2019 HSC Section 2 - Practice Management

Ann Thorac Surg 2017;103:373 – 80

QUALITY REPORT JACOBS ET AL VALUATION OF PHYSICIAN WORK

STS Workforce on Coding & Reimbursement is contin- uously reviewing all codes for such errors or perceived inappropriate valuation. However, this system of reimbursement has inherent limitations, because the populations of patients is de fi ned by the service that is provided and not by other charac- teristics of the patients such as age and comorbidities. This strategy is based on the implicit assumption that these nonprocedural factors are normally distributed on a statistical basis (bell-shaped curve) and that there will be equivalent numbers of patients with no comorbidities (low risk) as there are those with multiple comorbidities or risk factors. Much of the effort in revaluation of codes is therefore involved in de fi ning or rede fi ning the popu- lation of patients for which a given service is provided. A third reason for a code to be brought forward to the RUC would be at the request of CMS or the RUC if CMS or the RUC believes that a particular code (or even family of related codes) is inappropriately valued. CMS or the RUC would ask the specialty society to bring the code back to the RUC to be reevaluated. The overall process whereby a new code is valued or a preexisting code is revalued is an extraordinarily detailed process. A standardized form, the Summary of Recom- mendation, is compiled by the medical specialty society and presented at the RUC meeting. The form describes the typical patient, enumerates the entire encounter from the preoperative evaluation to the operation itself, and documents all of the postoperative care rendered by (in our case) the surgeon. The time expended at each phase of the encounter, as well as the intensity of the work involved, is carefully detailed, down to the minute. Most medical societies arrive at the times by means of a general survey sent to their members. The STS will survey its members but also goes one step further — it has precise times recorded in the STS National Database. (Although the STS uses the STS National Database to provide data to aid in the valuation of codes, the STS only uses the STS National Database to provide data about codes that can be unequivocally mapped to an individual CPT code.) Once the case is made for what the specialty society be- lieves is an appropriate RVU value and this RVU is accepted by the RUC, the RUC-approved RVU for the particular CPT code is submitted to CMS. Final assign- ment of value is determined by CMS and is published annually in the “ Final Rule ” as part of the Federal Register. The description of the RUC from the Web site ( https:// www.ama-assn.org/composition-rvs-update-committee-ruc ) is very useful: “ Composition of the RVS Update Committee (RUC) The RUC represents the entire medical profession, with 21 of its 31 members appointed by major national medical specialty societies. The members include those recog- nized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care and those that account for high percentages of Medicare expenditures. The RUC also includes 4 seats that rotate on a 2-year basis, with 2 reserved for an internal medicine

Professionals Advisory Committee Review Board Co- Chair, the Practice Expense Committee Chair, and rep- resentatives of the AMA, American Osteopathic Associ- ation, and the CPT Editorial Panel. The current RUC Chairperson is Peter K. Smith, MD, Professor and Chief of Thoracic Surgery at Duke University, Durham, North Carolina. Verdi DiSesa, MD, President and Chief Execu- tive Of fi cer of Temple University Hospital and Chief Operating Of fi cer of Temple University Health System, is the RUC member representing the STS. Joseph C. Cleveland, Jr, MD, Vice-Chair of Faculty Affairs in the Department of Surgery and Surgical Director of Cardiac Transplantation and Mechanical Circulatory Support at University of Colorado Anschutz Medical Center is a is the RUC alternate representing the STS. Similar to the CPT Advisory Panel, the RUC has three 3-day to 4-day meetings each year. However, the events at a RUC meeting represent the intersection of several groups with often differing interests, including repre- sentatives from CMS, support staff from the AMA, RUC of fi cials, and representatives from each of the specialty societies. The complex interaction of each of these par- ticipants occurs within the strict con fi nes of two economic realities: (1) congressionally-mandated budget neutrality, and (2) a governmental agency (CMS) that can only operate within a health care budget determined annually by Congress. Ideally, each of the sitting RUC members, while maintaining a posture of thoughtful impartiality, understands that agreeing (by vote) to increase the RVUs for a given code brought forward for evaluation (or reevaluation) by one society must necessarily be accom- panied by a commensurate decrease in value of another code that already exists (or a decrease in value distributed across all codes) to maintain budget neutrality. It is hoped that this critical balance is precisely what keeps the so- ciety representatives at the RUC objective, reasonable, and fair. Why are the CPT codes brought forward to the RUC for valuation or revaluation? One obvious reason the CPT codes are brought forward to the RUC for valuation or revaluation is that a new device or service has now been determined by the CPT Advisory Panel to be ready for approved clinical use and therefore will need an appro- priate RVU assignment so that physicians can be compensated for the work associated with this code. A recent example of this reason is the performance of transcatheter aortic valve replacement, which has grad- uated from a new technology in clinical trial to an accepted mode of therapy. Another reason the CPT codes are brought forward to the RUC for valuation or revaluation is that a professional society identi fi ed the CPT code as being potentially mis- valued. Many CPT codes describe clinical scenarios that have less relevance today as a result of changes in the population of patients. For example, because of increased risk in a given population, some CPT codes require far more work and are associated with far more risk than with the previous less complex population of patients; for example, the coronary artery bypass grafting procedure of today is quite different from that of the early 1990s. The

51