Transcript Slide 1

Relative Value Units in the MHS
Wendy Funk, Kennell and Associates
[email protected]
Objectives
• Attendees can:
 Characterize the differences between a SADR and CAPER
professional encounter record.
 Define an RVU and its components
 Describe changes in the underlying Relative Value Unit
weight tables
 Characterize the difference between Enhanced RVUs in
SADR, Enhanced RVUs in CAPER and Provider Aggregate
RVUs in CAPER.
 Identify trends in RVUs in the MHS
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Professional Encounter Records
• MTFs recently switched encounter record formats,
from SADR to CAPER.
• Standard Ambulatory Data Record (SADR).
 Policy requiring collection of SADRs began in mid-1990s.
 Initially, bubble sheets were used to collect encounter
level data.
 Bubble sheets were scanned, and resulting data were
stored in the CHCS Ambulatory Data Module (ADM).
 Coding compliance and quality were significant issues.
FOR OFFICIAL USE ONLY
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Professional Encounter Records
• AHLTA
 A new data capture system for professional encounters was
developed in the mid-2000s
 System was originally intended to replace CHCS, but mission
was scaled back considerably.
 Serves as an electronic health record for ~85-90% of
ambulatory care; other care still collected in CHCS. Not used
at all for inpatient care.
 Records that originate in AHLTA are sent back to CHCS ADM.
 Coding quality continues to be an issue, but compliance has
improved.
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Ambulatory Data Collection at MTFs
AHLTA
CDR
Coding
edits do
not flow to
CDR
APPT
CHCS Appt
Module
CHCS ADM
Coding
Editor
MDR
APPT
ADM + AHLTA
Records are in
SADR file for MDR
CAPER
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Professional Encounter Records
•
•
In 2003/2004, a broad set of new data element requirements
were established for SADR.
 SADR renamed “CAPER” (Comprehensive Professional
Encounter Record)
 Edit requirements were changed
CAPER data
 Many years of development efforts.
 SADR was not generally maintained after 2009. (updated,
but needed fixes were not made)
 Fully implemented CAPER data became available in
2011/2012.
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Professional Encounter Records
• New data elements in CAPER but not in SADR:
 Provider – procedure linkages
 Procedure – diagnosis linkages
 Additional procedure and diagnosis codes
 Additional provider information
 Appointment duration
 Referral Information, appt type
 Coding / Compliance Editor (CCE) information
 Some others…
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CHCS Edit Logic on CAPERs and SADRs
Passed Edits
Cleanly
SADR
SADR Edits
CAPER Only
Edits
Passed Edits
Cleanly
SADR Edits
CAPER
CAPER Only
Edits
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New Edits on Encounter Records
• New edits for CAPER enforced in CHCS (not in
SADR). Records will not be sent with these edits:
 CPT Code invalid
 Appt Provider Specialty Code missing
 Appt Provider has no taxonomy
• New edits for CAPER in MDR as well.
 SADRs had minimal unit of service edits and that is all.
 More significant edits are applied to CAPER.
 These edits don’t eliminate records, but rather, use
edited values for some of the RVU calculations (and in
some cases, overwrite the reported values)
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MDR Edits for CAPER
1
2
3
4
5
6
7
8
9
A
B
C
D
E
F
G
H
Z
Units of Service changed (exceeded the limit)
Units of Service changed (reduced/terminated procedure-mod 52/73)
Units of Service changed (bilateral)
Recoding for bilateral procedure (code not appropriate for bilateral adjustment)
Recoding for bilateral procedure (using mod 50 to apply bilateral adjustment)
Surgical Followup (coded incorrectly)
Surgical Followup (credited as 99024)
Surgical Followup (no credit for E&M)
Surgical Followup (no credit for surgical code)
TELCON (removed additional procedures)
TELCON (no additional credit for coordinated care or case management codes)
Provider/Procedure Pointer(s) modified (TELCON)
Provider/Procedure Pointer(s) modified (multiple, same provider)
Provider/Procedure Pointer(s) modified (invalid pointer)
Provider/Procedure Pointer(s) modified (missing pointer)
Provider/Procedure Pointer(s) modified (credit reassigned to Appt Provider)
Procedure recoded as surgical follow-up based on Provider skill type
Various modifications (the number of applicable edits exceeds the space available)
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MDR Edits for CAPER
• “Change Edit Flag” in M2 CAPER is there to identify
the types of edits applied, but is very difficult to use
except at record level.
