 percent of their time on RGSs and 35.1 percent on SVAs. Providers in the outpatient settings spent 59.0 percent of their time on RGSs and 38.2 percent on SVAs. This time and motion study demonstrated an innovative method and tool for the quantification and analysis of time spent on revenue- and non-revenue-generating services provided by healthcare professionals. The new information derived from this study can be used to accurately document productivity, determine clinical practice patterns, and improve deployment strategies of healthcare providers.

Professional Efficiencies for Diagnostic Imaging Services Rendered by Different Physicians: Analysis of Recent Medicare Multiple Procedure Payment Reduction Policy

The aim of this study was to quantify potential physician work efficiencies and appropriate multiple procedure payment reductions for different same-session diagnostic imaging studies interpreted by different physicians in the same group practice. Medicare Resource-Based Relative Value Scale data were analyzed to determine the relative contributions of various preservice, intraservice, and postservice physician diagnostic imaging work activities. An expert panel quantified potential duplications in professional work activities when separate examinations were performed during the same session by different physicians within the same group practice. Maximum potential work duplications for various imaging modalities were calculated and compared with those used as the basis of CMS payment policy. No potential intraservice work duplication was identified when different examination interpretations were rendered by different physicians in the same group practice. When multiple interpretations within the same modality were rendered by different physicians, maximum potential duplicated preservice and postservice activities ranged from 5% (radiography, fluoroscopy, and nuclear medicine) to 13.6% (CT). Maximum mean potential duplicated work relative value units ranged from 0.0049 (radiography and fluoroscopy) to 0.0413 (CT). This equates to overall potential total work reductions ranging from 1.39% (nuclear medicine) to 2.73% (CT). Across all modalities, this corresponds to maximum Medicare professional component physician fee reductions of 1.23 ± 0.38% (range, 0.95%-1.87%) for services within the same modality, much less than an order of magnitude smaller than those implemented by CMS. For services from different modalities, potential duplications were too small to quantify. Although potential efficiencies exist in physician preservice and postservice work when same-session, same-modality imaging services are rendered by different physicians in the same group practice, these are relatively minuscule and have been grossly overestimated by current CMS payment policy. Greater transparency and methodologic rigor in government payment policy development are warranted.

What Will the 2012 Presidential Election Mean for Physicians?

In this invited commentary, Gail Wilensky provides her perspective on the impact of the 2012 presidential election on health care. She outlines important differences on how each candidate would exp...

Psychiatrist’s Coding Expertise Benefits All of His Colleagues

Psychiatrist’s Coding Expertise Benefits All of His Colleagues

The Resource-Based Relative Value Scale and Neuroradiology

The Resource-Based Relative Value Scale (RBRVS) has been the defining algorithm for professional reimbursement of medical services since its introduction in 1992. This article reviews the history of the RBRVS, with an emphasis on the integral involvement of the radiology and neuroradiology communities. Appropriate reimbursement of radiology procedures has been chaperoned by physician volunteers and society staff attending Current Procedural Terminology Panel meetings and American Medical Association/Specialty Society RVS Update Committee (RUC) meetings. In recent years, governmental and RUC initiatives have created an unfavorable environment for neuroradiologists to maintain reimbursement levels seen previously.

New Medicare Models of Care and the LTC Physician

New Medicare Models of Care and the LTC Physician

What to Watch For: Summary of the Proposed 2012 Medicare Physician Fee Schedule (Resource-Based Relative Value Scale)

Points of interest in CMS proposed rule for services including reduction in conversion factor, modifier for quality of care as compared to cost, health risk assessment, and telehealth services.

Do market fees differ from relative value scale fees? Examining surgeon payments in New Zealand

Health funders face the challenge of determining the appropriate level of surgeon fees in fee-for-service schemes. A resource-based relative value scale (RBRVS) attempts to identify the fees that would exist in a competitive market. Private insurance providers in New Zealand do not use a RBRVS but rather rely on a market. We explore the extent to which private surgeon fees in New Zealand are consistent with fees that would be generated by a RBRVS. Data on 155,290 surgical procedures from 2004-06 were provided by New Zealand's largest private health insurer. 314 procedure codes were matched to the Australian Ministry of Health and Ageing's RBRVS. A random effects model determined predicted surgeon reimbursements based on the RBRVS, the location and the year. Procedure volume and specialty were explored as potential sources of deviations. The RBRVS, location and year explain 79% of the variation in surgeon fees. After accounting for the RBRVS, location and year, no statistical differences were found between five out of the seven specialties, but higher volume procedures were associated with lower fees. There was some evidence that the model explained less variation in lower volume procedures. Surgical fees were generally consistent with those predicted by the RBRVS. However, the fees for high volume procedures were relatively lower than predicted while the fees for low volume procedures appeared more variable. The findings are consistent with the hypothesis that market forces lowered prices for procedures with higher volumes. This has implications for how health funders might determine private surgical fees, especially in mixed public-private systems.

2012 Revisions to Medicare Fee Schedule Proposed

2012 Revisions to Medicare Fee Schedule Proposed

MTM services within community health centers

INTRODUCTION Pharmacists are well-trained, yet often underutilized within the primary care delivery system to identify, resolve, monitor and prevent medication-related problems (MRPs). Medication therapy management (MTM) is a term which describes a broad range of services that are provided by pharmacists to optimize individual patients’ therapeutic outcomes. The MTM care process includes conducting a comprehensive patient medication assessment to identify appropriateness of drug therapy, developing and documenting a care plan to achieve patient-specific goals of therapy and performing followup evaluation to resolve drug therapy problems. When structured to allow patients, pharmacists, physicians, and other caregivers to coordinate efforts toward achieving drug therapy treatment goals, MTM services can improve clinical outcomes, improve patient medication adherence, enhance medication safety, and stabilize or reduce health expenditures. In the state of Connecticut, a network of pharmacists provides diverse clinical services in various healthcare settings. Recently, this network provided MTM services within community health centers across the state; the network and process of MTM implemented is described here.

