Mar 26, 2015
Relative Value Units in the MHS
Wendy Funk, Kennell and [email protected]
2
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
FOR OFFICIAL USE ONLY3
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.
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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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CHCS ADMCHCS
Appt Module
Coding Editor
APPT
CDR
ADM + AHLTA Records are in SADR file for MDR
MDR
Ambulatory Data Collection at MTFs
AHLTA
APPT
Coding edits do
not flow to CDR
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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Passed Edits Cleanly
SADR Edits
CAPER Only Edits
SADR
Passed Edits Cleanly
SADR Edits
CAPER Only Edits
CAPER
CHCS Edit Logic on CAPERs and SADRs
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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 CAPER1 Units of Service changed (exceeded the limit)
2Units of Service changed (reduced/terminated procedure-mod 52/73)
3 Units of Service changed (bilateral)
4Recoding for bilateral procedure (code not appropriate for bilateral adjustment)
5Recoding for bilateral procedure (using mod 50 to apply bilateral adjustment)
6 Surgical Followup (coded incorrectly)7 Surgical Followup (credited as 99024)8 Surgical Followup (no credit for E&M)9 Surgical Followup (no credit for surgical code)A TELCON (removed additional procedures)
BTELCON (no additional credit for coordinated care or case management codes)
C Provider/Procedure Pointer(s) modified (TELCON)
DProvider/Procedure Pointer(s) modified (multiple, same provider)
E Provider/Procedure Pointer(s) modified (invalid pointer)F Provider/Procedure Pointer(s) modified (missing pointer)
GProvider/Procedure Pointer(s) modified (credit reassigned to Appt Provider)
HProcedure recoded as surgical follow-up based on Provider skill type
ZVarious 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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• 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.
MDR Edits for CAPER
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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 claimsEach 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.
04/10/2318
CPT Description Work Practice – own off
Practice - other
Mal-practice
99201Office/outpatient visit, new pt, min 0.48 0.70 0.24 0.03
99211Office/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
OR
Example HCPCS Codes and Relative Value Units
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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-Service-Payment/SustainableGRatesConFact/index.html?redirect=/SustainableGRatesConFact/
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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
Work RVUs Associated with Consults
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Code Desc2008-2009
2009-2010
2010-2011
2011-2012
99201
Est Pt
2% 6% 12% 3%99202 1% 6% 12% 2%99203 0% 6% 11% 2%99204 1% 6% 10% 1%99205 1% 6% 9% 1%99211
New Pt
-4% 2% 10% 0%99212 0% 5% 12% 3%99213 1% 5% 11% 2%99214 1% 5% 11% 1%99215 1% 5% 10% 1%99217 0% 2% 8% 1%
Trends in E&M Code RVU Base Weights from CMS
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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
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
% Change Yr to Yr 2% 8% 4%
Average Enhanced Total RVU
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Where do the RVU Weights Come From?
• Mostly, the weights that the MHS uses are CMS-driven.
• 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 pass-through; a new change in 2012)
Weights are also adjusted downward for global procedures to avoid over-crediting MTFs due to different data reporting practices.
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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.
04/10/2326
Person IDService
DateMEPRS4
CodeE&M Code Proc Encounters RVUs
1XXXXXXXXX 1/28/2010 BBDA 92014 1 1.42
1XXXXXXXXX 2/2/2010 BBD5 99499 66850 1 7.87
1XXXXXXXXX 2/3/2010 BBDA 99024 1 0.63
1XXXXXXXXX 2/8/2010 BBDA 99024 1 0.63
Total for the surgery and pre and post ops: 4 10.55
Example of HA Adjustments for Global CPT Codes
Direct Care Weight: 7.87
Purchased Care / Medicare Weight: 10.55
Sample CAPERs for Same Day Surgery Case
MHS RVU Table
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• 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 of the CAPER RVU elements
All of the TED RVUs
Some RVU Elements from M2
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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 provider-
specific 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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Some Differences
SADR Enhanced
CAPER PAR
EditsFewer Edits New UOS, Prov
Spec/Tax
DiscountingNo discounting Discounting per
PSI
ModifiersMinimal if any implemented
Some implemented
Nurses / Skill Types
Allowed credit Restricted Credit
Multiple Providers
No credit for >1
Some credit for >1
Changes in RVUs
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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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Code Description QtyBase RVU
99949 No E&M 1 0.00
54200 Treatment of Lesion 1 0.89
64450 Injection / Nerve Block 1 1.27
Discounting Example
• 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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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.
Changes in RVU Policy
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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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Code Description Modifier QtyBase RVU
99949 No E&M 1 0.00
64493 Injection 50 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.
Changes in RVU Policy
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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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• Primary provider is a family practice MD• Secondary provider is a general duty nurse• Neither enhanced RVU nor PAR recognize the secondary
nurse provider.
Changes in RVUs
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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