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MDR Edits for CAPER
• Change edit flag is a
concatenation of all the
flags that apply to a record.
• Can review easily at record
level.
• Cannot use to look at the
types of edits applied to
more than one record w/o
considerable work.
FOR OFFICIAL USE ONLY
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MDR Edits for CAPER
•
•
•
•
Note how the change edit flag is of variable length, and the
values don’t stay in the same position on each record?
If you just wanted records for say, the value “F”, you’d have to
create variables that indicate whether F appears in any
position of the change edit flag.
This means deriving 10 variables and then doing 10 slice and
dices to come up with all of the “F”s in each position.
Then you can add across all the positions.
13F
1F
1FG
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Relative Value Units
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What’s an RVU
• Basis of payment for most provider claims
 Each procedure code is given special “value”
based on expected expense.
 These values are called “RVUs”
 Doctor’s (and some others) are paid a certain
amount per RVU.
 In TRICARE, this translates to a CHAMPUS
Maximum Allowable Charge.
 (Additional non-RVU based payments are also
often made).
http://www.nhpf.org/library/the-basics/Basics_RVUs_02-12-09.pdf
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Types of RVUs
• There are three types of RVUS
• Work RVU
 Represents relative expense of the provider performing
the services represented by the procedure code.
• Practice Expense RVU
 Represents relative overhead expense associated with the
procedure.
 Includes nurses, supplies, billing, etc
 Different PE depending on whether care is provided in a
doctor’s office, or at another location.
• Malpractice RVU
 Relative expense (sort of) of malpractice insurance
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Where do the RVU Weights
Come From?
• CMS is the original producer of RVUs.
 But CMS only prepares RVUs for CPT/HCPCS codes that
they will pay for.
• Industry will develop RVUs for codes for things that
are not paid by CMS but normally paid by civilian
plans.
• Starting with an industry list, Health Affairs has a
group which:
 Adjusts global RVUs to accommodate MHS unique coding
 Modifies other weights in accordance with how HA would
like to reimburse the Services for ambulatory care.
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Example HCPCS Codes and
Relative Value Units
CPT
Description
Work
OR
Practice –
Practice own off
other
Malpractice
99201
Office/outpatient visit,
new pt, min
0.48
0.70
0.24
0.03
99211
Office/outpatient visit,
established pt, min
0.18
0.39
0.08
0.01
99281
Emergency dept visit
0.45
0.13
0.13
0.03
99291
Critical care, first hour
4.50
2.95
1.56
0.25
7/17/2015
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Where do the RVU Weights
Come From?
• Sometimes changes in RVUs are driven by CMS.
• CMS discontinued consult E&M codes for Medicare.
The MHS followed suit shortly thereafter.
• Also, pay attention to “Doc Fix” legislation, as this
could impact RVUs in the future, depending upon
how the “Sustainable Growth Rate” is implemented.
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SustainableGRatesConFact/index.html?redirect=/Sustainable
GRatesConFact/
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Work RVUs Associated with
Consults
CPT
Description
2010
2011
2012
99241 OFFICE CONSULT
0.64
0
0
99242 OFFICE CONSULT
1.34
0
0
99243 OFFICE CONSULT
1.88
0
0
99244 OFFICE CONSULT
3.02
0
0
99245 OFFICE CONSULT
3.77
0
0
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Trends in E&M Code RVU
Base Weights from CMS
Code
99201
99202
99203
99204
99205
99211
99212
99213
99214
99215
99217
Desc
Est Pt
New Pt
2008-2009 2009-2010 2010-2011 2011-2012
2%
6%
12%
3%
1%
6%
12%
2%
0%
6%
11%
2%
1%
6%
10%
1%
1%
6%
9%
1%
-4%
2%
10%
0%
0%
5%
12%
3%
1%
5%
11%
2%
1%
5%
11%
1%
1%
5%
10%
1%
0%
2%
8%
1%
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Trends in E&M Code RVUs
• CMS made significant changes to E&M codes in
2011.
• This is because of the consult code deletions –
providers were instructed to use E&M codes instead.
• Since the overwhelming majority of RVUs in the MHS
come from E&M codes, changes like these generally
result in significant increases in service budgets.
