Relative Values for Physicians. Relative Value Studies, Inc.
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1 Relative Values for Physicians Relative Value Studies, Inc.
2 Contents Contents...1 Introduction...1 User Guide... 1 Definitions of Terms in Relative Values for Physicians... 1 The Global Period... 2 Services With Significant Direct Costs... 3 Historical Background... 3 Relative Value Studies Legal and Fair... 4 The Research Behind Relative Value Units... 4 Relative Values for Physicians with CPT Codes... 4 How to Use This Relative Value Scale... 5 Determining Fees... 5 Conversion Factor Development... 5 Productivity Measurement Cost and Profitability Analysis Capitation RVUs and the Capitation Contract Modifiers Anesthesia...27 Guidelines Calculations of Total Anesthesia Values Anesthesia Section Surgery...43 Guidelines Surgery Section Radiology Guidelines Radiology Section Pathology and Laboratory Guidelines Pathology and Laboratory Section Medicine Guidelines Medicine Section Evaluation and Management Guidelines Evaluation and Management Section Category II Codes Guidelines Category II Section Category III Codes Guidelines Category III Section HCPCS HCPCS Disclaimer Level II (HCPCS/National) Modifiers HCPCS Section R Code Crosswalk Guidelines Services with Significant Direct Costs Procedural Index
3 Introduction 2010 Relative Values for Physicians 5 Descriptions and unit value information have been developed by RVSI to help users address reimbursement issues the CPT book does not cover. When a procedure or service provided is not adequately identified, use of an unlisted procedure code for the related anatomical area is usually appropriate. Most codes of this nature have 99 for the last two digits. Under some unlisted service/procedure code descriptions and unit values, the editors have listed some code descriptions and unit values that might help the user with reimbursement. These codes are clearly identified by an R. A complete listing of descriptions and unit value information that was developed by RVSI to help users speak to reimbursement issues is listed in the R Code Crosswalk. Relative Values for Physicians will continue to expand the coding system to further simplify the reimbursement process, and will maintain such codes under separate designation. Payers and physicians may use either the separate code or the CPT code indicated, including the description and value listed in Relative Values for Physicians. Many new or uncommon procedures may require an operative report based upon the individual case, physician, and/or payer. (Note: Payers and providers may or may not contractually require specific use of nomenclature. Communicate your questions to the individual payer or physician, as appropriate.) The editors of Relative Values for Physicians will accept suggestions for additional coding to clarify procedural definitions where no CPT code exists. Each suggestion will be carefully considered and surveyed. All responses are confidential and should be addressed to Relative Value Studies, Inc. (see address under Customer Comments on the Notices page at the front of the book). How to Use This Relative Value Scale This book is organized into nine sections. These are: Anesthesia Surgery Radiology Pathology Medicine Evaluation and Management Category II Category III HCPCS Level II Each section begins with a guideline to define particular values or processes as applicable. Section nine, HCPCS Level II, provides a complete listing of non-cpt codes that are developed and maintained by CMS. With the exception of Medicine, Evaluation and Management, and HCPCS Level II, each section of the book has been developed on a different scale. The same relative value scale has been developed for Medicine, Evaluation and Management, and HCPCS Level II procedures so these can be compared together. However, the Anesthesia, Surgery, Radiology, and Pathology sections require adjustments to the scale when comparing values between these sections and with Medicine, Evaluation and Management, and HCPCS Level II sections. The method for adjusting the values is described in Productivity Measurement later in this Introduction. Category II codes cannot be evaluated as they were developed for performance measurement and are intended to be used for tracking purposes only. The services, procedures, and tests they describe are typically included in evaluation and management services, radiology services, laboratory tests, and/or other procedures. For this reason, relative values have not been assigned to category II codes. Category III codes are evaluated on a limited basis as these codes represent emerging technology services and procedures. These codes are assigned relative values as data becomes available. The value guidelines in each section reprint similar information from section to section as is appropriate. Modifiers are provided in a comprehensive list at the end of this Introduction. Modifiers of particular importance to a specific section are referenced in that section s guidelines. Determining Fees The formula for setting a fee is: Relative Value Unit (Units) x Conversion Factor (CF) = Fee The relative values listed under the Units column for each procedure are determined by physician input as described in The Research Behind Relative Value Units section in this Introduction. The conversion factor (CF) should be determined by taking into consideration current fees (if available), prevailing area rates, and overhead costs, including malpractice insurance, rent, salaries, and the cost of living. Conversion Factor Development A conversion factor is required to use relative values in developing a fee schedule. Individual practices should have a customized conversion factor that reflects practice type, its clinical reputation, and local market pricing. Discounts and participation in lower paying plans are at the discretion of the practice; therefore, it is a sound and legal business practice to maintain more than one fee schedule. The easiest method to determine a conversion factor is to use your current charges. A medical practice that has no established fee schedule could use as a starting point Medicare's fee schedule or fee schedules from managed care groups. NOTE: Fee schedules for Medicare and managed care groups are usually discounted from customary charges. To develop the individual monetary CF, the following basic process is recommended: Step 1: Step 2: List 20 to 30 basic procedures (those that constitute a high volume of practice) for each of the seven sections of the book. In compiling your list of codes, do not use any that show BR or RNE instead of a relative value. List the relative value opposite the procedure. Introduction
4 Surgery 2010 Relative Values for Physicians 167 UPD Code Description Units Anes Global Insertion of cannula(s) for prolonged extracorporeal circulation for cardiopulmonary insufficiency (ECMO) (separate procedure) Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft nonautogenous graft (eg, biological collagen, thermoplastic graft) Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) 100 M Plastic repair of arteriovenous aneurysm (separate procedure) This code has been deleted Insertion of Thomas shunt (separate procedure) Surgery Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome) External cannula declotting (separate procedure); without balloon catheter 11.6 (I) with balloon catheter S K Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) Note: This code has been identified as a service requiring a significant direct cost, please see SDC list for additional service cost reimbursement in a place of service which is not separately paid Venous anastomosis, open; portocaval renoportal caval-mesenteric splenorenal, proximal splenorenal, distal (selective decompression of esophagogastric varices, any technique) Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation) K Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation) (I) (I) s Revised code l New code M Deleted from CPT S SDC Code R RVSI Code (I) Interim Value Note: For a complete explanation of each icon, please see the Introduction
5 Pathology and Laboratory 2010 Relative Values for Physicians 391 UPD Code Description Units Global Candida species, direct probe technique Candida species, amplified probe technique Candida species, quantification Chlamydia pneumoniae, direct probe technique Chlamydia pneumoniae, amplified probe technique Chlamydia pneumoniae, quantification Chlamydia trachomatis, direct probe technique Chlamydia trachomatis, amplified probe technique Chlamydia trachomatis, quantification Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique (I) (I) Path/Lab cytomegalovirus, direct probe technique cytomegalovirus, amplified probe technique cytomegalovirus, quantification enterovirus, amplified probe technique (I) (I) vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique (I) (I) Gardnerella vaginalis, direct probe technique 3.8 s Revised code l New code M Deleted from CPT S SDC Code R RVSI Code (I) Interim Value Note: For a complete explanation of each icon, please see the Introduction
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