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RBRVS

B

Blackhorse

Guru
Messages
229
Location
Orange, CA
Medicare fee schedule for 62321 is $314.94 with POS 11. We got paid $265 and was told it is paid based on RBRVS by AppleCare. Is RBRVS a fee schedule just like the physician fee schedule? How do I search for a price for 62321?
 
The Medicare fee schedule is based on the RBRVS (Resource-Based Relative Value Scale). Every CPT code has a RVU (relative value unit) that is a measure of how much work goes into it (in the simplest sense), with a geographic component (GPCI) thrown in.

The formula for the Medicare fee schedule is:

[(Work RVUs x Work GPCI) plus (Non-Facility Practice Expense RVUs x PE GPCI) plus (Professional Liability Expense RVUs x PL GPCI)] x Conversion Factor (CF)

For 2020, in my town GPCIs were: Work was 1.024, Practice Exp was 1.070, and Prof Liab was 0.580.

For sake of example, let's use 99215. The Work RVU for that code is 2.11; the PE is 1.85, and the PLI is 0.15

(2.11 x 1.024) plus (1.070 x 1.85) plus (0.580 x 0.15) = (2.161) plus (1.980) plus (0.087) = 4.228

So in my town, 99215 is worth 4.228 RVUs. Compare that to a surgery which may have RVUs in the double digits. The last component is the conversion factor. The Medicare conversion factor for 2020 was $36.09. So 4.228 times 36.09 = $152.59, which is what we got paid for a 99215 from Medicare. The beauty in this is that you don't have to refigure your fee schedule every year, all you do is change the conversion factor (to adjust for inflation, for instance), and your software (if it's set up properly) will adjust your fee schedule for you. Medicare doesn't go through every CPT code every year and manually change the dollar amounts; they simply adjust the conversion factor.

Apparently AppleCare has a different Conversion Factor than Medicare does.

This page (click me) gives you a brochure to help you understand, plus a link to a RBRVS Conversion Spreadsheet.
 
RBRVS is basically a scale to compare how much work, practice expense and malpractice expense are needed for each CPT. The locality applies a further adjustment (GPCI) to determine your RVUs.
The fee schedule is determined by the insurance company. I had never heard of AppleCare (other than for my iPhone) but Google tells me it's a Medicaid plan on the west coast. It would not be unusual for a Medicaid plan to pay less than Medicare. Most likely on their website, or in your contract, there is a fee schedule. Many insurances set their fee schedule by the RBRVS, but some do not.
 
I did look up Applecare and it appears it is an HMO that covers Medicare, Medi-Cal (California Medicaid) and some other plans. You should have a contract with them if you are seeing their patients. They have a webpage where you can login to find out their fee schedule.

If it is a Medi-Cal plan, then consider yourself lucky... regular Medi-Cal has a fee schedule that is generally 50% of Medicare.
 
"Pain Management Associates contract is 100% of current year RBRVS which is the national rate and the code comes out to $277.75. Once you deduct the small fees, the $265.98 would be the correct payment amount". What is current year RBRVS?
 
When you search in the Physician Fee Schedule, one of the options is "National Payment Amount". You'll see the non-facility price as $277.75.

1617063999918.png




If your locality is 0118226 (Orange County), then you will see that that is a more expensive area, and you would get paid more:

1617064074988.png

So it appears that Applecare does not use the geographic portion of the fee schedule, but instead uses the National Payment Amount. Here is the fee schedule lookup tool (click me). On the drop-down box that says "MAC Option", choose "National Payment Amount."
 
SharonCollachi said:
When you search in the Physician Fee Schedule, one of the options is "National Payment Amount". You'll see the non-facility price as $277.75.

View attachment 5218




If your locality is 0118226 (Orange County), then you will see that that is a more expensive area, and you would get paid more:

View attachment 5219

So it appears that Applecare does not use the geographic portion of the fee schedule, but instead uses the National Payment Amount. Here is the fee schedule lookup tool (click me). On the drop-down box that says "MAC Option", choose "National Payment Amount."
Click to expand...
I see, thank you so much!!! RBRVS is on the physician fee schedule. I really appreciate your help 👍👍👍
 
Our freestanding Pain Mgmt ASC has been billing out $12K for 62321 for POS 24. I ws recently hired to clean up the A/R. Do you think it is practical to expect even half of that in a payment from a PPO?
 
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