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MHS RVU Trend
Average Enhanced Total RVU
Service
2009
2010
2011
2012
A
1.91
1.96
2.12
2.18
F
1.77
1.84
1.99
2.06
N
2.21
2.20
2.33
2.44
2%
8%
4%
% Change Yr to Yr
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Where do the RVU Weights
Come From?
• Mostly, the weights that the MHS uses are CMSdriven.
• Exceptions:
 Weights are added for originally zero-weighted
procedures the MHS will value (like LASIK or t-cons)
 Weights are set to zero where funding has already been
provided under a different mechanism (pharmacy passthrough; a new change in 2012)
 Weights are also adjusted downward for global
procedures to avoid over-crediting MTFs due to different
data reporting practices.
FOR OFFICIAL USE ONLY
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Where do the RVU Weights
Come From?
• Global procedure codes:
 Cover more than 1 day of care.
 Include things like post-operative follow ups, or prenatal
and postpartum follows in the case of obstretrics.
• RVUs for a global procedure from CMS include the procedure
and pre/post care as applicable.
• Providers may not bill for the pre/post care that is already
covered under a global under Medicare (and TRICARE
Purchased Care, too).
• However, MTF providers must code the pre/post op care.
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Example of HA Adjustments
for Global CPT Codes
Sample CAPERs for Same Day Surgery Case
Person ID
Service
Date
MEPRS4
Code
E&M Code
1XXXXXXXXX
1/28/2010
BBDA
92014
1XXXXXXXXX
2/2/2010
BBD5
99499
1XXXXXXXXX
2/3/2010
BBDA
1XXXXXXXXX
2/8/2010
BBDA
Proc
Encounters
RVUs
1
1.42
1
7.87
99024
1
0.63
99024
1
0.63
4
10.55
66850
Total for the surgery and pre and post ops:
Direct Care Weight:
7.87
Purchased Care / Medicare Weight:
10.55
7/17/2015
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MHS RVU Table
• Can be downloaded directly from M2
• CPT/HCPCS Table contains RVU values.
• Be sure to incorporate the setting flag
into your queries.
 DC: For use with MTF Data
 PC: For use with TED Data
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Changes in Relative
Value Unit Policy
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Changes in RVU Policy
• RVUs continue to be the basis for funding the
Services for the O&M for most ambulatory care.
 Additional reimbursement is provided for ER and Same
Day Surgery based on “APC”s (called OPPS)
 Some types of ambulatory care are not funded via RVUs
(some immunizations, hearing conservation)
• There are 47 RVU elements in the CAPER, and 5 in
the TED.
 Selecting which RVU to use for a business question can
be complicated!
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Changes in RVU Policy
• Many of the extra RVU elements in the CAPER
represent provider or procedure specific values.
 These are not necessary in TEDs, where each record
contains only one provider and one procedure.
 Provider and procedure specific queries are simple in the
TED but a bear in the CAPER.
 There are plans to make a provider-procedure centric
version of CAPER in the MDR, structured like TEDs.
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Some RVU Elements from M2
Some of the CAPER
RVU elements
All of the TED RVUs
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Changes in RVU Policy
• Determining RVUs by provider in TEDs (claims) is
done by running a TED query by Provider NPI.
• Determining RVUs by provider in the CAPER is
similar to the change edit example.
 Create a query with all provider IDs and all providerspecific RVUs.
 Slice and dice appt provider with appt provider 1 RVUs.
 Provider 2 with provider 2 RVUs. Etc..
 Combined the summarized results and recap by provider,
regardless of which provider position was coded.
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Changes in RVUs
• Enhanced RVU in SADR:
 Was the primary source of RVU data until 2012, when
SADRS ceased to be processed.
 RVU Table was mapped to the CPTs on the SADR
 Multiplied by a slightly modified unit of service
 Based on 5 reported procedure codes. Other 8 mot
considered (minimal impact).
 Enhanced RVUs were calculated for many types of care
that were generally filtered out by users.
 For example, prov spec 910-999 for Service budget
calculations (PPS) and business plans.
 Only element processed consistently with purchased
care
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Changes in RVUs
• Enhanced RVU, Interim Plus in CAPER
 An “interim” element
 Has not generally been used for analysis due to timing
of MHS switch to CAPER and availability of Provider
Aggregate RVU.