Professional Component Payment Reductions for Diagnostic Imaging Examinations When More Than One Service Is Rendered by the Same Provider in the Same Session: An Analysis of Relevant Payment Policy

The aim of this study was to assess potential physician work efficiencies when more than one diagnostic imaging study is interpreted by the same provider during the same session. Medicare Physician Fee Schedule data from the American Medical Association Resource-Based Relative Value Scale Data Manager for 2011 were analyzed to quantify relative contributions of preservice, intraservice, and postservice physician work to the total work of rendering diagnostic imaging services. An expert panel review identified potential duplications in preservice and postservice work when multiple examinations are performed on the same patient during the same session. Maximum potential percentage work duplication for various diagnostic imaging modalities was calculated and compared to US Government Accountability Office estimates. The relative contributions of preservice and postservice work to total work varied by modality, ranging from 20% [computed tomography (CT)] to 33% (ultrasound). The maximum percentage of potentially duplicated preservice and postservice activity ranged from 19% (nuclear medicine) to 24% (ultrasound). Maximum mean potentially duplicated work relative value units ranged from 0.0212 for radiography to 0.0953 for magnetic resonance imaging (MRI). Maximum percentage work reduction ranged from 4.32% for CT to 8.15% for ultrasound. This corresponds to maximum professional Physician Fee Schedule reductions of only 2.96% (CT) to 5.45% (ultrasound), approximating an order of magnitude less than the Government Accountability Office's recommendations. Although potential efficiencies in physician work occur when multiple services are provided to the same patient during the same session, these are highly variable and considerably less than previously estimated.

Revised Handbook Guides Psychiatrists Through CPT Coding Thicket

Back to table of contents Previous article Next article Professional NewsFull AccessRevised Handbook Guides Psychiatrists Through CPT Coding ThicketMark MoranMark MoranSearch for more papers by this authorPublished Online:17 Jun 2011https://doi.org/10.1176/pn.46.12.psychnews_46_12_17_2AbstractThe fourth edition of a handbook for psychiatrists on how to use CPT codes has been published by American Psychiatric Publishing Inc. (APPI). Procedure Coding: Handbook for Psychiatrists, Fourth Edition, was written by psychiatrist Chester Schmidt Jr., M.D., a consultant to the APA Committee on RBRVS, Codes, and Reimbursement, and two staff members of APA's Office of Healthcare Systems and Financing—Rebecca Yowell and Ellen Jaffe. (Previous editions of the book were titled CPT Handbook for Psychiatrists.)Schmidt told Psychiatric News that the new edition updates material from the previous editions and adds several new features, including more detailed information, along with case examples, of how psychiatrists can use the evaluation and management (E&M) codes. The book provides templates that show how to document the level of services provided during an initial psychiatric evaluation and to determine the appropriate E&M code to use. (E&M coding is based on level-of-service criteria established by the AMA and the federal Centers for Medicare and Medicaid Services.) A new chapter provides clinical vignettes for different kinds of service sites, with suggestions for how the vignettes can be coded. It also includes a section on frequently asked questions, derived from queries received by APA's Managed Care Help Line. "These are not complicated concepts, but they are detailed," Schmidt said. "We have tried to present a lot of detailed information in a user-friendly way. That's been a trend in all of the editions of the handbook—to continually go back and work on clarifying the language." "The handbook is a great resource for APA members, particularly younger members who are just starting practice," said Carol Bernstein, M.D., immediate past president of APA and a psychiatric educator. "Correct coding reflects the work you do caring for your patients and ensures that you are reimbursed appropriately. Some physicians tend to down code out of fear, depriving themselves of proper reimbursement." The genesis of the handbook was in the late 1980s and early 1990s, when the AMA substantially revised the CPT manual and the federal government adopted the Resource-Based Relative Value Scale for paying physicians in the Medicare program. "Those two events really required significant education for all physicians about how to deal with the new codes and to come to grips with the new model for reimbursement," Schmidt said. "APA recognized that there was a real need for something to educate the practicing psychiatrist on how to best use these codes, and to learn how payers manage the codes and process them in a way that eventually leads to reimbursement," he said. Schmidt said real fraudulence, though not unheard of, is rare. More often clinicians, lacking information, use poor or inadequate documentation that leads to trouble. "There is a lot of deficiency in the way psychiatrists document their services, especially among solo private practice psychiatrists," he said. "Notes can be really sketchy and sometimes clinicians have difficulty defending their charges when audited. So far as the federal government is concerned, if it wasn't written down, it didn't happen." But Schmidt said psychiatrists who read and assimilate the handbook's advice will be safe. "If you read this and use the information in it, you are going to be compliant with the documentation requirements of CMS and other payers," he said. Procedure Coding: Handbook for Psychiatrists, Fourth Edition can be purchased from APPI at <http://appi.org/SearchCenter/Pages/default.aspx?k=Procedurecoding>. Discounted prices are available for APA members and members-in-training. ISSUES NewArchived