Vestibular Reimbursement – Part V

How is a code valued?

There are many more detailed explanations for those interested, but I will keep this post short and related to vestibular codes.

The first step, as mentioned last week, is to proceed from a category III to a category I code once data is collected regarding usage and effectiveness. The coding language (or description of the procedure or service) takes place at the CPT (Current Procedural Terminology) Editorial Panel.

The next step is to make a request to the RUC (Relative Value Scale Update Committee) to have the code surveyed to establish a value for the work RVU (explained below). A survey is then sent out to willing practitioners who are asked to rate the time and complexity of the procedure, and compare it to procedures with known valuations. This last part is called a Key Reference Service list, and lists procedures from the same profession and others used by other specialties. There is intentionally a wide range of values on this list, and the respondent is asked to choose one that most closely approximates the code undergoing survey.

The survey respondent must make an estimate of how long the procedure takes, and must break it down into three time blocks. Pre-service work includes things such as scheduling and chart review (things you or your staff do before you see the patient). Intra-service work time includes the time to perform the actual procedure. Post-work time includes report writing and counseling the patient and family after the procedure.

Then the survey respondent is asked to compare difficulty level (complexity) with the key reference service code chosen, and make an estimate of the most accurate RVU (Relative Value Unit) for the procedure. The RVU is directly related to reimbursement level.

Total RVU for a procedural code includes Work value (the professionals effort, skill, etc.), Practice Expense value (the cost of equipment, supplies, needed staff, etc), and Professional Liability Insurance. Once the professional society that requested the survey has gathered all this information, the code is brought before the RUC, a 29-member panel of mostly specialist physicians. The RUC asks questions, makes recommendations, and ultimately votes on recommended values and passes its suggestions along to Medicare. Medicare historically accepts these recommendations most of the time.

While this may sound complicated enough, in reality it is far more complicated than it sounds.

Because most of the physicians on the RUC are not ENT specialists or Neurologists, it is important that they have as clear an understanding as possible about the procedure in question. Next week, I will provide a sample of a description of CPT code 92541, Gaze and Spontaneous Nystagmus Test.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.