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Relative Value Units in the MHS Wendy Funk, Kennell and Associates

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Presentation on theme: "Relative Value Units in the MHS Wendy Funk, Kennell and Associates"— Presentation transcript:

1 Relative Value Units in the MHS Wendy Funk, Kennell and Associates

2 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 FOR OFFICIAL USE ONLY 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.

4 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.

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

6 FOR OFFICIAL USE ONLY 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.

7 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…

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

9 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 dont eliminate records, but rather, use edited values for some of the RVU calculations (and in some cases, overwrite the reported values)

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

11 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.

12 FOR OFFICIAL USE ONLY 12 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. MDR Edits for CAPER

13 FOR OFFICIAL USE ONLY 13 MDR Edits for CAPER Note how the change edit flag is of variable length, and the values dont stay in the same position on each record? If you just wanted records for say, the value F, youd 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 Fs in each position. Then you can add across all the positions. 13F 1F1F 1FG1FG

14 FOR OFFICIAL USE ONLY 14 Relative Value Units

15 FOR OFFICIAL USE ONLY 15 Whats 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 Doctors (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).

16 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 doctors office, or at another location. Malpractice RVU Relative expense (sort of) of malpractice insurance

17 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.

18 1/15/ CPTDescriptionWorkPractice – own off Practice - other Mal- practice Office/outpatient visit, new pt, min Office/outpatient visit, established pt, min Emergency dept visit Critical care, first hour OR Example HCPCS Codes and Relative Value Units

19 FOR OFFICIAL USE ONLY 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. Payment/SustainableGRatesConFact/index.html?redirect=/Sustainable GRatesConFact/


21 FOR OFFICIAL USE ONLY 21 Code Desc Est Pt 2%6%12%3% %6%12%2% %6%11%2% %6%10%1% %6%9%1% New Pt -4%2%10%0% %5%12%3% %5%11%2% %5%11%1% %5%10%1% %2%8%1% Trends in E&M Code RVU Base Weights from CMS

22 FOR OFFICIAL USE ONLY 22 Trends in E&M Code RVUs CMS made significant changes to E&M codes in 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.

23 FOR OFFICIAL USE ONLY 23 MHS RVU Trend Service A F N % Change Yr to Yr2%8%4% Average Enhanced Total RVU

24 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.

25 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.

26 1/15/ Person ID Service Date MEPRS4 Code E&M CodeProcEncountersRVUs 1XXXXXXXXX1/28/2010BBDA XXXXXXXXX2/2/2010BBD XXXXXXXXX2/3/2010BBDA XXXXXXXXX2/8/2010BBDA Total for the surgery and pre and post ops: Example of HA Adjustments for Global CPT Codes Direct Care Weight: 7.87 Purchased Care / Medicare Weight: Sample CAPERs for Same Day Surgery Case

27 MHS RVU Table 27 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 FOR OFFICIAL USE ONLY 28 Changes in Relative Value Unit Policy

29 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 APCs (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!

30 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.

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

32 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.

33 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

34 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.

35 FOR OFFICIAL USE ONLY 35 Some DifferencesSADR EnhancedCAPER PAR Edits Fewer EditsNew UOS, Prov Spec/Tax Discounting No discountingDiscounting per PSI Modifiers Minimal if any implemented Some implemented Nurses / Skill Types Allowed creditRestricted Credit Multiple ProvidersNo credit for >1Some credit for >1 Changes in RVUs

36 FOR OFFICIAL USE ONLY 36 Changes in RVUs Edits (noted earlier) 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

37 FOR OFFICIAL USE ONLY 37 Code DescriptionQty Base RVU No E&M Treatment of Lesion Injection / Nerve Block11.27 Discounting Example Both procedures are subject to discounting. Enhanced RVU = = 2.16 Provider Aggregate RVU = % (.89) = 1.71

38 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.

39 FOR OFFICIAL USE ONLY 39 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. Changes in RVU Policy

40 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.

41 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

42 FOR OFFICIAL USE ONLY 42 Code DescriptionModifierQty Base RVU No E&M Injection 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 Changes in RVU Policy

43 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) providers 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.

44 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

45 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

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

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

48 FOR OFFICIAL USE ONLY 48 RVU Trends – Case Mix

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