What Is the RUCKUS with the AMA/Specialty Society Relative Value Update Committee (RUC) Survey?

Jane T. Dillon, MD, and Tricia Bardon The AMA advocates for fair and accurate valuation for all physician services within the Resource-Based Relative Value Scale (RBRVS). To ensure that physician services across all specialties are well-represented, the AMA established the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC makes recommendations regarding valuation for new and revised Common Procedural Terminology (CPT) codes to the Centers for Medicare and Medicaid Services (CMS). The Academy actively participates in the RUC process, and as part of that process, you may be asked to participate in a survey to help value a CPT code. Familiarity with the survey instrument and methodology is essential for accurate completion of a survey and has important implications for code valuation. Survey instruments are standardized across all specialties. The purpose of the survey of a CPT code is to obtain estimates of: • Physician time and intensity/complexity; and • The relative value of the physician work component of the total relative value (total relative value includes physician work, practice expense, and professional liability components). RUC methodology involves determining the proper fit of the surveyed code within the existing relative value system. Definition of Physician Work Physician work includes the following elements: • The time it takes to perform the service; • Three intensity/complexity measures: • The mental effort and judgment necessary with respect to the amount of clinical data that needs to be considered, the fund of knowledge required, the range of possible decisions, the number of factors considered in making a decision, and the degree of complexity of the interaction of these factors; • The technical skill required with respect to knowledge, training, and actual experience necessary to perform the service and physical effort involved to perform the service; and • Psychological stress factors such as risk of significant complications, morbidity, and mortality; risk of a malpractice suit with a poor outcome. Physician work does not include services provided by support staff that are employed by your practice and cannot be billed separately including registered nurses, licensed practical nurses, medical secretaries, receptionists, and technicians. Survey Process A request for survey may originate from the CPT process (new or revised codes) or the RUC process (existing codes that are deemed by various criteria to require review). Once the request is received, the Academy must follow a well-defined process with short time frames. The major steps are: • Develop a short description of the service and typical patient for each code being surveyed. These “vignettes” will be included on the questionnaire form distributed to the survey participants. • Identify a representative sample of physicians who are familiar with the service or procedure they are being asked to evaluate. To be considered representative, samples must include a range of sub- specialization and generalists in the specialty (as appropriate for the codes being surveyed), practice circumstances and settings (e.g., solo practice, academic settings, large group practice, and HMOs), and relevant geographic and other dimensions. • Select a set of reference codes representative of a broad range of services and work relative values, which are well understood and commonly performed by members of the specialty. The work of the surveyed code will be compared to the work of the codes on this list. • Obtain responses from at least 30 physicians. A high response rate lends heightened credence to the results and facilitates an easier process for the Academy to gain support for the code values. • Discuss the survey results with a specialty-specific expert consensus panel to formulate specific recommendations for physician work value, procedure times, and number/level of visits. The panel also formulates recommendations for practice expense and physician liability insurance (PLI). Our Academy’s panel is the Physician Payment Policy Work Group (3P). Other physicians within our specialty are often asked to participate by providing expert opinion to the panel. • Submit the recommendations to the AMA. • Present the recommendations at the RUC meeting. Meetings take place three times per year. • The RUC may take one of several actions: approve the specialty society recommendation, modify the recommendation, or send it back to the specialty society or CPT for further input/modification. • The RUC sends its recommendations for work values, practice expense inputs, and PLI crosswalks to CMS. The recommendations are confidential until the CMS publication of the Final Rule in November. • Values go into effect in January of the following year. Please note that CMS determines the final value of any code for payment by Medicare. Throughout this process, it is important that we coordinate with the other specialty societies whose members also perform the surveyed procedure or service. Each society involved in developing a recommendation for a code should be involved in developing the vignette; reviewing the reference service list; selecting a sample of survey participants; convening a meeting to discuss the survey results; preparing a consensus recommendation; and presenting the recommendation to the RUC. The Academy often works with other specialty societies such as the American College of Surgeons (ACS), the American Society of Plastic Surgery (ASPS), and American Academy of Neurology (AAN) The Survey Instrument The survey instrument is based upon the service to a “typical patient,” which should guide responses. If you do not believe the vignette reflects the typical patient, this can be indicated on the survey. Other things to be aware of when you fill out a survey are: • Although contact and basic practice information is collected, your name is never forwarded to the AMA or used for tracking purposes. • If you have any questions, a specialty society’s contact information will be provided but the society cannot interfere in how you answer the survey. The survey includes a list of procedures that have been selected for use as comparison for this survey because their relative values are sufficiently accurate and stable to compare with other services. Select a procedure from the list that is most similar in time and work to the new/revised CPT code descriptor and typical patient/service described. This code does not have to be equal but should be similar in work. • It is very important to consider the global period when you are comparing the new/revised code to the reference code. • A service paid on a global basis includes: • Visits and other physician services provided within 24 hours prior to the service; • Provision of the service; • Visits and other physician services; for a specified number of days after the service is provided (000 day global = 0 days of post care included in the work relative value unit (RVU); 090 day global = 90 days of post care included in the work RVU). • Using the vignette and the description of service periods, the survey asks you to estimate how much time it takes you when you perform the procedure. These estimates should be based on personal experience. • The pre-service period includes physician services provided from the day before the operative procedure until the time of the operative procedure. • The intra-service period includes all “skin to skin” work that is a necessary part of the procedure. Immediate post service period includes physician services provided from the end of the intra-service period until discharge from recovery. • E&M visits both in the facility and in the office are assigned as the proxy for the physician work performed postoperatively. Although these services are not paid to surgeons separately for those procedures having greater than a 0 day global period, it is very important to carefully consider these visits, as they are built into the value of the code. • In the final step of the survey you are asked to estimate the work RVU. The value should be considered relative to the value assigned to the reference code you have chosen as a best fit to the surveyed code. Although this process may seem complicated, after you complete a few surveys you will become more comfortable with the survey process. Academy Representation at the RUC The Academy is fortunate to have dedicated and experienced representation at the RUC. Wayne M. Koch, MD, serves as the Academy’s RUC advisor. Serving on the RUC panel at a national level is Jane T. Dillon, MD, RUC panel member alternate and former Academy advisor, Charles F. Koopmann, MD, MHSH, RUC panel member, and Willard B. Moran, Jr., MD, the RUC practice expense review committee chair. Tricia Bardon, assistant director of health policy, serves as Academy staff to support the considerable efforts of these physicians. Any questions can be directed to her at TBardon@entnet.org.