How a code becomes a check......

What I love about learning this whole system is that you begin to understand that people who are not doctors are always trying to quantify what you do and how you do it. Things such as RVUs turn a clinician into a blue collar worker. 

It is one of the most disgusting things that I have seen. That's why I gave up working for anyone who wishes to tell me how productive I am. At the end of the day, just ask my patients, they will tell you how productive I am......

This coding and auditing system cracks me up. Here you have a bunch of people from the AMA, HCFA, and other organizations trying to explain what we do in a very, VERY detailed way, without having the direct professional understanding of how we do it.

Granted, there are some physicians on these panels......but they are NOT all specialties or the majority. CPT was started in the late 60s and encouraged to use as a data reporting tool, to "standardize" what we do......sounds eerily familiar to PQRI.....

It was then accepted by Medicare in 1983 as the mode of reporting for reimbursement......that's when hell came on earth.......slowly...

The CPT manual is updated annually through an editorial review process. The CPT Editorial Panel meets 3-4 times per year to review requests received from specialty societies, manufacturers and individuals. The Panel is supported in its deliberations by a larger body of CPT advisors, known as the CPT Advisory Committee

This body, it is oft complained as existing to serve the specialists and not the generalists.....This could be seen as sour grapes, or it could represent a serious lack of voice....

Either way, you have a coding committee who may not represent all parties.....Which is not  an equitable or reasonable position to take.

That being said

Once a coding change is accepted by the CPT Editorial Panel, the next step in the CPT process is to determine the reimbursement for the code, through a survey of physician work and determination of direct practice expense (PE). The survey results are submitted to the RUC for negotiation for a mutually acceptable value to be submitted to CMS for final approval and publication in the Federal Register Final Rule. The approved CPT code and their associated RVUs are then published. 

You may be asking......What is the RUC and What is an RVU

The RUC is:

The Relative Value Update Committee, a decision-making body which reviews all surveys of physician work values (52 percent of the total RVU for a service/procedure) and practice expense or PE (44 percent of the total RVU for a service/procedure) and makes recommendations regarding these components to the Centers for Medicare and Medicaid Services (CMS) for reimbursement  determination. Members of the RUC are appointed by national medical specialty societies.

What in an RVU?

An evil way to turn us into worker bees, rather than professionals....

If you really must know, then you can read about it here.

Relative value units

Although several relative value systems are recognized and used nationally, the most identifiable system is the Resource-Based Relative Value Scale, or RBRVS. The RBRVS system was adopted in 1992 by CMS as a method for setting Medicare reimbursement levels. Under the RBRVS methodology, services are assigned a numerical value or weight, which is relative to all other codes. The numerical value, or relative value unit (RVU), is actually made up of three component units — designated for work, practice expenses, and malpractice expenses.

To set the Medicare allowable rate, the component units are factored by corresponding geographic indices, summed, and then multiplied by a standard conversion factor. Basically, it is a lot of economic shenanigans to devalue what we do....

 Each year, CMS makes changes to the RBRVS component units, based upon the introduction of new CPT codes, changes to code values by the American Medical Association (AMA) and specialty societies’ RUC (Relative Value Update Committees), and government budget constraints and indices.

For the last decade or so, Mediare has been trying to cut payments to physicians, despite practice expenses and malpractice expenses going up each year. Funny really when you think that their equation relies so heavily on these 2 factors. The real issue lies in the standard conversion factors......

With one simple change of an equation, the entire system, which is already on its knees, could be dropped to the floor.

So, the question becomes, "So this is Medicare and Medicaid, what about regular insurance?"

The AMA receives approximately $70 million annually from licensing fees for anyone wishing to relate RVUs with CPT codes, making them reluctant to allow the free distribution of tools and data that might help physicians calculate their fees accurately and fairly.

I.E. the AMA makes millions off of the insurers who want to use the governmental system for setting their fee schedules....

So, the AMA is in bed with the government AND the commercial insurers.....to "help the doctor-members"

But just like most politicians who go to Washington, this system is corrupted. And we need to fix it, by learning the system and using it to our advantage to get paid fairly for what we do.

That my friend is how we turn a code into a check.....I am going to post links to each of these important boards.

About the RUC only 5 of the 29 are primary care. 

Not exactly the 2/3rds majority required to change payments....Did you know that the AMA could have been threatened with Anti-Trust laws by telling the public what this committee does?

I can't find the membership of the CPT editorial committee.....does anyone have this information???

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