1. Relative Value Units in the MHS
Wendy Funk, Kennell and Associates
Recent Changes in RVU Measurements
Presenter: Ms. Wendy Funk (Kennell & Assoc.)
The purpose of this session is to characterize RVU measurement for Changes in RVU measurement will be discussed, and impacts of the changes will be quantified.
After completing this session the attendee can:
Define relative value unit
Describe changes in the underlying weights from CMS.
Identify families of codes for which the MHS uses different weights than CMS.
Characterize the difference between the enhanced total and the provider aggregate RVU.
Identify the appropriate RVU elements to use for make/buy, productivity, and other analyses.
Describe the components of an RVU and their role in payment (work, practice expense and malpractice)
Identify trends in workload, irrespective of changes in RVU weights.

2. Objectives Attendees can:
Characterize the differences between a SADR and CAPER professional encounter record.
Define an RVU and its components
Describe changes in the underlying Relative Value Unit weight tables
Characterize the difference between Enhanced RVUs in SADR, Enhanced RVUs in CAPER and Provider Aggregate RVUs in CAPER.
Identify trends in RVUs in the MHS

3. Professional Encounter Records
MTFs recently switched encounter record formats, from SADR to CAPER.
Standard Ambulatory Data Record (SADR).
Policy requiring collection of SADRs began in mid-1990s.
Initially, bubble sheets were used to collect encounter level data.
Bubble sheets were scanned, and resulting data were stored in the CHCS Ambulatory Data Module (ADM).
Coding compliance and quality were significant issues.
FOR OFFICIAL USE ONLY

4. Professional Encounter Records
AHLTA
A new data capture system for professional encounters was developed in the mid-2000s
System was originally intended to replace CHCS, but mission was scaled back considerably.
Serves as an electronic health record for ~85-90% of ambulatory care; other care still collected in CHCS. Not used at all for inpatient care.
Records that originate in AHLTA are sent back to CHCS ADM.
Coding quality continues to be an issue, but compliance has improved.
FOR OFFICIAL USE ONLY

5. Coding edits do not flow to CDR
Ambulatory Data Collection at MTFs
AHLTA
CDR
Coding edits do not flow to CDR
APPT
Coding Editor
CHCS ADM
CHCS Appt Module
MDR
ADM + AHLTA Records are in SADR file for MDR
CAPER
APPT

6. Professional Encounter Records
In 2003/2004, a broad set of new data element requirements were established for SADR.
SADR renamed “CAPER” (Comprehensive Professional Encounter Record)
Edit requirements were changed
CAPER data
Many years of development efforts.
SADR was not generally maintained after (updated, but needed fixes were not made)
Fully implemented CAPER data became available in 2011/2012.
FOR OFFICIAL USE ONLY

7. Professional Encounter Records
New data elements in CAPER but not in SADR:
Provider – procedure linkages
Procedure – diagnosis linkages
Additional procedure and diagnosis codes
Additional provider information
Appointment duration
Referral Information, appt type
Coding / Compliance Editor (CCE) information
Some others…
FOR OFFICIAL USE ONLY

8. CHCS Edit Logic on CAPERs and SADRs
Passed Edits Cleanly
SADR
SADR Edits
CAPER Only Edits
Passed Edits Cleanly
CAPER
SADR Edits
CAPER Only Edits
FOR OFFICIAL USE ONLY

9. New Edits on Encounter Records
New edits for CAPER enforced in CHCS (not in SADR). Records will not be sent with these edits:
CPT Code invalid
Appt Provider Specialty Code missing
Appt Provider has no taxonomy
New edits for CAPER in MDR as well.
SADRs had minimal unit of service edits and that is all.
More significant edits are applied to CAPER.
These edits don’t eliminate records, but rather, use edited values for some of the RVU calculations (and in some cases, overwrite the reported values)
FOR OFFICIAL USE ONLY

10. MDR Edits for CAPER 1 Units of Service changed (exceeded the limit) 2
Units of Service changed (reduced/terminated procedure-mod 52/73) 3
Units of Service changed (bilateral) 4
Recoding for bilateral procedure (code not appropriate for bilateral adjustment) 5
Recoding for bilateral procedure (using mod 50 to apply bilateral adjustment) 6
Surgical Followup (coded incorrectly) 7
Surgical Followup (credited as 99024) 8
Surgical Followup (no credit for E&M) 9
Surgical Followup (no credit for surgical code) A
TELCON (removed additional procedures) B
TELCON (no additional credit for coordinated care or case management codes) C
Provider/Procedure Pointer(s) modified (TELCON) D
Provider/Procedure Pointer(s) modified (multiple, same provider) E
Provider/Procedure Pointer(s) modified (invalid pointer) F
Provider/Procedure Pointer(s) modified (missing pointer) G
Provider/Procedure Pointer(s) modified (credit reassigned to Appt Provider) H
Procedure recoded as surgical follow-up based on Provider skill type Z
Various modifications (the number of applicable edits exceeds the space available)
FOR OFFICIAL USE ONLY

