Understanding RBRVS

What is RBRVS

RBRVS to Discover & Set Fees

RBRVS to Choose Procedure Code
(Resource Based Relative Value Scale)
1
What is RBRVS?

It is how 3rd parties pay
RVU x CF = Payment
2
What is RBRVS?




RVU = Relative Value Unit
All procedures assigned “relative
value”
Based on resources needed to deliver
procedure
3 types of resources
3
What is RBRVS?

3 types resources:

Physician Work (PW)

Practice Expense (PE)

Malpractice (MP)
4
What is RBRVS?

Each type resource assigned a
“relative value”
5
What is RBRVS?

PW RVU

PE RVU

MP RVU
6
What is RBRVS?

3 resources totaled =

PW RVU + PE RVU + MP RVU =
Total RVU
7
What is RBRVS?

8000 CPT codes

8000

= Relative Value Scale, ie

(total)
RVUs
Resource-Based Relative Value Scale
(RBRVS)
8
Examples of RVUs

RVU range 0 to 470.33

RVU of 0?
9
Things Assigned “0” RVU

Category 3 CPT
0207T
(evacuation meib gland)
(Lipiflow)

S codes
(HCPCS Level 2)
S0620
(exam + ref, routine, new)
(TOS handout)

After hours office visits

Routine Exam

“Dump” codes 92499
99050
10
(unlisted ophthal service/proced)
Examples of RVUs



RVU of 470.33?
CPT 37227 Revascularization of femoral
artery (for occlusive disease)
X 34.023 = $16,002
(2013)
11
Examples of RVUs

Eye Codes

92004 = 4.45
(x 34.023 = $151.40)

92015 = 0.58
($19.73)

65600 = 12.07
($410.66) (tattoo)

92950 = 9.05
($307.91)
(2013)
12
Facility vs. Non-Facility RVU

Facility RVU < Non-facility RVU, ie

Provider: Facility $$ < Non-facility $$

Facility: Facility & provider split pay
13
Facility vs. Non Facility
Non-Facility:
 Physician office

Patient home

Freestanding imaging center

Independent pathology lab
14
Facility vs. Non Facility
Facility:
 Hospital

Ambulatory surgical center (ASC)

Skilled nursing facility (SNF)
15
GPCI
Geographic Practice Cost Index

Alters RVU for local economy
Separate GPCI for each economic area

(PW x GPCI) + (PE x GPCI) + (MP x GPCI)
= total RVU (for specific area)
16
GPCI
Geographic Practice Cost Index

Medicare – Uses GPCI

Non-Medicare – May or may not use
17
What is RBRVS?
RVU x CF = Payment
18
Conversion Factor

Converts RVU to payment

3rd parties choose CF

Usually one CF, sometimes more

2013 Medicare CF 34.023
19
Yearly RVU & CF Change
20
Yearly RVU Change

RVU data updated yearly; Up & down

GPCIs may change
21
Adopt RVU Change

Medicare
January 1
Adopts new RVUs & GPCIs
22
Adopt RVU Change

Non-Medicare
Anytime
Year of RVU
Any year
GPCI
Used or not
23
Adopt RVU Change

Non-Medicare
10 sets RVUs in past 5 years
24
Yearly CF Change

Medicare
CF changes Jan 1: budget neutrality
Published Nov 1 Fed. Register
25
Yearly CF Change

Non-Medicare
Pick their CF: market forces
Often higher than Medicare
Occurs anytime
26
Examples
RVU x CF = Payment
27
Examples
92004
Medicare 2013
4.45 x 34.023 = $151.40
28
Examples
92015
Medicare 2013
0.58 x 34.023 = $19.73
29
Examples
65600
Medicare 2013
12.07 x 34.023 = $410.66
30
Examples
92950
Medicare 2013
9.05 x 34.023 = $307.91
31
Understanding RBRVS

