RVU File Contains Essential Coding Information for Family Practices
HCFA updates the RVU file annually and posts it on its Web site. There is a lot of valuable information coders can have right on their desktop, simply by downloading the file, points out Jennifer Butler, billing operations manager with Arizona Medical Provider Services Inc., in Cottonwood, Ariz., which provides billing and management services to physician practices in Arizona.
The RVU file used as the basis for this article can be found on the HCFA Web site (www.hcfa.gov). Directions for downloading are on the insert accompanying this issue of Family Practice Coding Alert. The RVU file was also published in the November 2000 Federal Register. However, that version appears in a modified format, and column headings differ from those downloaded from HCFA and appearing in this story.
Columns A, B, C and D
Each column of the RVU file provides information of value to coders. The fields explained below are those that most affect family practice coding. Those that dont appear have minimal impact.
Column A lists the codes, while Column C contains abbreviated code descriptions. Column B (Modifiers) identifies whether the code has a professional or technical component. These are indicated with modifier -26 (professional component or PC) or modifier -TC (technical component), Butler says. If a code has both TC and PC portions and the field is blank, it generally means that the service is global.
Some codes may be reported any of these three ways, Butler notes, such as 73600 (radiologic examination, ankle; two views), which appears three times in the file once with no indication in the modifier column, once with modifier -TC and once with modifier -26. (See insert.) A family physician (FP) who owns x-ray equipment and interprets the films would assign 73600 globally, while the FP who performs an x-ray but then asks a radiologist to interpret the film would code 73600-TC.
Further information about these modifiers is in Column Q (PC/TC Indicator). Numeric indicators are assigned to each CPT code to specify which modifiers may be appended. A 0 in this column, for instance, signifies that the code represents physician services only (e.g., E/M codes) and that no -26 or -TC modifier applies. A 1 denotes a diagnostic service such as pulmonary function tests (e.g., 94010) where modifiers -26 or -TC may be used.
An indicator of 2 signals that the code describes the professional component only (e.g., 93010, electrocardiogram, routine ECG with at least 12 leads; interpretation and report only). This indicator represents the physician work involved with diagnostic tests when there is an associated code describing the technical component (93005, electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report). The corresponding technical codes carry an indicator of 3 in column Q to indicate they represent only the staff and equipment costs for the service. Because codes with a 2 or 3 in column Q are already identified as professional component or technical component only codes, a -26 or -TC modifier is unnecessary.
Column D indicates the current status of the code. An A indicates the code is active, while R represents restrictions where special coverage instructions apply. A status indicator D shows that it has been deleted, explains Anne Masters, a coding specialist who works with Butler.
Codes designated with an I are not valid for Medicare. Alternately, they may be reported with HCPCS Level II codes. One example is code 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). This service would be reported with G0001 (routine venipuncture for collection of specimen[s]) for Medicare beneficiaries.
Less common designations include C, which is often assigned to unlisted services (e.g., 90799, unlisted therapeutic, prophylactic or diagnostic injection) to indicate that local carriers determine the fee allowance; B, signifying that the code is bundled into another primary procedure (e.g., 36540, collection of blood specimen from a partially or completely implantable venous access device); and N, indicating codes not covered by Medicare (e.g., 58300, insertion of intrauterine device [IUD]).
Determining Relative Value Units
Relative value units found in 10 fields ranging from F to P are the foundation for calculating Medicare payments. FPs are also finding that more and more private practices use RVUs as a basis to calculate physician compensation.
Three components physician work, practice expense and malpractice expense are added together to produce the RVU total. Physician work (Column F) and malpractice (Column L) RVUs occupy one column each, but practice expense may vary depending on whether the service is performed in a facility (e.g., hospital) or nonfacility (e.g., office).
Additionally, both facility and nonfacility practice expense RVUs are listed two ways: transitioned and fully implemented. The difference relates to HCFA adjustments of fees paid for procedures over a four-year cycle that began in 1999. For procedures or services performed in 2001, only the transitioned column applies. In 2002, when HCFAs fee schedule changes are in place, the fully implemented column will be applicable.
The file also provides the total number of RVUs for each procedure, so coders do not have to add the columns. There are four columns with this information (Columns M-P), again relating to the setting (facility or nonfacility) in which the procedure or service was performed and including both transitional and fully implemented fees.
