Formulating UCR in the Absence of CMS Assigned RVUs

[martinni1974]

Good Afternoon,

Are there any coders working for payers or any other colleagues who could share how their companies formulate UCR when there is no RVU assigned to the code by CMS?

This may be a long shot in this forum but I figured it would be worth a shot.

The code in question is 00160.

Thanks in advance!

[cmcgarry]

This being anesthesia, there wouldn't be RVU's established by Medicare for it. There are various ways to figure reimbursement for anesthesia. The simplest, of course, is a percent of billed charges; but starting with the base factor for each is more accurate.

This code has a base factor of 5; if there were any physical status modifiers (P1 - P6), you would add those factors in (for example, P1 and P6 add zero because they add no complexity), then multiply this number by the conversion factor you choose. This would then be multiplied by the units filed on the claim (15 minutes = 1 unit) to get the allowance on that claim.

P1, P5 and P6 add zero; P2 adds 1 (one); P3 adds 2 (two) and P4 adds 3 (three) - I'm pretty sure. I'll check this text I have at home to make sure. To find the base factor, if you have Encoder Pro, call up the code - on the ranges page go over to the right and there's a button ANES - hover over that and you'll get the base factor. It's also listed on the main page with the code and description, etc. They're in some editions of CPT, but not all. The best source is a publication from the American Society of Anesthesiologists called the (YYYY) Relative Value Guide (2013 is now available).

Hope this helped you out!

[mambocoder]

I concur with this assessment. The CF's are also availabel through most MACs by locality or zip code so you may be able to find that. If oyu are good with statistics and can get the historical rates billed to your office you can find the 60th percentile (or some percentile your office agrees to use) of the bills and choose that rate for UCR.

-Jennifer
Medical Information Analyst (aka coder)
Direct General Insurance Co
Tampa office

Originally Posted by cmcgarry

This being anesthesia, there wouldn't be RVU's established by Medicare for it. There are various ways to figure reimbursement for anesthesia. The simplest, of course, is a percent of billed charges; but starting with the base factor for each is more accurate.

This code has a base factor of 5; if there were any physical status modifiers (P1 - P6), you would add those factors in (for example, P1 and P6 add zero because they add no complexity), then multiply this number by the conversion factor you choose. This would then be multiplied by the units filed on the claim (15 minutes = 1 unit) to get the allowance on that claim.

P1, P5 and P6 add zero; P2 adds 1 (one); P3 adds 2 (two) and P4 adds 3 (three) - I'm pretty sure. I'll check this text I have at home to make sure. To find the base factor, if you have Encoder Pro, call up the code - on the ranges page go over to the right and there's a button ANES - hover over that and you'll get the base factor. It's also listed on the main page with the code and description, etc. They're in some editions of CPT, but not all. The best source is a publication from the American Society of Anesthesiologists called the (YYYY) Relative Value Guide (2013 is now available).

Hope this helped you out!

[mambocoder]

I concur with this assessment. The CF's are also available through most MACs by locality or zip code so you may be able to find that. If you are good with statistics and can get the historical rates billed to your office, you can find the 60th percentile (or some percentile your office agrees to use) of the bills and choose that rate for UCR.

-Jennifer
Medical Information Analyst (aka coder)
Direct General Insurance Co
Tampa office

Originally Posted by cmcgarry

This being anesthesia, there wouldn't be RVU's established by Medicare for it. There are various ways to figure reimbursement for anesthesia. The simplest, of course, is a percent of billed charges; but starting with the base factor for each is more accurate.

This code has a base factor of 5; if there were any physical status modifiers (P1 - P6), you would add those factors in (for example, P1 and P6 add zero because they add no complexity), then multiply this number by the conversion factor you choose. This would then be multiplied by the units filed on the claim (15 minutes = 1 unit) to get the allowance on that claim.

P1, P5 and P6 add zero; P2 adds 1 (one); P3 adds 2 (two) and P4 adds 3 (three) - I'm pretty sure. I'll check this text I have at home to make sure. To find the base factor, if you have Encoder Pro, call up the code - on the ranges page go over to the right and there's a button ANES - hover over that and you'll get the base factor. It's also listed on the main page with the code and description, etc. They're in some editions of CPT, but not all. The best source is a publication from the American Society of Anesthesiologists called the (YYYY) Relative Value Guide (2013 is now available).

Hope this helped you out!