11. MDR Edits for CAPER
“Change Edit Flag” in M2 CAPER is there to identify the types of edits applied, but is very difficult to use except at record level.
FOR OFFICIAL USE ONLY

12. MDR Edits for CAPER
Change edit flag is a concatenation of all the flags that apply to a record.
Can review easily at record level.
Cannot use to look at the types of edits applied to more than one record w/o considerable work.
FOR OFFICIAL USE ONLY

13. MDR Edits for CAPER
Note how the change edit flag is of variable length, and the values don’t stay in the same position on each record?
If you just wanted records for say, the value “F”, you’d have to create variables that indicate whether F appears in any position of the change edit flag.
This means deriving 10 variables and then doing 10 slice and dices to come up with all of the “F”s in each position.
Then you can add across all the positions.
13F 1F
1FG
FOR OFFICIAL USE ONLY

14. Relative Value Units
FOR OFFICIAL USE ONLY

15. What’s an RVU Basis of payment for most provider claims
Each procedure code is given special “value” based on expected expense.
These values are called “RVUs”
Doctor’s (and some others) are paid a certain amount per RVU.
In TRICARE, this translates to a CHAMPUS Maximum Allowable Charge.
(Additional non-RVU based payments are also often made).
FOR OFFICIAL USE ONLY

16. Types of RVUs There are three types of RVUS Work RVU
Represents relative expense of the provider performing the services represented by the procedure code.
Practice Expense RVU
Represents relative overhead expense associated with the procedure.
Includes nurses, supplies, billing, etc
Different PE depending on whether care is provided in a doctor’s office, or at another location.
Malpractice RVU
Relative expense (sort of) of malpractice insurance
FOR OFFICIAL USE ONLY

17. Where do the RVU Weights
Come From?
CMS is the original producer of RVUs.
But CMS only prepares RVUs for CPT/HCPCS codes that they will pay for.
Industry will develop RVUs for codes for things that are not paid by CMS but normally paid by civilian plans.
Starting with an industry list, Health Affairs has a group which:
Adjusts global RVUs to accommodate MHS unique coding
Modifies other weights in accordance with how HA would like to reimburse the Services for ambulatory care.
FOR OFFICIAL USE ONLY

18. Example HCPCS Codes and Relative Value UnitsOR
CPT
Description
Work
Practice – own off
Practice - other
Mal-practice
99201
Office/outpatient visit, new pt, min
0.48
0.70
0.24
0.03
99211
Office/outpatient visit, established pt, min
0.18
0.39
0.08
0.01
99281
Emergency dept visit
0.45
0.13
99291
Critical care, first hour
4.50
2.95
1.56
0.25
3/25/2017

19. Where do the RVU Weights
Come From?
Sometimes changes in RVUs are driven by CMS.
CMS discontinued consult E&M codes for Medicare. The MHS followed suit shortly thereafter.
Also, pay attention to “Doc Fix” legislation, as this could impact RVUs in the future, depending upon how the “Sustainable Growth Rate” is implemented.
FOR OFFICIAL USE ONLY

20. Work RVUs Associated with
Consults
CPT
Description
2010
2011
2012
99241
OFFICE CONSULT
0.64
99242
1.34
99243
1.88
99244
3.02
99245
3.77
FOR OFFICIAL USE ONLY

21. Trends in E&M Code RVU Base Weights from CMS
Desc
99201
Est Pt 2% 6%
12% 3%
99202 1%
99203 0%
11%
99204
10%
99205 9%
99211
New Pt
-4%
99212 5%
99213
99214
99215
99217 8%
FOR OFFICIAL USE ONLY

22. Trends in E&M Code RVUs
CMS made significant changes to E&M codes in 2011.
This is because of the consult code deletions – providers were instructed to use E&M codes instead.
Since the overwhelming majority of RVUs in the MHS come from E&M codes, changes like these generally result in significant increases in service budgets.
FOR OFFICIAL USE ONLY

