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Kalmar CL, Patel VA, Golinko MS. Surgical Complexity and Physician Workload in Craniofacial Surgery: Do RVUs Need to be Adjusted? J Craniofac Surg 2024:00001665-990000000-01320. [PMID: 38315753 DOI: 10.1097/scs.0000000000009989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 11/16/2023] [Indexed: 02/07/2024] Open
Abstract
RVU valuations need to be revisited regularly as procedure complexity and patient care pathways continue to evolve. The NSQIP-P database was queried for craniofacial procedures performed in North America between 2012 and 2019. Multivariate regression was performed to determine correlation coefficients of perioperative variables deemed to reflect procedure severity, including procedure duration, blood transfusion, length of stay, serious adverse events, related readmission, and related reoperation. CPT 21159 Le Fort III with forehead advancement remains the craniofacial procedure with the highest RVUs using our model at 33.93 units. The most underestimated procedure is CPT 42235 Repair of anterior palate, including vomer flap, with a suggested change of +8.27 units, which is a 194% increase from current compensation. Adjusted RVUs based on quantitative and nationally representative perioperative variables that reflect procedure severity might be a better alternative for procedure valuation over current survey methods to determine appropriate insurance compensation.
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Affiliation(s)
- Christopher L Kalmar
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Vijay A Patel
- Department of Head & Neck Surgery, UCLA Health, Los Angeles, CA
| | - Michael S Golinko
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN
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Wu G, Segovis CS, Nicola LP, Chen MM. Current Reimbursement Landscape of Artificial Intelligence. J Am Coll Radiol 2023; 20:957-961. [PMID: 37604328 DOI: 10.1016/j.jacr.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 08/23/2023]
Abstract
One of the biggest hurdles to widespread adoption of new procedures and technology such as artificial intelligence (AI) algorithms is payment and coverage policy. Noninvasive assessment of coronary fractional flow reserve is one AI imaging algorithm that will successfully achieve reimbursement through multiple pathways of CMS payment mechanisms in 2024. CMS is the largest provider of health care in the United States. Understanding how this AI algorithm is paid through the different fee schedules will help to understand the challenges CMS has in paying for new services and innovation in the United States.
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Affiliation(s)
- George Wu
- Department of Radiology, Baylor College of Medicine, Houston, Texas
| | - Colin S Segovis
- Medical Director for the Revenue Cycle Operations, Director of MRI Quality and Safety, Codirector of Radiology Elective Clerkship for the Department of Radiology and Imaging Sciences, Department of Radiology, Emory University School of Medicine, Atlanta, Georgia; American Society of Neuroradiology CPT (Current Procedure Terminology) Advisor, Chair of the ASNR Economics Committee and Treasurer of the Georgia Radiological Society
| | - Lauren P Nicola
- Chief Executive Officer, Triad Radiology Associates, Winston Salem, North Carolina; Inpatient Medical Director of Novant Forsyth Medical Center, ACR Relative Value Scale Update Committee Advisor, Chair of the ACR Reimbursement Committee, and member of the ACR Board of Chancellors as the Chair of the Ultrasound Commission
| | - Melissa M Chen
- Patient Safety Quality Officer for Diagnostic Imaging and is Associate Executive Director for the MD Anderson Cancer Network, Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas; American Society of Neuroradiology Relative Value Scale Update Committee Advisor, Chair of the American Society of Neuroradiology Health Policy Committee, ACR Council Steering Committee Member, and Treasurer for the Texas Radiological Society.
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Correlation of Relative Value Units With Surgical Complexity and Physician Workload: A Contemporary Nationwide Analysis of Orthopaedic Procedures. J Am Acad Orthop Surg 2023; 31:413-420. [PMID: 36749881 DOI: 10.5435/jaaos-d-22-00866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/31/2022] [Indexed: 02/09/2023] Open
Abstract
INTRODUCTION Although previous studies have demonstrated inconsistencies between surgeon work and reimbursement, no previous study has calculated expected relative value units (RVUs) based on procedure-specific variables. Our study aimed to evaluate how measures of physician workload and surgical complexity correlate with the work RVUs (wRVUs) assigned to orthopaedic procedures and compare our predicted wRVUs with actual wRVUs. METHODS The National Surgical Quality Improvement Program was used to identify orthopaedic surgeries with the highest procedural volume in 2019. For each Current Procedural Terminology (CPT) code, variables related to surgical complexity and postoperative management were retrieved. A multivariable linear regression was conducted, and R2 values were calculated. RESULTS A total of 229,792 cases from the top 20 CPT codes by frequency in 2019 were identified. Base RVU values ranged from 7.03 mRVUs for arthroscopic meniscectomy to 30.28 mRVUs for revision total hip arthroplasty. A total of 15 (75%) of the projected mRVUs were lower than the actual mRVU of the procedure. For the 5 (25%) procedures with mRVU projections higher than actual values, the largest differences were seen for CPT codes 29,888 (arthroscopic anterior cruciate ligament [ACL] repair; difference: 7.81), 22,630 (posterior arthrodesis of the lumbar interbody; difference: 7.75), and 27,487 (revision total knee arthroplasty; difference: 4.04). CONCLUSION Our analysis demonstrates that current orthopaedic wRVUs do not appropriately compensate for objective measures of overall complexity as it relates to each procedure. Significant undercompensation in projected RVUs was noted for several high-volume orthopaedic procedures including arthroscopic ACL repair and revision total knee arthroplasty.
