Posts tagged with rbrvs

[Note: Since this post, there are have been major changes to the RVUs. Check more recent posts in this blog, like this one.  You may also want to go directly to PCC's on-line RVU tools.]

First, a sincere thank you to Linda Walsh at the AAP for this update. Linda is like a sharp dagger who cuts through all of the baloney for me when I get confused about some CPT or RVU issue. She must get a dozen questions (or more) a day from AAP folks and always answers them quickly, graciously, and - most importantly - correctly. And she even responds that way to me!

So...race to the URLs below to see the latest information from the AAP about 2008 RVUs, etc.:

• http://www.aap.org/visit/coding.htm
  (AAP public site)
• http://www.aap.org/moc/reimburse/codingrbrvsresources.htm
  (AAP Member Center)
• http://www.aap.org/visit/rbrvsbrochure.pdf
  (direct link to RBRVS Brochure)
• http://www.aap.org/visit/RBRVSConversionSpreadsheet.xls
  (direct link to RBRVS Conversion Spreadsheet)

Here's the most important section from the brochure:

2008 Medicare Conversion Factor = $34.0682 (Note that this is an 11% reduction!)
Additional components of the Medicare RBRVS physician fee schedule factored into the payment structure include the following:

MEI: The allocation of RVUs to pools for physician work, practice expense, and professional liability insurance, have been revised to correspond with the Medicare Economic Index. Work is now allocated 52% of the total RVUs, practice expense is 44%, and professional liability insurance is 4%.

HPSA: Incentive payments for physician services provided to patients in Health Professional Shortage Areas (HPSAs), which are medically underserved communities, urban and rural locations that have a documented shortage of medical professionals.

Non-Par Physician: Reduced payments for physicians, called “non-participating” physicians, who do not accept “assignment,” the Medicare approved amount that consists of the 80% Medicare payment and the 20% patient co-payment, as payment in full for services rendered to Medicare recipients.

Budget Neutrality: Statutory guidelines indicate that revisions to the RVUs for physician services may not alter physician expenditures within the Medicare RBRVS physician fee schedule by more than $20 million from the principal expenditures that would have resulted if the RVU adjustments were never initiated. CMS normally maintains Medicare budget neutrality exclusively via annual adjustments to the Medicare Conversion Factor. However, in 2008 the Medicare program will additionally apply a separate budget neutrality adjustment factor to the physician work RVUs to ensure Medicare budget neutrality in light of work RVU increases tied to the 2005 Five-Year Review.

First, I have to be clear: my knowledge of the arcane RBRVS system, the RUC committees, CMS, etc., is all driven by my work for pediatricians. Thus, I have a very skewed view of how it works. Almost all of the changes to the CMS budget affect my clients indirectly and I have very little understanding of the big picture/politics of it all. Often, when I read through the RVU content, I gloss over big sections of important-looking information because it doesn't seem to apply to pediatrics. I don't know why I'm offering this caveat today, perhaps it's the GI bug I picked up from my kids speaking.

Anyway, the interesting news.

• There is language on the table to remove the scheduled 10.1% reduction and replace it with a .5% increase. However, there may be a related relationship to an expansion of the physician quality reporting system. No idea yet.
• There will be an extension of the 1.0 floor to the work geographic adjustment (the effects of the loss of which were heroically outlined par moi).
• Both of these changes last only until June, 2008, at which point the original proposals will be enacted. I think. We don't know, yet.

You can seem some other reactions to this news in obvious places, such as the WSJ. One thing I find interesting is that it looks like the language to make the changes above may be knowingly vetoed by GWB, but there are enough votes to override the veto. [This is a good example of what I talked about above.]

As the world turns!

I am feeling a little like the Winooski River, when it freezes over and then dams up, causing the water to overflow the banks and wreak havoc locally.

Whew.  They are up.  Want to know what the RVU values for the top 30 codes in pediatrics will be in 2008? Want to check any code?  I finished the Build-Your-Own RVU Calculator for 2008 and the Online Pediatric RVU Calculator for 2008.  Please check my work.

Get your letter writing implements out, spread the word, tell everyone you know.

Really. I can't over-dramatize this issue.

I reported the expected pediatric-focused changes to the 2009 RVUs two weeks ago and pointed out how CMS is not planning to add the appropriate value to the PE elements of immunization administration. IIRC - and of course, I do, because I went back and checked - I called this pathetic. Now the AAP agrees, but they are far more mature and constructive in their language.