• Provider Aggregate RVU in CAPER:
 Is now the primary source of RVU data for direct care
data (except for when comparing to purchased care).
 Rules for preparation of PARs incorporate many of the
“payment” rules used by TRICARE.
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Changes in RVUs
Some Differences
Edits
Discounting
Modifiers
Nurses / Skill Types
Multiple Providers
SADR Enhanced
CAPER PAR
Fewer Edits
New UOS, Prov
Spec/Tax
Discounting per PSI
No discounting
Minimal if any
implemented
Allowed credit
Some implemented
No credit for >1
Some credit for >1
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Restricted Credit
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Changes in RVUs
• Edits (noted earlier)
 Edits from source
 New edits in MDR
• Discounting:
 Used with multiple procedures; either more than one
of the same procedure, or more than one that are
different.
 Payment Status Indicator (PSI) tells whether a
procedure is subject to discounting.
 MDR uses the 3M PSI mappings; in the CPT/HCPCS
reference table in M2.
 100% RVU credit for highest weighted procedure, 50%
for all others (subject to PSI), generally
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Discounting Example
Qty
Base
RVU
No E&M
1
0.00
54200
Treatment of Lesion
1
0.89
64450
Injection / Nerve Block
1
1.27
Code
Description
99949
• Both procedures are subject to discounting.
• Enhanced RVU = 1.27 + .89 = 2.16
• Provider Aggregate RVU = 1. 27 + 50% (.89) = 1.71
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Discounting Example
• Notice that the procedure specific RVU for procedure
1 in CAPER says .44.
• This does not represent the weight for the CPT, but
rather, the discounted weight for provider aggregate
RVU.
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Changes in RVU Policy
Treatment of modifiers:
• Modifiers are rarely coded in MTF data, except for
lab and rad
• SADR Enhanced RVUs initially did not incorporate
any modifiers into the calculations.
• CAPER Provider Aggregate uses more modifiers.
• 5 modifier values are reflected in the CPT/HCPCS
weight table, and are applied that way, while others
are applied via programming code after application
of the weight table.
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Changes in RVU Policy
Modifiers listed in the CPT/HCPCS weight table:
• Professional Component
• Technical Component
• New DME
• Rental DME
• Used DME
If both TC and PC are coded, then the unmodified
weight is used.
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Changes in RVU Policy
Modifiers not listed in the CPT/HCPCS weight table that
are used in RVU calculations:
• Unrelated E&M service: Full credit unless otherwise
affected
• Bilateral Procedure: 150% credit
• Unusual Procedure: 120% credit
• Reduced/Discounted Procedure: 50% credit
• Follow up: 99024 credit
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Changes in RVU Policy
•
•
•
•
Code
Description
99949
No E&M
64493
Injection
Modifier
50
Qty
Base
RVU
1
0.00
1
1.52
Modifiers in Provider Aggregate
Enhanced RVU = 1.52
Provider Aggregate RVU = 150% (1.52) = 2.28
M2 shows 2.28 as the RVU for 64493 for procedure 1
in the CAPER while the CPT/HCPCS table shows 1.52.
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Changes in RVUs
• Provider specialty codes:
 Records with more than one independent provider are
rare.
• Enhanced RVUs only considered the primary
(appointment) provider’s work and did not
generally consider provider specialty, if one was
listed.
• Under PAR, multiple providers are considered, as
well as the provider specialty codes.
 Nurses and other non-independent providers will
receive credit only for certain CPT/HCPCS Codes.
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• Provider Aggregate RVU:
 The list of nurse-credited codes is in the CPT/HCPCS
reference table in M2 (Nurse Credit Flag).
 Also, under provider aggregate RVU, discounted credit is
applied for secondary independent providers (@20%).
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Changes in RVUs
•
•
•
•
Primary provider is a general surgeon
Secondary provider is a PA
Enhanced RVU does not recognize the additional provider.
PAR does. PAR = 1.16 + 20% (1.16) = 1.39
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Changes in RVUs
• Primary provider is a family practice MD
• Secondary provider is a general duty nurse
• Neither enhanced RVU nor PAR recognize the secondary
nurse provider.
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RVU Trends – Total Volume
• Very little difference
among the RVUs
• PAR is smaller than
the other two
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RVU Trends – Case Mix
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