Use the PFS RVF to Expand Your Coding Knowledge

You’ll find a wealth of information in this single spreadsheet.

The Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule (PFS) Relative Value File (RVF) is a free, downloadable spreadsheet that compiles loads of useful information—from global periods to supervision requirements to proper modifier application—in a single, easy-to-navigate resource. Taking advantage of this resource can help to make you a better educated and more efficient coder.

Find It First

The PFS RVF is updated regularly on the CMS website. Files are available going back to 2003, so be sure you refer to the most recent version. The most up-to-date (as of writing this) RVF is named “RVU11B.”

After downloading and opening the “RVU11B” folder (compressed in .zip format), you will see over a dozen files in several formats. Of these, the two most useful are “PPRVU11.xls” and “RVUPUF11.doc.” The first of these files is a Microsoft® Office Excel spreadsheet (saved in .xls format) listing more than 10,000 physician services by CPT® or HCPCS Level II code. This is the RVF. The second file is a Microsoft® Office Word document (.doc) explaining the contents of, and indicators from, the RVF spreadsheet. Together, these two files contain a mother lode of coding information.

Navigating the Files

The RVF is arranged alpha-numerically by HCPCS Level II/CPT® code, with the code listed in “column A.” You can quickly find any individual code in the spreadsheet by holding down the “Ctrl” (or “command,” if you are a Macintosh user) and “F” keys simultaneously, and typing the code you wish to find in the search box.

Several dozen columns follow each code listing, providing a variety of values and indicators. For example, column C contains an abbreviated descriptor of the code, while column F is the first of several columns listing relative value units (RVUs) (work RVUs, practice expense RVUs, facility vs. non-facility totals, etc.).

The accompanying Word document describes the values in each column of the RVF spreadsheet. In other words, it helps you to interpret the RVF. For example, column D of the RVF spreadsheet is labeled “Status Code.” The Word file explains that the indicator in this column determines “whether the code is in the fee schedule and whether it is separately payable if the service is covered … Only RVUs associated with status codes of ‘A,’ ‘R,’ or ‘T,’ are used for Medicare payment.” It then explains the meaning of the “A,” “R,” “T,” and other indicators.

Global Guidance Made Easy

Under CMS guidelines, every procedure or service includes a global period, during which payment for the primary procedure or service includes related services and procedures. Global days may be found in column U of the RVF, as defined by one of six indicators:

000 – Codes with zero-day global periods include related preoperative and postoperative care on the day of the procedure only.

010 – A 10-day global period includes all related care the day of the procedure and for 10 days following the procedure.

090 – The 90-day global begins one day prior to the procedure and extends for 90 days. These are “major” services, and include one pre-procedure evaluation (either on the day of or day before the procedure).

MMM – The MMM indicator applies only to maternity codes, to which the usual global period rules do not apply. CPT® guidelines explain, “The services normally provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care.”

XXX – These services/procedures include only the service or procedure and its “inherent” evaluation and management (E/M) component.

YYY – CMS has not established a global period for the procedure at a national level. Instead, individual carriers may determine whether the global concept applies.

ZZZ – The ZZZ indicator is assigned to add-on or bundled codes, which do not have a global period of their own, but are included in another (primary) service’s global period.

Knowing the global period of a service/procedure has many applications, not the least of which is deciding whether you may report post-procedure services/procedures separately, and whether modifiers may apply (e.g., modifier 24 Unrelated evaluation and management service by the same physician during a postoperative period, modifier 58 Staged or related procedure or service by the same physician during the postoperative period, modifier 79 Unrelated procedure or service by the same physician during the postoperative period, etc.).

For example, a surgeon performs excisional breast biopsy (19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions) to examine a lump in the patient’s left breast. Pathology indicates a malignancy, for which surgeon subsequently performs a modified radical mastectomy (19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle).

Per chapter one of the National Correct Coding Initiative NCCI Manual for Medicare Policy Services, “If biopsy is performed on the same lesion on which a more extensive procedure is performed, it is separately reportable … if the biopsy is utilized for immediate pathologic diagnosis prior to the more extensive procedure, and the decision to proceed with the more extensive procedure is based on the diagnosis established by the pathologic examination.” The conditions are met in this example, and we may report both the biopsy (19120) and the mastectomy (19307). But is a modifier required?

Looking at RVF, you see 19120 has a 90-day global period. Because the mastectomy was a more extensive procedure during the global period of a previous procedure, we would append modifier 58 to 19307.