23. MHS RVU Trend Service 2009 2010 2011 2012 A 1.91 1.96 2.12 2.18 F 1.77
Average Enhanced Total RVU
Service
2009
2010
2011
2012 A
1.91
1.96
2.12
2.18 F
1.77
1.84
1.99
2.06 N
2.21
2.20
2.33
2.44
% Change Yr to Yr 2% 8% 4%
FOR OFFICIAL USE ONLY

24. Where do the RVU Weights
Come From?
Mostly, the weights that the MHS uses are CMS-driven.
Exceptions:
Weights are added for originally zero-weighted procedures the MHS will value (like LASIK or t-cons)
Weights are set to zero where funding has already been provided under a different mechanism (pharmacy pass-through; a new change in 2012)
Weights are also adjusted downward for global procedures to avoid over-crediting MTFs due to different data reporting practices.
FOR OFFICIAL USE ONLY

25. Where do the RVU Weights
Come From?
Global procedure codes:
Cover more than 1 day of care.
Include things like post-operative follow ups, or prenatal and postpartum follows in the case of obstretrics.
RVUs for a global procedure from CMS include the procedure and pre/post care as applicable.
Providers may not bill for the pre/post care that is already covered under a global under Medicare (and TRICARE Purchased Care, too).
However, MTF providers must code the pre/post op care.
FOR OFFICIAL USE ONLY

26. Example of HA Adjustments for Global CPT Codes
Sample CAPERs for Same Day Surgery Case
Person ID
Service Date
MEPRS4 Code
E&M Code
Proc
Encounters
RVUs
1XXXXXXXXX
1/28/2010
BBDA
92014 1
1.42
2/2/2010
BBD5
99499
66850
7.87
2/3/2010
99024
0.63
2/8/2010
Total for the surgery and pre and post ops: 4
10.55
Direct Care Weight:
Purchased Care / Medicare Weight:
3/25/2017

27. MHS RVU Table Can be downloaded directly from M2
CPT/HCPCS Table contains RVU values.
Be sure to incorporate the setting flag into your queries.
DC: For use with MTF Data
PC: For use with TED Data

28. Changes in Relative Value Unit Policy
FOR OFFICIAL USE ONLY

29. Changes in RVU Policy
RVUs continue to be the basis for funding the Services for the O&M for most ambulatory care.
Additional reimbursement is provided for ER and Same Day Surgery based on “APC”s (called OPPS)
Some types of ambulatory care are not funded via RVUs (some immunizations, hearing conservation)
There are 47 RVU elements in the CAPER, and 5 in the TED.
Selecting which RVU to use for a business question can be complicated!
FOR OFFICIAL USE ONLY

30. Changes in RVU Policy
Many of the extra RVU elements in the CAPER represent provider or procedure specific values.
These are not necessary in TEDs, where each record contains only one provider and one procedure.
Provider and procedure specific queries are simple in the TED but a bear in the CAPER.
There are plans to make a provider-procedure centric version of CAPER in the MDR, structured like TEDs.
FOR OFFICIAL USE ONLY

31. Some RVU Elements from M2
Some of the CAPER RVU elements
All of the TED RVUs
FOR OFFICIAL USE ONLY

32. Changes in RVU Policy
Determining RVUs by provider in TEDs (claims) is done by running a TED query by Provider NPI.
Determining RVUs by provider in the CAPER is similar to the change edit example.
Create a query with all provider IDs and all provider-specific RVUs.
Slice and dice appt provider with appt provider 1 RVUs.
Provider 2 with provider 2 RVUs. Etc..
Combined the summarized results and recap by provider, regardless of which provider position was coded.
FOR OFFICIAL USE ONLY

33. Changes in RVUs Enhanced RVU in SADR:
Was the primary source of RVU data until 2012, when SADRS ceased to be processed.
RVU Table was mapped to the CPTs on the SADR
Multiplied by a slightly modified unit of service
Based on 5 reported procedure codes. Other 8 mot considered (minimal impact).
Enhanced RVUs were calculated for many types of care that were generally filtered out by users.
For example, prov spec for Service budget calculations (PPS) and business plans.
Only element processed consistently with purchased care
FOR OFFICIAL USE ONLY

34. Changes in RVUs Enhanced RVU, Interim Plus in CAPER
An “interim” element
Has not generally been used for analysis due to timing of MHS switch to CAPER and availability of Provider Aggregate RVU.
Provider Aggregate RVU in CAPER:
Is now the primary source of RVU data for direct care data (except for when comparing to purchased care).
Rules for preparation of PARs incorporate many of the “payment” rules used by TRICARE.
FOR OFFICIAL USE ONLY

