Five Year Review
Centers for Medicare and Medicaid Services Announces Third 5-Year Review
With the implementation of Medicare’s Resource Based Relative Value Scale Physician Fee Schedule in January, 1992, a review of the relative value units associated with the CPT codes in the Medicare Fee Schedule (MFS) has been required by Congress no less than every five years. This process is known as the Five-Year Review. This review serves as a mechanism for the Centers for Medicare and Medicaid Services (CMS) to identify misvalued codes and update them accordingly. Currently the review focuses only on the physician work component of specific procedures paid under the MFS. However, future reviews will include the practice expense (technical) component when the resource-based values are established in the MFS.
The third five-year review is currently underway and CMS has requested that the medical community and Carrier Medical Directors (CMDs) identify and nominate misvalued procedures (i.e., CPT codes where the physician work is either overvalued or undervalued in the MFS). Based on comments received from the medical community as well as their own review, CMS has released the list of codes for the five year review. This list of codes is based on high-volume codes across specialties, codes that have not been reviewed by the Relative Value Update Committee (RUC) and codes that were valued as being performed in the inpatient setting, but are now predominantly performed on an outpatient basis. The list contains approximately 59 radiology codes to include 5 CT, 11 plain film, 8 interventional, 4 MR, 1 DEXA, 3 ultrasound, 8 radiation oncology and 5 nuclear medicine codes). Click here for a list of Radiology codes or Click here for a complete list of all CPT codes for this five year review .
The ACR will be collecting survey data on CPT codes identified as misvalued for radiology in late spring and early summer and will present this data to the RUC early in the fall. The values accepted by the RUC will be submitted to CMS for review by end of this year. The final revised work values are expected to be released in November 2006 for a January 1, 2007 implementation.
If you receive a survey, it is crucial that you participate in the process and return the completed survey to the ACR promptly. If you are unfamiliar with a procedure being surveyed, please forward the survey to a colleague who is familiar with the procedure. If you would like to help with the surveys, please email carolro@acr.org with your name and type of survey(s) you would like to receive (i.e., MR, CT, nuclear medicine, radiation oncology, interventional, and/or ultrasound).
It is important to note that although CMS is soliciting public comments and involving the RUC and specialty organizations, CMS will ultimately decide whether the physician work value for the identified misvalued code will be increased or decreased.
If you have any questions regarding the five-year review process, please contact the Economics and Health Policy Department at the ACR (800-227-5463, ext. 4584) or email (carolro@acr.org) for more information.