Multiple Procedure Rule Affects Payment

You’ve probably heard of the “multiple procedure rule,” which reduces Medicare payment by 50 percent for the second and subsequent procedures provided to the same patient on the same day. The logic of the rule is that pre- and post-procedure services are “combined” when multiple procedures are performed, which yields efficiencies that should be reflected in reimbursement. Column Y of the RVF determines exactly how the multiple procedure rule affects a given code, per the following indicators:

0 – Multiple procedure reductions do not apply. Usually, the “0” indicator is assigned to add-on codes (and other modifier 51 exempt codes), for which the assigned RVUs account for the “additional” nature of the procedure/service. Even when submitted with other procedures on the same day, codes with a “0” multiple procedure indicator should be reimbursed at full value.

Spinal bone grafts (e.g., 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)), for example, are “0” indicator codes that always occur with other procedures, such as spinal arthrodesis. Payment for 20930 would be 100 percent of the RVU total, regardless of how many additional procedures were performed during the same session.

2 – Standard multiple procedure reductions apply. As explained above, payers typically will reimburse 100 percent of the assigned RVUs for the primary procedure and 50 percent of the assigned RVU value for any subsequent procedures. For instance, the physician performs two procedures for which the standard multiple procedure reduction applies. The procedures are valued at 4 RVUs and 2.5 RVUs, respectively. The higher-valued procedure would be paid in full, while payment for the lesser procedure will be reduced by half, for a total of 5.25 RVUs (4 + (2.5/2) = 5.25).

3 – The “multiple endoscopy” rule applies. Medicare will pay the total RVUs for the highest-valued code in an endoscopic family. Payment for additional, same-day endoscopies in the same family is determined by subtracting the value of the base endoscopy from the value of the additional endoscopy(ies). You can find endoscopic base codes by consulting column AD (Endo Base) of the RVF.

For example, the surgeon performs sigmoidoscopy with tumor removal by hot forceps (45333 Sigmoidscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot forceps or bipolar cautery), followed by polyp removal by snare technique (45338 Sigmoidscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Because both scopes are in the same family, Medicare will reimburse the full value of the more extensive procedure (in this case, 45338), and will pay the second scope (45333) minus the value of the base procedure (45330 Sigmoidscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure), as found in column AD). The work value for 45338 is 2.34 RVUs. The work value for 45333 is 1.79 RVUs, from which you must subtract the 0.96 RVUs assigned to the base code, 45330 (which is already paid under the more extensive scope, 45338). The work RVU total for this claim is 3.17 (2.34 + 1.79 – 0.96 = 3.17).

4 – This indicator applies only the technical component of diagnostic imaging procedures, and works in a manner similar to the multiple endoscopy rule. If you report two or more diagnostic imaging tests from the same family (as indicated in column AH, “Diagnostic Imaging Family Indicator”), Medicare will reimburse 100 percent of the technical component value for the first test and 75 percent of the technical component value for each subsequent test. Payment for the professional component is not affected.

9 – The concept of multiple procedures does not apply (Medicare will make no payment adjustment).

Determine Modifier Application at a Glance

Several columns in the RVF pertain to modifier use. For example, column Z (Bilat Surg) indicates whether modifier 50 Bilateral procedure properly applies to a code and, if so, how it affects payment. A “0” indicator means that modifier 50 does not apply; a “1” means the payer will pay 150 percent of the fee schedule amount when modifier 50 is applied properly.

For example, 21282 Lateral canthopexy, a unilateral procedure performed on the eye has been assigned a “1” indicator for this column. If the physician performs canthopexy on both eyes, you may append modifier 50. In that case, the RVU total paid to the physician would increase by half.

Whether you may append modifier 62 Two surgeons is indicated in column AB (Co-surg). A “0” indicates you may not bill for co-surgeons; a “1” means you may append modifier 62 with documentation to establish medical necessity; a “2” means you may append modifier 62 as long as each of the operating surgeons is of a different specialty, and; a “9” means the concept of co-surgery does not apply (You should not report modifier 62 for these procedures).

For instance, a “1” in the CO-SURG column of 47100 Biopsy of liver, wedge tells you that Medicare will allow payment for two surgeons with modifier 62, as long as documentation can support the need for each surgeon. By the same token, you’d know that reporting 31237 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) with modifier 50 would be fruitless because that code is assigned a “0” co-surgery indicator.

Additional columns provide guidance on applying modifiers for team surgery (modifier 66 Surgical team) and assistants at surgery (modifiers 80, 81, 82, and AS, depending on the payer and circumstances).

Explore More on Your Own

The highlights above only scratch the surface of what the PFS RVF can reveal. Additional columns provide physician supervision requirements for diagnostic tests, the pre-, post-, and inter-operative values assigned to each code, and separate values for professional (modifier 26 Professional component) and technical components (modifier TC Technical component) of services. Do yourself a favor: Spend a little time with the RVF (and its explanatory file), and uncover a valuable resource to refine your coding and compliance efforts.

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G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

 

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