2019 HSC Section 2 - Practice Management

J A M A CAD D ERMATOL V OLUME 78, N UMBER 4

Barbieri et al

societies and represent nurses, physician assistants, podiatrists, psychologists, chiropractors, occupational and physical therapists, optometrists, audiologists, speech pathologists, registered dieticians, and social workers. This subcommittee, along with 3 physician members of the RUC, make up the RUC Health Care Professionals Advisory Committee Review Board, which develops RVU recommendations for codes that are reported principally by nonphysicians. THE RUC UPDATE PROCESS The RUC update process is summarized in Fig 1 . Codes can be brought before the RUC for review if they are for a novel procedure or service (eg, confocal microscopy), they are identified as potentially misvalued by the RAW, or CMS recommends the code be evaluated. Once a code has been identified for review, the RUC solicits input from the relevant specialty societies. If the code is relevant to multiple specialty societies, they are encouraged to work together throughout the update process. The specialty societies have the option to survey members to obtain data on the time and RVUs involved in the service, write a recommendation to the RUC without surveying members (often based on data for a similar code that has been evaluated in the past), or take no action. If the specialty society chooses to complete a random survey of their members, they then distribute a survey instrument asking clinicians to describe the pre-, intra-, and postservice time required to complete the procedure or service. These surveys also provide a reference service list, which is comprised of codes with values that are expected to be lower than, about equal to, and higher than the code under review; the surveyed clinicians are asked to choose a code from the list that most closely reflects the work of the code under review. 4 This process whereby the surveyed clinicians select a code to estimate the work RVUs for the code under review is referred to as magnitude estimation, which underpins the entire fee schedule. Quite simply, the surveyed clinician is grading the service by inserting it into a ranked list of services (from easier to harder), and then that ranked position is used to estimate the RVUs for the service. The specialty society then presents their recommendations to the RUC who can adopt the recommendation, refer it back to the specialty society for additional work, or modify it before submission to CMS. For an existing code to increase in value, the code must meet stringent criteria such as documentation that technology has changed, that there are anomalous relationships between the code and multiple key reference services, or that incorrect assumptions were made in the previous valuation of

the service (eg, it was previously surveyed by one specialty, but the service is now primarily provided by a different specialty), among others. Even if the code does meet these stringent criteria, an increase in the value will only occur if there is additional survey evidence to support that the code is undervalued and if the RUC agrees with the specialty society recommendation. In contrast, there are not similar stringent criteria required for a code to decrease in value. As a result, when a code is reviewed by the RUC, it is unlikely for it to increase in value. Once the RUC has completed its review, final recommendations to CMS require a two-third majority vote by the RUC committee members for approval and the majority of RUC recommendations to CMS are based on a unanimous vote. 8 These codes are then presented to CMS for consideration in updating the Medicare Physician Payment Schedule, which is released for public comment every year in the summer and finalized in the late fall. Historically, [ 90% of recommendations from the RUC have been accepted by CMS ( Fig 2 ). While this rate has decreased in recent years, the final RVUs assigned by CMS typically have remained very close to those recommended by the RUC. Finally, it is important to note that although the RUC is involved in the CMS process for updating RVUs, absolute reimbursement rates are dependent on the conversion factor used by CMS to convert these RVUs to a dollar amount of reimbursement for services. Therefore, while the RUC has a role in determining the relative reimbursement for different services, the absolute value of these services is ultimately determined by CMS and the Medicare budget. As a result, the RBRVS is essentially a zero-sum game; if the RVUs for a code were to increase, all other codes would be relatively less Fig 2. Percentage of AmericanMedical Association-Specialty Society Relative Value Scale Update Committee recommen- dations accepted by the Centers for Medicare and Medicare Services.

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