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The RBRVS and the AMA/ Specialty Society RVS Update Committee (RUC) Process. 2009. Medicare RBRVS. Medicare implemented the Resource-Based Relative Value Scale (RBRVS) on January 1, 1992
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*The Conversion Factor for CY 2009 = $36.0666
Since the introduction of RBRVS, changes have included:
RUC CompositionAmerican Medical AssociationCPT Editorial PanelAmerican Osteopathic AssociationPractice Expense Review CommitteeHealth Care Professionals Advisory Committee
* indicates rotating seat
CPT Editorial Panel
Level of Interest
Speech PathologistsHealth Care Professionals Advisory Committee (HCPAC) Composition
Example: Gynecologic procedures to equate urology procedures
In its March 2006 Report to Congress, the Medicare Payment Advisory Commission (MedPAC) commented that the RUC’s Five-Year Review process leads to substantially more increases in work RVUs than decreases.
MedPAC expressed concerns about the RUC’s ability to identify overvalued physician services.
MedPAC recommended the establishment of a separate standing panel of medical economic experts to identify overvalued services.
MedPAC suggested that the new panel could identify overvalued services through various statistical analyses.
Though no action was taken by the Congress, MedPAC reiterated these comments and recommendations in subsequent reports to Congress in 2007 and 2008.
MedPAC also expressed an opinion that the growth in volume of services might be evidence of misvaluation.
The RUC maintained that it has the requisite expertise in identifying appropriate valuation and has a history of doing so.
Prior to the MedPAC recommendations, the RUC recommended reducing the RVUs for nearly 400 services (1992 – 1997).
The RUC established its Five-Year Review Identification Workgroup in October 2006.
The purpose of the Five Year Review Identification Workgroup is to identify potentially misvalued services using objective mechanisms for reevaluation during the upcoming Five-Year Review. The Workgroup is also charged with developing and maintaining processes associated with the identification and reconsideration of the value of “new technology” services. (Approved by the RUC October 2006)
The identification and review of potentially misvalued services will be conducted on an ongoing basis, rather than at the upcoming Five-Year Review. (Approved by the RUC February 2008)
The Workgroup develops an objective criterion (also called a “screen”) for identification of potential misvaluation.
The Workgroup recommends the criterion to the RUC for approval.
The Workgroup applies the screen to the universe of physician services and generates a list of codes meeting the screen.
The codes identified by a screen are forwarded to all specialty societies before a RUC meeting in a “level of interest” process.
Specialties are asked to develop work-plans to either explain why the service is appropriately valued despite meeting the screen criteria or, if there is no clinical explanation, a plan to address the aberration.
Codes that have no clinical explanation for appearing on the screen may be addressed through:
Referral to CPT where the descriptor is ambiguous and results in incorrect reporting.
If a change in the descriptor is not necessary, referral to CPT Assistant to develop education to promote appropriate reporting.
Survey and re-valuation of physician work or practice expense, where the service is potentially misvalued.
The Workgroup reviews the comments of the specialty society and makes a recommendation to the RUC.
The RUC, then refers the service to CPT or recommends that the service be surveyed after solicitation from CMS.
CMS then approves/requests review of valuation for existing CPT codes.
To date, the Workgroup has identified 485 codes for review. The following is a summary of the RUC recommendations based on these reviews.
*Recommendation of a CPT Assistant article for these 21 codes was a secondary action, made in addition to another recommended action.