Use RBRVS to Set Your Fees
Published on Wed Nov 01, 2000
If you have already converted your practice fee schedule to one based on the resource-based relative value scale (RBRVS), good for you you have solid ground to stand on when battling for higher reimbursements from insurance companies. But if youre like most pediatricians, you havent made the leap yet. Part of this lag is because pediatricians rarely work in the Medicare system, where the Medicare RBRVS is the de-facto physician fee schedule. But pediatricians need to know about RBRVS because it can help them set fee schedules that work for them, not against them. If nothing else, using RBRVS guarantees that there is a level playing field among physicians.
RBRVS is a system that establishes a total work value for any procedure or service in CPT, explains Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics (AAP) coding and reimbursement committee and the founding chair of the AAPs RBRVS project advisory committee (PAC). RBRVS takes into account three components: physician work, practice expense, and malpractice expense. Those three components, totalled together, give the total relative work value for a code, says Tuck. To arrive at a fee, you multiply the RVU by the current conversion factor, which for the year 2000 is $36. This will give you the Medicare fee for the code. As will be seen, you need to use a higher conversion factor or percentage of Medicare RVU if you are a pediatrician setting a fee schedule. But the point is that once youve accepted the RBRVS, then you can use any conversion factor and arrive at relative fees that make sense.
More Than Medicare
Pediatricians who work mainly with commercial insurance companies should know that the Medicare fee schedule is less than theirs should be. When negotiating contracts with private payers, set reimbursement on Medicare, multiplied by a percentage. Lee F. Thompson, MD, FAAP, a member of the AAPs coding and reimbursement committee and a practicing physician in Denver, recommends 130 percent of 2000 RBRVS. You should try to get 125 to 130 percent of the RBRVS, he says.
And you need to pay careful attention to E/M services codes because they constitute the majority of the codes you will be billing. Pediatrics is different from surgery, notes Thompson. Seventy-five to 80 percent of our codes are E/M services codes.
A.D. Jacobson, MD, FAAP, a former member of the AAP coding and reimbursement committee, suggests another approach. You need to use what you do most as the basis for your fees. The most common code used in pediatrics is CPT 99213 (established patient office or other outpatient visit). So you must be very careful about what fee you set for that code, [...]
