This year marks the third five-year review update of the Medicare fee schedule for physicians. The work relative value units for a large number of procedural codes, and therefore subsequent physician payment for those procedures, is predominantly determined by results of the Relative-value Update Committee survey, which will be given to physicians in May for completion by early August. Therefore, it is critical for the physicians who receive surveys to complete them in an accurate and timely manner.
This Coding Corner reviews the survey process in the interest of helping neurosurgeons understand the critical importance of completing surveys as well as the methods involved in the survey process itself.
Congress mandated that physician work values should be examined and challenged by individuals, medical specialty societies, or the Centers for Medicare and Medicaid Services no less than once every five years. The last major update to the neurosurgical physician work values occurred in 1995 under the leadership of Robert Florin, MD. Although the resource-based relative value system was originally developed by Drs. Hsiao and Braun more than 25 years ago, the American Medical Association’s RUC is responsible for maintenance and updates of the physician work relative value units.
For this year’s update process, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, the American Society of Anesthesiologists, the American Association of Pain Management, a consortium of primary care specialties, and the CMS itself, will submit recommendations to the RUC. The primary method for making physician work recommendations is the RUC survey process. The multispecialty physician members of the RUC critically analyze the survey results in the context of similar physician services with established work values in order to make recommendations to the CMS concerning the physician work value. Typically, the CMS accepts 95 percent of the RUC recommendations. Consequently, survey results largely determine the physician work relative value units in the Medicare fee schedule.
Survey Overview
Although the survey at first appears to be onerous and complicated, the actual components are fairly easy to understand and complete. It is important to keep in mind that most of the physician work values are driven by the amount of time the physician performs various components of the service as well as by the level and complexity of the postoperative follow-up during the global period, which is typically 90 days for most major surgical procedures.
The survey begins with a request to identify a reference procedure from a list of procedures. Based on a process termed magnitude estimation, most physicians can reliably compare one procedure with another and determine whether the work entailed is more, less or similar to the reference procedure. The relative value of the chosen reference procedure becomes the value to which the various physician work components of the surveyed procedure are compared. The remainder of the survey examines the preoperative, intraoperative, and postoperative components of a procedure.
Preoperative Period In the preoperative period (before skin incision), several physician activities are performed. A preoperative history and physical is required for admission to the hospital. It should be included in the work of the procedure if it is typically performed the day before or the day of the procedure and not separately billed. The physician is asked to estimate the time spent with the patient in the holding area reviewing the planned procedure, reviewing the documentation including radiographic and laboratory studies and consultant recommendations, obtaining or reaffirming the surgical consent form, and answering any questions from the patient, family, anesthesiologist, or surgical team. Additional time components before the skin incision is made include changing into surgical scrub attire, washing hands, waiting for anesthesia induction, positioning and prepping the patient, and affirming availability of the required equipment for the procedure. In the interest of completing the survey accurately, it may be helpful to actually keep track of the time required in these phases for a typical patient.
Intraoperative Period The intraoperative component describes the “skin-to-skin” time needed to complete the procedure for the “typical patient.” The vignette at the beginning of the survey summarizes a description of the typical patient and the primary components of the procedure. Rather than thinking of the overall time of the fastest case or most difficult case, the physician is asked to estimate the average time that is required to complete the procedure. Unfortunately, surgeons in particular frequently underestimate the actual time required to perform a procedure. Operative logs can be helpful in identifying the average time required.
Postoperative Period Upon closure of the skin, the postoperative period commences. The physician estimates the time in the immediate postoperative period required to return the patient to a gurney, complete postoperative orders, dictate an operative note, speak with the family, and bring the patient to the recovery room. The duration of a subsequent visit later in the day to check on the patient should be estimated as well, even for same day procedures in which discharge instructions are given. If the patient remains in
| Survey results largely determine the physician work relative value units in the Medicare fee schedule. |
The survey also asks for an estimation of the intensity and complexity of the surveyed procedure when compared with the reference procedure. Although the actual work value is not determined from these measures, the RUC uses these numbers to judge whether the reference procedure is more or less work than the surveyed procedure. At the end of the survey, the physician is asked to estimate the work RVU for the surveyed procedure.
Given the three months allowed for survey completion, it can be useful for the physician to obtain data from operative logs as well as measure the times of various components during their day to day practice in order to provide the most accurate data. Timely and accurate completion of the survey cannot be overemphasized.
Gregory J. Przybylski, MD, is professor and director of neurosurgery at JFK Medical Center in Edison, N.J. He is a member of the AANS/CNS Coding and Reimbursement Committee and on the faculty for AANS coding and reimbursement courses. He also is council director of socioeconomic affairs for the North American Spine Society and program chair of its coding update courses.
Related Articles
Florin RE. “Five-Year Review of the Medicare Fee Schedule Underway,” AANS Bulletin Summer 1995. www.AANNS.org, Article ID 10122.
Przybylski GJ. “Estimating a Physician’s Work,” AANS Bulletin Fall 2000. www.AANS.org, Article ID 10185.