For example, the total number of RVUs (2.66) for the destruction of a 1-cm malignant lesion on a patients arm (17261) performed in the office in 2001 is found in Column N, which lists the transitioned total RVUs for services performed in a nonfacility (see sample on enclosed insert).
Geographic Practice Cost Indices (GPCIs) have also been developed to adjust the RVUs on a regional basis. Because there are separate GPCIs for work, practice expense and malpractice, GPCI adjustments cannot be applied to the total RVU column. Rather they must be made to each of the respective three specific RVUs, which are then added to determine the GPCI adjusted total. This number is multiplied by the current National Conversion Factor ($38.2581 in 2001) to arrive at the Medicare Fee Schedule expected allowance (see example below).
RVUs are not meant to guide physicians on how much to bill. Because some payers exceed Medicares fee schedule, coding experts agree that physicians should bill based on internal fee calculations and not use Medicares fee as a baseline.
Global Periods and Multiple Procedures
Columns R, S, T and U provide information about global periods. Column R indicates the number of global days HCFA assigns to a procedure or service (i.e., 0-, 10-, or 90-day global periods). For instance, they assign 26720 (closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each) a 90-day global period.
In addition, the RVU file includes procedures with global periods XXX (the global concept does not apply), YYY (carrier determines if a global period applies and establishes the postoperative period, if appropriate, at the time of pricing), and ZZZ (the code is related to another service and is always included in the global period of the other service). The XXX designation typically applies to diagnostic tests, such as 73600 or 74000 (radiologic examination, abdomen; single anteroposterior view) and E/M services, while ZZZ is for add-on codes.
Column V indicates how a procedure should be paid if it is not the primary procedure performed during the session. Diagnostic tests, like x-rays, usually include an indicator of 0, meaning that no payment adjustment is made and the service is paid at 100 percent even if it was performed at the same time as another service. Other procedures, on the other hand, may have an indicator of 2, meaning the standard multiple-procedure payment rule (100 percent for the highest-paying procedure, 50 percent for all the others) applies.
For instance, a 10-year-old boy tripped during a cookout and fell against a hot grill. Besides incurring first- degree burns on the palm of his left hand, he suffered a simple fracture of his forearm (radius). The family practice coder may report both 25500 (closed treatment of radial shaft fracture; without manipulation) and 16000 (initial treatment, first degree burn, when no more than local treatment is required). Because both codes carry an indicator of 2 in the multiple procedures column, 25500 would be paid at 100 percent, while 16000 would be paid at 50 percent.
Bilateral Procedures
Column W tells physicians and coders how a procedure should be paid if it is performed on both sides. Procedures that cannot be billed as bilateral simply because two sides do not exist (e.g., 44900, incision and drainage of appendiceal abscess; open) will show a 0 in column W. Alternatively, if the procedure can be performed on two sides and there are distinct codes for the procedure when performed bilaterally and unilaterally, the unilateral procedure will show a 0 in column W as well (i.e., 73500, radiologic examination, hip, unilateral; one view).
If the procedure shows a 1 in column W and is reported with modifier -50 (bilateral procedure) or by any other means such as -RT (right side) and -LT (left side) modifiers or with a 2 in the units field of the HCFA 1500 claims form there is a 150 percent payment adjustment, says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions in Lakewood, N.J.
If column W contains a 2 (e.g., 73050), no fee adjustment should be made because the RVUs for the code assume a bilateral procedure. If a procedure performed bilaterally includes a 3 in column W (e.g., 73600), both sides should be billed at 100 percent. A 9 in column W indicates that the concept of bilateral procedures does not apply.
By definition, Geographic Practice Cost Indices differ from region to region. Here is an example of how a joint injection would be calculated in Ohio.
Procedure: A joint injection (20600), performed in the office (nonfacility), transitional for 2001.
Work Practice Expense Malpractice
National RVU: 0.66 1.14 0.06
Ohios GPCI: 0.989 0.941 1.016
To determine the total RVUs for Ohio, multiply the national RVU by the Ohio GPCI, and add:
Work 0.66 x 0.989 = 0.65274
PE 1.14 x 0.941 = 1.07274
MP 0.06 x 1.016 = 0.06096
TOTAL 1.78644
To calculate the actual fee schedule amount for a joint injection, multiple the GPCI-corrected total RVU by the National Conversion Factor of $38.2581. This reveals that the anticipated Medicare payment would equal $68.35 in 2001.
