RBRVS: how new physician fee schedule will work - resource-based relative value scale payment system

Healthcare Financial Management, Sept, 1991 by Paul L. Grimaldi

* Initial and follow up consultations;

* Initial and follow up consultations;

* Initial and subsequent nursing facility visits; and

* Initial and subsequent rest home visits.

Payments would vary by site of service. Generally, payment in hospital settings would be lower because practice expenses would be incurred by the hospital (and paid under Medicare Part B);

* Levels of service. Each class of visit would consist of five levels of service. The levels would be differentiated by the content of the visit (complexity of medical treatment) and the average or typical physician encounter time with the patient; and

* Special patient needs. A service's content may vary because of communication barriers, a patient's cognitive or physical impairment, or the need for extraordinary counseling and coordination time. Based on documentation in the medical record, the service's relative value would be adjusted to recognize special patient needs.

Exhibit 4 contains proposed relative value units for several evaluation and management services and the corresponding new HCFA common procedure codes (HCPCS). At each level of service, the relative value unit for:

* An office visit for a new patient is higher than the value for an established patient;

* An initial consultation is higher than the value for a follow-up consultation; and

* An initial hospital visit is higher than the value for a follow-up hospital visit.

Relative value units for levels of physician visits to nursing facilities, rest homes, and domicialiary facilities have not been finalized. HCFA also is working on relative values for levels of emergency department services and preventive medicine. Although Medicare does not cover preventive medicine, codes for it are being revised so that reform of evaluation and management services coding is consistent.

Global surgery. Medicare carriers currently define a "global surgical package" differently. Differences may exist in the package's preoperative, interoperative, or postoperative component. A uniform definition is essential to implement a national fee schedule and to minimize the possibility of unbundling.

HCFA has tentatively identified the generic contents of a global surgical package for all settings in which physician services are rendered:

* A surgeon's initial evaluation and consultation would be paid separately;

* All of a surgeon's preoperative visits -- whether in or outside the hospital -- would be covered from evaluation until surgery;

* The global fee would cover all medical and surgical services related to a procedure that do not require a separate trip to the operating room. All medically necessary return trips would be billed separately and paid on the basis of the value of intra-operative services performed.

* The global fee generally would cover a 90-day postoperative period for all visits by a primary surgeon, unless the visit is for a condition unrelated to the diagnosis for which surgery was performed or is for an added course of treatment; and