Here is copy from a draft letter that the AAP plans to send to CMS before the 08/29/08 comment deadline. I have been asked to share this with as many practicing physicians as I can and encourage you to send your comments to CMS in an effort to get them to recognize the significant and growing cost of providing immunizations in this country. You are welcome to use and adopt the points made below.

From the letter, which is not official nor approved by the AAP, yet:

Immunization Administration: Practice Expense Inputs

In February 2008, the RUC Practice Expense (PE) Subcommittee approved the movement of some of the indirect PE into the pool of direct PE inputs for the immunization administration (IA) codes. During that meeting, the RUC approved moving the following, additional PE inputs into the existing pool of direct PE inputs for the IA codes:

For the "initial" codes (90465, 90467, 90471, 90473):

• 4 minutes RN/LPN/MA ($0.37 per minute) for:

  • Vaccine registry input

  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]

  • Refrigerator/freezer alarm monitoring/documentation

• 17 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]

• 17 minutes for refrigerator/freezer vaccine temperature monitor/alarm

For the "each additional" codes (90466, 90468, 90472, 90474):

• 1 minute RN/LPN/MA ($0.37 per minute) for:

  • Vaccine registry input

  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]

  • Refrigerator/freezer alarm monitoring/documentation

• 8 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]

• 8 minutes for refrigerator/freezer vaccine temperature monitor/alarm

In the 2009 RBRVS proposed rule, however, CMS states,"...we are in agreement with the RUC (PE) recommendations...except for inclusion of the clinical staff time related to quality activities for the following immunization administration codes: CPT codes 90465-90474. While we allow this time for mammography services due to the specific regulatory requirements required by the Mammography Quality Standards Act (MQSA) of 1992, such MQSA time is not required for immunization services."

This means that CMS is proposing to exclude the clinical staff times (as listed above) when calculating the 2009 PE RVUs for the IA codes. The Academy strongly urges CMS to reconsider this decision for the following reasons:

1) During the course of RUC deliberations, it was noted that in August 2003, the Practice Expense Advisory Committee refined code 77057 (screening mammography, bilateral (2-view film study of each breast), allotting clinical staff time for "quality services" based on MQSA regulatory requirements. This, however, was not the basis of the RUC's recommendations with regard to IA. It was simply recognition of a precedent for moving practice expenses previously designated as "indirect" into the pool of direct PE inputs.

2) While MQSA does not apply to the provision of vaccines, there are several federal/state programs that require quality assessment for the following immunization services

• • Vaccine registry input

    • Thirty states have laws authorizing a vaccine registry. Of those 30 states, 14 mandate reporting (Source: Unpublished data, Immunization Information Systems Support Branch, Immunization Services Division, Centers for Disease Control and Prevention)

    • One of the objectives of Healthy People 2010 is to increase to 95 percent the proportion of children younger than 6 years of age who are enrolled in fully operational, population-based immunization registries (http://www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm)

• • Refrigerator/freezer temperature log monitoring/documentation and refrigerator/freezer alarm monitoring/documentation

    • The Vaccines For Children (VFC) program requires providers to participate in an annual Assessment, Feedback, Incentives, and eXchange (AFIX) program, where clinical staff visit offices to conduct quality checks, including vaccine temperature monitoring (http://www.cdc.gov/vaccines/programs/afix/default.htm)

    • The Centers for Disease Control and Prevention has "Recommendations and Guidelines for Vaccine Storage and Handling" (http://www.immunize.org/catg.d/p3035chk.pdf), which include the following:

      • A designated person in charge of the handling and storage of vaccines

      • A back-up person in charge of the handling and storage of vaccines

      • A vaccine inventory log

      • Maintenance of a refrigerator temperature between 35-46°F

      • Maintenance of a freezer temperature of +5°F or colder

      • A posted temperature log on the refrigerator door where the refrigerator and freezer temperatures are recorded twice a day, as well as notation as whom to call if either temperature goes out of range

      • A contingency plan in the event of refrigerator/freezer failure

The aforementioned federal/state requirements and guidelines provide compelling evidence for the RUC-recommended clinical staff times for "quality activities" to be included in the 2009 PE RVUs for the immunization administration codes.

All letters must be sent to:

Acting Administrator Kerry Weems

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Room 443-G

Hubert H. Humphrey Building

200 Independence Avenue, SW

Washington, DC 20201

Re:Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; Proposed Rule; CMS- 1403-P

Those of you who have had to pay for immunization registry interfaces (not our clients, but the rest of you), those of you who - as outlined nicely above - are dealing with fridge management (and I know three practices, personally, who have had this process fail spectacularly leading to $thousands$ lost), or are simply paying to double-enter your registry data should feel obligated to write to Acting Administrator Weems and give CMS an understanding of your daily chores.