What is RBRVS

RBRVS to Discover & Set Fees

RBRVS to Choose Code
32
Set Medical Fees

Obtain pay schedule, all contracted plans

Or calculate with RVU x CF = Payment

Identify highest payer

Set office fees above highest plan
RVU x CF = Office Fee
33
Set Medical Fees

Choose your CF

Twice-yearly re-assess

Fees accurate, reasonable

Not good when insurance pays your
charge
34
Set Medical Fees

Medical fees already determined

Insurance defines value
35
Set Routine Fees

Market-driven

Routine service unrelated to Medical

Routine fees unrelated to Medical

RBRVS unrelated
36
Control Accounts Receivable
GOAL
Collect all patient portion on day of service
37
Control Accounts Receivable
3 Parts
A. Prepare Payment Schedules
B. Verify Insurance
C. Day of Service – Collect Patient Portion
38
Control Accounts Receivable
A. Prepare Payment Schedules
Spreadsheet, common codes (40)
Columns
1st – U&C
2nd – Insurance Maximum Allowed
3rd – Write Off
4th - Insurance Due
5th - Patient Due
(spreadsheet example)
39
Control Accounts Receivable
file://localhost/Users/alanhomestead/Docu
ments/My Documents B 3-813/Adventures 11-3-12/1
AccuFee/2013/AccuFee 2013 Files
XLSX/1 AccuFee 2013 15.4.xlsx
40
Control Accounts Receivable
A. Prepare Payment Schedules
One spreadsheet per insurance (8 - 10)
If more than one plan,
One spreadsheet per plan
(1 – 2)
41
Control Accounts Receivable
B. Verify insurance
Before patient arrival
Beginning of month, employer paid
premium?
Ask Deductible, Co-Pay, Co-Insurance %
42
Control Accounts Receivable
B. Verify insurance
Co-Pay, Co-Insurance may vary with
office call
surgery
test
specialty
43
Control Accounts Receivable
B. Verify insurance
Deductible
Amount
Amount not met
44
Control Accounts Receivable
B. Verify insurance
Medicare – application allowing access to
Medicare claim and eligibility information.
Deductible balance
If Medicare Advantage
(can see pending claims)
45
Control Accounts Receivable
B. Verify insurance
Medicare, claim & eligibility information
Noridian – Endeavor: online
(Jursdctn F-WA,OR,ID,MT,ND,SD,WY,AK,UT,AZ,CA,HI,NV)
Novitas – IVR:
Interactive Voice Response 855-252-8782
(Jursdctn L-DE,NJ,PA,MD,DC, Arlington & Fairfax county, city of Alexandria)
Palmetto – OPS:
Online Provider Services, or IVR
(Jursdctn 11/M-WV,VA,NC,SC)
46
Control Accounts Receivable
B. Verify insurance
Medicare, claim & eligibility information
CGS – CSI: (online) Claim Status Inquiry, or IVR
(Jursdctn 15-OH,KY)
WPS – C-SNAP:
(online) CMS Secure Net Access Portal,
or IVR
(Jursdctn 8-IN,MI)
47
Control Accounts Receivable
C. Day of Service – Collect Patient Portion
Deductible –
Co-Pay –
found before patient arrive
found on insurance card
Co-Insurance -
found on spreadsheet at checkout
48
Control Accounts Receivable
C. Day of Service
Write off un-collectable
A/R very accurate
49
Control Accounts Receivable
C. Day of Service
Patient portion of A/R = small fraction of
monthly production
50
Catch Mistakes
Check daily production sheet
No 2nd write off, unless explained
(eliminate double write-offs)
Insurance paid wrong?
Office prediction wrong?
51
Weekly Meeting
Short stand-up review of A/R
Review Patient-Portion,
30 + 60 + 90 days
How did account get on A/R
52
Results
Firmly controlled A/R
Few statements
Refund checks
Cash flow optimal
53
Understanding RBRVS

What is RBRVS

RBRVS to Discover & Set Fees

RBRVS to Choose Code
54
Office Visit 99 or 92

How many codes?
Ophthalmic – 4
EM – 10
7 New, 7 Established
55
Office Visit 99 or 92
Ophthalmic vs EM New Patient (2013)
99205 5.99
$217.89
92004 4.45
$151.40
92002 2.44
$83.02
99204 4.84
$176.49
99203 3.18
$116.77
99202 2.19
$80.85
99201 1.29
$47.91
56
Office Visit 99 or 92
Ophthalmic vs EM Established Patient (2013)
99215 4.2
$153.68
92014 3.71
$126.23
92012 2.57
$87.44
99214 3.14
$115.25
99213 2.14
$78.74
99212 1.29
$47.91
99211 0.6
$22.54
57
Office Visit 99 or 92
MEDICARE
New
Est
99205 99215
99204 92014
92004 99214
99203 92012
92002 99213
99202 99212
99201 99211
58
Office Visit 99 or 92
Choose office visit:
The one that pays the most
59
Office Visit 99 or 92
Choose office visit:
Note: 92012 > 92002 !
60
Office Visit
Billed Level 5?
61
99 Codes
file://localhost/Users/alanhomestead/Docu
ments/My Documents B 3-813/Adventures 11-3-12/O S/Presentations/Repository of My
PowerPoints/1 Topic Modules/99/99 Aug
13.ppt
62