October 1995 Bulletin

Academy helps RUC review of RBRVS codes

The resource-based relative value scale (RBRVS) was introduced as the physician payment system for the Medicare program on Jan. 1, 1992. At that time, Congress passed legislation mandating a review of the entire RBRVS at least once every five years. The Health Care Financing Administration (HCFA), which administers the Medicare program, and the medical community are currently conducting the first five-year review of Medicare work values, to take effect in 1997. The Academy is participating in the five-year review process through the AMA/Specialty Society Relative Value Scale Update Committee (RUC).

The five-year review has proven to be a difficult and time-consuming process, however, it is the best opportunity for specialty societies to address inequities in the current payment system.

The RUC was originally created in late 1991 by the AMA to provide HCFA with suggested physician work values for new or revised CPT codes not included in the original RBRVS. Twenty-two specialty societies are represented on the RUC, including the Academy. Alan H. Morris, MD, is the current orthopaedic RUC representative. Sixty-five medical and surgical specialty societies that participate in the AMA House of Delegates are represented on the RUC Advisory Committee. Members of the advisory committee present recommended work values on behalf of their specialty society to the RUC for consideration. A two-thirds vote is required for acceptance. The RUC then submits those accepted work values to HCFA as recommendations. During the past several years, more than half of the RUC recommendations have been accepted by HCFA.

For the five-year review process, HCFA solicited comments from the public (including medical specialty societies) and Medicare carrier medical directors, and then forwarded these comments to the RUC for review and recommendations. More than 1,100 codes were recommended for review. The RUC then directed the specialty societies to conduct mail surveys, using a survey format approved by the RUC, to gather "compelling evidence" that a particular code was misvalued in the current Medicare RBRVS and should be changed.

The Academy hoped to use the results of its Abt Associates study of physician work for orthopaedics, conducted in 1992, to serve as a substitute for the regular RUC survey process. The Abt study had involved the work of more than 100 orthopaedic surgeons, representing the musculoskeletal specialty societies, Academy clinical committees, and the Board of Councilors. The study included small consensus panels and a larger random sample telephone survey to produce a work value scale for virtually all orthopaedic procedures.

Reject study

When the Abt study was completed in 1992, the results were presented to HCFA. At that time, HCFA officials indicated that an appropriate time to address the findings of the Abt study would be during the five-year review process. This past spring, HCFA forwarded the Abt study report and findings to the RUC for its consideration. However, a research subcommittee of the RUC reviewed the methodology of the Abt study and determined that it would not be an acceptable substitute for the RUC survey process.

The Academy selected 83 codes to review in the survey process. The selected codes represented the most egregiously misvalued procedures in the current RBRVS, and included procedures performed by all of the musculoskeletal specialties within orthopaedics. Several hundred orthopaedic surgeons received mail surveys to contribute their input on the appropriate work value for these codes. Physicians were asked to assess the time and physician effort used to perform the procedures, and to assign an appropriate work value based on comparison to clinically similar "reference services." In order to bring a recommendation before the RUC, at least 30 physicians had to respond to each surveyed code, and the recommended work value had to be at least ten percent greater (or lower) than the current value. Nine of the codes surveyed by the Academy did not meet these criteria, and they were subsequently withdrawn from consideration.

Tell recommendations

In July, specialty societies presented their recommendations to small RUC workgroups. These workgroups were made up of three to four RUC members each, representing different specialties than the societies making the recommendations. Richard J. Haynes, MD, the Academy's advisor to the RUC, presented recommended work values for 74 orthopaedic codes at this meeting. Dr. Haynes was assisted by several other orthopaedic surgeons representing the musculoskeletal specialty societies.

Dr. Haynes and the others had to answer many detailed clinical questions about each surveyed code and each recommended work value; the entire presentation took about 13 hours.

The work groups reviewed each code presented and made one of the following recommendations:

The recommendations of each work group were then made to the full RUC at its meeting in late August for final consideration and approval. At this meeting, 37 of the codes presented by the Academy were recommended for an increase in work value by the RUC.

The final RUC recommendations were delivered to HCFA in September. HCFA will review the recommendations with the assistance of the Medicare carrier medical directors, and will publish interim work values for all the reviewed codes in the Federal Register in spring 1996. A period of public comment will follow the publication, during which specialty societies, physicians, and others will have a final opportunity to comment and offer additional information for HCFA to evaluate. At this time, it appears likely that Medicare reimbursement for several important orthopaedic procedures will increase in 1997. Once HCFA has made its final determination on work values, additional information will be forthcoming on how orthopaedics is affected.

- Reported by Laura Nuechterlein, Academy department of health policy

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