Wow, that was long-winded. Sorry. Just send a letter! The deadline for commentary is August 29.

Thanks to my new bf at the AAP (to whom I am significantly indebted), here is a copy of the AAP's response to the proposed RVU changes for 2009. I wrote about this a few weeks ago and would like to remind you all that you have one more day to get your comments in about the immunization admin disappointment. Copy the language in my previous post or here, it doesn't matter. Just get that letter in - pediatrics will continue to get the short end of the stick until we all stand up to be heard. I received some excellent examples of letters our clients sent...keep up the good work.

Some good data coming shortly about overdue physicals.

Wow, some shockers.  Anyone here live in Alaska?

Just like last year, I’ve gone through the entire GPCI catalog and have calculated the impact of the geographical adjustment changes for RBRVS in 2009.  While folks focus 99% of the attention on the impact of individual codes or the new annual multiplier, not enough attention is paid to the GPCI impacts.  For some of you, the impact is greater than any change.

Some highlights from the table below:

• Whoa, Alaska!  What has happened there that has called for a 22% increase in Medicare rates?
• OK, New Orleans I understand.  They probably have a problem with doc volume right now and will for a bit.  But why is Ventura, CA enjoying a 3.7% increase over the last two years while Santa Clara, SF, Oakland, etc., are getting killed?  Why is LA “doing well?”
• I’m sure it’s out there somewhere, but does someone have a good resource for explaining the creation and adjustment of this table?  I still scratch my head at having distinct pricing for places like…Brazoria, TX or Beaumont, TX but there’s nothing distinct for San Antonio.  Or even here in VT, where practicing in Chittenden County is not at all like practicing in the Northeast Kingdom (though some could argue that anyone providing medical service up in the Kingdom should get a bonus).  I have plenty of clients who either benefit or are zapped - usually the latter - by this piece of the calculation.

Location	Difference (’08-’09)	Difference (’07-’09)
Alaska	22.24%	21.43%
New Orleans, LA	2.13%	4.31%
Ventura, CA	1.84%	3.70%
Rhode Island	1.55%	3.21%
Miami, FL	1.33%	2.75%
Los Angeles, CA	1.31%	2.69%
Fort Lauderdale, FL	1.22%	2.47%
Hawaii/Guam	0.92%	1.72%
Rest of Pennsylvania	0.85%	1.67%
Rest of Louisiana	0.61%	1.23%
Rest of Missouri*	0.61%	1.22%
Rest of Florida	0.58%	1.12%
Anaheim/Santa Ana, CA	0.52%	1.09%
Idaho	0.46%	0.93%
Mississippi	0.47%	0.89%
Indiana	0.48%	0.87%
Beaumont, TX	0.43%	0.81%
Delaware	0.42%	0.79%
Arkansas	0.38%	0.77%
Connecticut	0.34%	0.74%
South Carolina	0.42%	0.74%
Vermont	0.33%	0.61%
New Mexico	0.33%	0.56%
Rest of Texas	0.30%	0.55%
Northern NJ	0.26%	0.49%
Rest of New Jersey	0.23%	0.47%
Rest of Illinois	0.20%	0.40%
Tennessee	0.24%	0.38%
Rest of Maryland	0.17%	0.30%
Nebraska	0.20%	0.29%
Southern Maine	0.11%	0.26%
Oklahoma	0.11%	0.23%
Ohio	0.13%	0.21%
Rest of Georgia	0.13%	0.20%
Virginia	0.14%	0.18%
North Carolina	0.10%	0.16%
Galveston, TX	0.09%	0.13%
Rest of Oregon	0.09%	0.08%
Metropolitan Philadelphia, PA	0.01%	0.07%
Rest of Maine	0.06%	0.02%
West Virginia	0.03%	-0.00%
Rest of Massachusetts	-0.04%	-0.04%
Rest of California*	-0.07%	-0.15%
Kentucky	-0.06%	-0.19%
Alabama	-0.11%	-0.22%
Kansas	-0.11%	-0.22%
Iowa	-0.10%	-0.26%
Puerto Rico	-0.12%	-0.30%
Montana	-0.18%	-0.36%
Rest of New York	-0.15%	-0.40%
Queens, NY	-0.23%	-0.43%
New Hampshire	-0.22%	-0.44%
Rest of Washington	-0.21%	-0.52%
South Dakota	-0.25%	-0.54%
Poughkpsie/N NYC Suburbs, NY	-0.31%	-0.58%
NYC Suburbs/Long I., NY	-0.32%	-0.68%
Wisconsin	-0.33%	-0.72%
Wyoming	-0.34%	-0.74%
Baltimore/Surr. Cntys, MD	-0.41%	-0.76%
Utah	-0.36%	-0.77%
Rest of Michigan	-0.37%	-0.80%
Nevada	-0.44%	-0.87%
East St. Louis, IL	-0.42%	-0.88%
Manhattan, NY	-0.44%	-0.92%
Metropolitan St. Louis, MO	-0.44%	-0.92%
Metropolitan Kansas City, MO	-0.47%	-1.03%
DC + MD/VA Suburbs	-0.61%	-1.26%
Houston, TX	-0.64%	-1.27%
North Dakota	-0.64%	-1.33%
Colorado	-0.73%	-1.40%
Minnesota	-0.70%	-1.43%
Fort Worth, TX	-0.81%	-1.70%
Virgin Islands	-0.84%	-1.72%
Metropolitan Boston	-0.87%	-1.76%
Chicago, IL	-0.97%	-1.92%
Portland, OR	-1.01%	-2.00%
Brazoria, TX	-1.03%	-2.13%
Suburban Chicago, IL	-1.12%	-2.22%
Detroit, MI	-1.10%	-2.23%
Arizona	-1.11%	-2.24%
Seattle (King Cnty), WA	-1.19%	-2.35%
Dallas, TX	-1.44%	-2.79%
Austin, TX	-1.53%	-3.01%
Marin/Napa/Solano, CA	-1.80%	-3.54%
Atlanta, GA	-1.93%	-3.79%
Oakland/Berkley, CA	-1.98%	-3.88%
San Francisco, CA	-2.20%	-4.31%
San Mateo, CA	-2.20%	-4.35%
Santa Clara, CA	-5.04%	-9.57%