35. Minimal if any implemented
Changes in RVUs
Some Differences
SADR Enhanced
CAPER PAR
Edits
Fewer Edits
New UOS, Prov Spec/Tax
Discounting
No discounting
Discounting per PSI
Modifiers
Minimal if any implemented
Some implemented
Nurses / Skill Types
Allowed credit
Restricted Credit
Multiple Providers
No credit for >1
Some credit for >1
FOR OFFICIAL USE ONLY

36. Changes in RVUs Edits (noted earlier) Discounting: Edits from source
New edits in MDR
Discounting:
Used with multiple procedures; either more than one of the same procedure, or more than one that are different.
Payment Status Indicator (PSI) tells whether a procedure is subject to discounting.
MDR uses the 3M PSI mappings; in the CPT/HCPCS reference table in M2.
100% RVU credit for highest weighted procedure, 50% for all others (subject to PSI), generally
FOR OFFICIAL USE ONLY

37. Discounting Example Code Description Qty Base RVU 99949 No E&M 1 0.00
54200
Treatment of Lesion
0.89
64450
Injection / Nerve Block
1.27
Both procedures are subject to discounting.
Enhanced RVU = = 2.16
Provider Aggregate RVU = % (.89) = 1.71
FOR OFFICIAL USE ONLY

38. Discounting Example
Notice that the procedure specific RVU for procedure 1 in CAPER says .44.
This does not represent the weight for the CPT, but rather, the discounted weight for provider aggregate RVU.
FOR OFFICIAL USE ONLY

39. Changes in RVU Policy Treatment of modifiers:
Modifiers are rarely coded in MTF data, except for lab and rad
SADR Enhanced RVUs initially did not incorporate any modifiers into the calculations.
CAPER Provider Aggregate uses more modifiers.
5 modifier values are reflected in the CPT/HCPCS weight table, and are applied that way, while others are applied via programming code after application of the weight table.
FOR OFFICIAL USE ONLY

40. Changes in RVU Policy Modifiers listed in the CPT/HCPCS weight table:
Professional Component
Technical Component
New DME
Rental DME
Used DME
If both TC and PC are coded, then the unmodified weight is used.
FOR OFFICIAL USE ONLY

41. Changes in RVU Policy
Modifiers not listed in the CPT/HCPCS weight table that are used in RVU calculations:
Unrelated E&M service: Full credit unless otherwise affected
Bilateral Procedure: 150% credit
Unusual Procedure: 120% credit
Reduced/Discounted Procedure: 50% credit
Follow up: credit
FOR OFFICIAL USE ONLY

42. Changes in RVU Policy Code Description Modifier Qty Base RVU 99949
No E&M 1
0.00
64493
Injection 50
1.52
Modifiers in Provider Aggregate
Enhanced RVU = 1.52
Provider Aggregate RVU = 150% (1.52) = 2.28
M2 shows 2.28 as the RVU for for procedure 1 in the CAPER while the CPT/HCPCS table shows 1.52.
FOR OFFICIAL USE ONLY

43. Changes in RVUs Provider specialty codes:
Records with more than one independent provider are rare.
Enhanced RVUs only considered the primary (appointment) provider’s work and did not generally consider provider specialty, if one was listed.
Under PAR, multiple providers are considered, as well as the provider specialty codes.
Nurses and other non-independent providers will receive credit only for certain CPT/HCPCS Codes.
FOR OFFICIAL USE ONLY

44. Provider Aggregate RVU:
The list of nurse-credited codes is in the CPT/HCPCS reference table in M2 (Nurse Credit Flag).
Also, under provider aggregate RVU, discounted credit is applied for secondary independent providers
FOR OFFICIAL USE ONLY

45. Changes in RVUs Primary provider is a general surgeon
Secondary provider is a PA
Enhanced RVU does not recognize the additional provider.
PAR does. PAR = % (1.16) = 1.39
FOR OFFICIAL USE ONLY

46. Changes in RVUs Primary provider is a family practice MD
Secondary provider is a general duty nurse
Neither enhanced RVU nor PAR recognize the secondary nurse provider.
FOR OFFICIAL USE ONLY

47. RVU Trends – Total Volume
Very little difference among the RVUs
PAR is smaller than the other two
FOR OFFICIAL USE ONLY

48. RVU Trends – Case Mix
FOR OFFICIAL USE ONLY