Radiologists must understand the building blocks of current FFS payment systems as medicine transitions to a value-based reimbursement landscape.
After three years attending and participating in the AMA/Specialty Society RVS Update Committee (RUC) — which makes recommendations to CMS on assigning appropriate relative values for Current Procedure Terminology (CPT®) codes — I strongly feel that more radiologists should understand the valuation process. As we prepare for changes in the healthcare system, the reality is that future value-based payment systems for radiologists will likely be predicated on the principles established by the resource-based relative value scale (RBRVS).
CPT and RUC Processes
Fee-for-service-based reimbursement comprises two central pieces: coding and valuation. Those are encapsulated in two processes: the CPT and RUC processes, respectively. More than half a century ago, the AMA created CPT codes to be used for filing reimbursement claims and tracking procedures. CPT became the national coding standard for reporting physicians’ and other healthcare professionals’ services under the Health Insurance Portability and Accountability Act of 1996.1 Established in 1992, RBRVS looks at the relative value of physicians’ work, as defined by the CPT codes, when compared to one another.2
The process of adding/revising and valuing CPT codes is outlined in the accompanying graphic. CPT codes are managed by the AMA through an advisory panel of practicing physicians, representatives from private insurance, CMS, and the co-chair of the Healthcare Professionals Advisory Committee (HCPAC). The AMA created the RUC to advise CMS on appropriate relative values for these CPT codes. The RUC is comprised of members appointed by national specialty societies, as well as the chair of the RUC, the co-chair of the HCPAC, representatives from the AMA and the American Osteopathic Association, the chair of the AMA’s Practice Expense Advisory Committee, and the CPT editorial panel.3
Valuation of Codes
The concept of relativity is central to the RUC process. Codes are valued with consideration of how the amount of physician work compares to other codes in the fee schedule. Any new codes introduced or considered to be potentially misvalued will typically require re-examination of any related codes in order to preserve the relative value in the fee schedule. For example, in 2016, CT neck with IV contrast (CPT code 70491) was identified on a CMS high expenditure screen as potentially misvalued. Codes 70490 and 70492 (CT neck without IV contrast and CT neck without and with IV contrast) were re-evaluated by the RUC at the same time. In the valuation process, CMS re-affirmed the current value for 70490 and 70491, and increased the value for 70492.
Through an annual process, CMS and the RUC identify potentially misvalued codes through screens for high expenditures, fastest growth, and new technology, to name a few. An explanation of these and other screens is beyond the scope of this article. Through the Patient Protection and Affordable Care Act, Congress promoted the identification and correction of misvalued physician fee schedule services by providing direction to the Secretary of Health and Human Services to validate relative value units (RVUs). In addition, Congress included a provision on the belief that too little attention has been devoted to the monitoring of whether services have become overvalued. CMS has formalized a process for the public to nominate potentially misvalued codes. This year, Anthem nominated several codes, including a radiology code based on RUC validation projects by the RAND and Urban Institute. In particular, the RAND report selected a few codes to evaluate absolute time estimates, ignoring the concept of relativity.4
Despite current pressures to increase productivity, we must take the time to ensure appropriateness of imaging and maintain quality in our work.
The process of RUC valuation is a lengthy one and was developed with multispecialty physician input. Essentially, specialty societies expressing interest in participating in the valuation process will create a survey based on a RUC-validated instrument. The survey is sent to random specialty society members, and the data from the survey provided by you, the specialty society members, ultimately is factored into the value of the code. The important variables are the amount of physician time a procedure or service requires and the intensity and complexity of the work. Time is perceived as easy to measure and compare. Recent studies scrutinizing the RUC process have focused on the absolute time component.4
However, comparing the intensity and complexity of procedures is more of an art, being difficult to quantify and requiring the expertise of specialty societies. Mental effort and judgement are factors, which account for the level of knowledge required, the complexity of decision-making, and the amount of clinical data that must be considered given the potential pathology. Length of training and amount of skill required to perform a particular procedure, as well as psychological stress factors — such as risk of significant complications, morbidity, and mortality — are also considered.
Finally, the RUC examines the recommended code valuations relative to other codes across the fee schedule to ensure that the code is not under- or overvalued.5 CMS makes final determinations of valuations based on RUC recommendations. In the recently published Final Rule, CMS accepted 80 percent of RUC recommendations.6 CMS publishes the proposed rule in July of each year and solicits feedback from stakeholders. This is an important process, allowing specialty societies to work together with the AMA to advocate for appropriate valuation.
Despite current pressures to increase productivity, we must take the time to ensure appropriateness of imaging and maintain quality in our work. Even within a fee-for-service environment, we are not rewarded for volume. Reimbursement to physicians within the Medicare Physician Fee Schedule is shared across the house of medicine — from a fixed amount of money that is distributed each year. As imaging volume increases, an adjustment factor is used to calculate the dollar value of the RVU. If overall volume increases, the RVU dips lower in value. Furthermore, as imaging volume increases disproportionately to the rest of healthcare expenditures, total payments to radiology increase at the expense of payments to other specialties. As specialty society advisors continue to advocate for proper valuation of radiology services and fight against controlling utilization through valuation, we as radiologists need to ensure we are championing appropriate imaging, improving our reports, and communicating with clinical colleagues and patients to remain visible and valuable to our stakeholders.