Yesterday, I asked if anyone knows how the awkward RBRVS GPCI system is developed.  Siouxsie, of course, had the answer.  In fact, more than answer.  Those of you who are dinged by the GPCI breakdown should head Reed Tinsley’s quick review of it and then check out CMS’s PDF…and get in touch with CMS! Remember, it worked with the imms admin for 2009, why not for GPCIs as well?

Andrew Cuomo, you are my new friend.

It’s also nice to feel vindicated.  Lynn Cramer, pay attention - this relates to your questions to me about St. Anthony’s RVU values.  For anyone who is using St. Anthony’s or Ingenix to set prices, etc., pay attention here!

Ingenix, owned by United, settled with the state of NY and will be overhauling its data-gathering effort. I wrote about how my experience with their data made me feel like they were cheating.  And now we know they were.

Here’s a highlight from the article below:

A statement from Mr. Cuomo’s office said the industry had engaged in “a scheme to defraud consumers” by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade.

You can read the entire thing at the NYTimes here, I’ll excerpt the first part of the article below (I recommend reading the entire thing, it’s quick).

In a settlement with one of the nation’s biggest insurers, New York’s attorney general, Andrew M. Cuomo, has ordered an overhaul of the databases the industry uses to determine how much of a medical bill is paid when a patient uses an out-of-network doctor.

A statement from Mr. Cuomo’s office said the industry had engaged in “a scheme to defraud consumers” by systematically underpaying the nation’s patients by hundreds of millions of dollars over the last decade.

The move, to be announced Tuesday, is part of a settlement with the insurance giant UnitedHealth Group, which operates the industry databases. It results from a yearlong investigation by Mr. Cuomo’s office that concluded the data had understated the true market rates of medical care by up to 28 percent.

The settlement will have a nationwide impact because UnitedHealth, the biggest health insurer in New York, operates the databases used by the entire industry, through its Ingenix business unit. The deal calls for creation of a new independent database, to be run by a university that is still to be selected…(keep going)

Finally, don’t forget: we are moving to pedsource.com/chipsblog!

I forgot to mention last week that I updated the Build Your Own RVU calculator for 2009.  You can find it and the instructions in the PedSource library.

To make a long story short, for those who don’t know it - I really don’t like the fact that do do any proper RVU analysis of your practice, you have to pay for expensive software.  Especially for software owned by organizations who have admitted to ripping off the very people they claim to serve.  So, I designed a free tool that, using the license for which you are granted permission to access CPT codes (thanks, greedy AMA), you can do the calculation work you need.

Share and enjoy.  Flash-based pediatric coding tool coming soon, I hope.