As we move forward in our discussions on RVUs and the Resource-Based Relative Value Scale database, it is important to become familiar with the Physician Fee Schedule (PFS) Relative Value Files. These can be downloaded from the CMS website. These files are available, sorted by release date and version and contain all of the RVU data relied upon by Medicare (and most third-party payers).
Of interest is the fact that not every procedure code listed in the database is associated to an RVU. In fact, of the 15,866 individual procedure code/modifier line items listed within the table for the July 2014 release, 7,008 have no total RVU associated to them. When this happens, the reason can often be found in the Status Indicator column in the table. For example, an "X" in that column reports that code as a "Statutory Exclusion," meaning that the procedure is not payable and as such, no RVU values are reported. An "E" in that column indicates that the procedure is "Excluded from Physician Fee Schedule by regulation," meaning that CMS chose to exclude it for one reason or another and as such, there is no associated payment and no RVUs. Others, however, such as those procedures represented by an ''I" in the status column ("Not valid for Medicare purposes"), while excluded from payment, do, in fact, have associated RVU values if such values were originally created. These include commonly used codes such as consults (99241 – 99245 and 99251 – 99255).
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One question we might ask is, "Why wouldn't there be any associated RVU values for those codes that are paid by Medicare?" The answer is that their consumption of resources is either variable (such as supplies), known (such as with drugs), or associated to a code with a non-standard definition (such as those ending in 99). It makes sense, actually, since all but the latter codes do not have a direct involvement of provider resources. For example, a drug (j-code) is just a supply with a known value and the provider does not add or take away from the value or resources consumed by that drug. If, however, the drug is injected, there is normally an injection code and that code will be associated to an RVU value because there is an associated cost in both dollars and time for that procedure.
Even amongst those procedures that do have associated RVU values, not all of those values are represented. For example, of the 8,859 procedure code/modifier line items in the PFS RBRVS database, 963 do not have a work RVU; this is a real concern for those looking to establish work RVU-based compensation plans. Again, we need to ask "Why?" For some, it's a modifier issue. For example, of those procedures that have a total RVU but no work RVU, 833 are associated to a TC modifier. This modifier indicates that the procedure is a technical component only and the resources are associated only to the cost of the equipment and testing/procedures and not inclusive of the physician time and effort. For each of these procedure codes, you will also see an associate modifier -26, which describes the physician time and effort associated to the global procedure. Others define supplies and/or services that exclude the physician's participation.
So what do we do with these line items that lack either all or some RVU components? My advice is to leave them alone; they are absent these values for a reason. But for some, like those codes ending in 99, you may want to create RVU values.
There are two methods to do this that tend to work out pretty well.
The first is to divide the Medicare allowed amount by the current conversion factor. For example, procedure code 80051 (electrolyte panel) has a Medicare fee amount but no associated RVU values. In Florida, Medicare allows $9.57. If I divide this by the current conversion factor of 35.8228, I get a total RVU value of 0.267.
Some procedures lack both a fee schedule amount and RVU values, such as 48999 (pancreas surgery procedure). In the second method, we find a similar procedure that has RVU values and adjust that accordingly. For example, we might use code 48146 (pancreatectomy) as a starting point with a work RVU of 30.6, a practice expense RVU of 16.59, and malpractice expense RVU of 6.24 (total RVU = 53.43). Maybe the physician determined that the 48999 procedure required 25 percent more time and effort. In this case, just multiply each of the components by 1.25 and you have your new RVU value.
In summary, it is important to know that, not only are there procedures without RVU values, but they lack those values for a reason — and sometimes it is a good reason. As such, use care when assigning RVU values to procedures that do not have them. Often, there are better ways to figure out resource consumption.