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Chen MM, Golding LP, Nicola GN. Who Will Pay for AI? Radiol Artif Intell 2021; 3:e210030. [PMID: 34142090 DOI: 10.1148/ryai.2021210030] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 12/18/2022]
Abstract
In 2020, the largest U.S. health care payer, the Centers for Medicare & Medicaid Services (CMS), established payment for artificial intelligence (AI) through two different systems in the Medicare Physician Fee Schedule (MPFS) and the Inpatient Prospective Payment System (IPPS). Within the MPFS, a new Current Procedural Terminology code was valued for an AI tool for diagnosis of diabetic retinopathy, IDx-RX. In the IPPS, Medicare established a New Technology Add-on Payment for Viz.ai software, an AI algorithm that facilitates diagnosis and treatment of large-vessel occlusion strokes. This article describes reimbursement in these two payment systems and proposes future payment pathways for AI. Keywords: Computer Applications-General (Informatics), Technology Assessment © RSNA, 2021.
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Affiliation(s)
- Melissa M Chen
- Department of Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1482, Houston, TX 77030 (M.M.C.); Triad Radiology, Winston-Salem, NC (L.P.G.); and Hackensack Radiology, Hackensack, NJ (G.N.N.)
| | - Lauren Parks Golding
- Department of Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1482, Houston, TX 77030 (M.M.C.); Triad Radiology, Winston-Salem, NC (L.P.G.); and Hackensack Radiology, Hackensack, NJ (G.N.N.)
| | - Gregory N Nicola
- Department of Radiology, University of Texas MD Anderson Cancer Center, 1400 Pressler St, Unit 1482, Houston, TX 77030 (M.M.C.); Triad Radiology, Winston-Salem, NC (L.P.G.); and Hackensack Radiology, Hackensack, NJ (G.N.N.)
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Chen MM, Hirsch JA, Lee RK, Hughes DR, Nicola GN, Rosenkrantz AB. Determining the Patient Complexity of Head CT Examinations: Implications for Proper Valuation of a Critical Imaging Service. Curr Probl Diagn Radiol 2019; 49:177-181. [PMID: 31160096 DOI: 10.1067/j.cpradiol.2019.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/05/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE The head-computed tomography (CT) exam code was recently identified by policy makers as having a potentially overvalued resource value units (RVU). A critical aspect in determining RVUs is the complexity of patients undergoing the service. This study evaluated the complexity of patients undergoing head-CT. METHODS The 2017 Medicare PSPS Master File was used to identify the most common site for performing head-CT examinations. Given the most common location, the 5% Research Identifiable File, was then used to evaluate complexity of patients undergoing head CT on the same day as an emergency department (ED) visit based on the Evaluation & Management (E&M) "level" of these visits (1-least complex to 5-most complex patient) and the ICD-10 diagnosis coding associated with the billed head CT claims. RESULTS 56.1% of head CT examinations were performed in the ED. Seventy percent of noncontrast exams performed in the ED were ordered in the most complex patient encounters (level 5 E&M visits). The most common ICD-10 code for head-CT without intravenous contrast billed with a level 5 E&M visit was "dizziness and giddiness," and for head-CT without and with intravenous contrast was "headache." CONCLUSION Head-CT is not only most frequently ordered in the ED, but also during the most complex ED visits, suggesting that the ICD-10 codes associated with such exams do not appropriately reflects patient complexity. The valuation process should also consider the complexity of associated billed patient encounters, as indicated by E&M visit levels.
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Affiliation(s)
| | | | - Ryan K Lee
- Thomas Jefferson University, Philadelphia, PA
| | - Danny R Hughes
- Georgia Institute of Technology, Atlanta, GA.; Harvey L. Neiman Health Policy Institute, Reston, VA
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Sireci AN, Aggarwal VS, Turk AT, Gindin T, Mansukhani MM, Hsiao SJ. Clinical Genomic Profiling of a Diverse Array of Oncology Specimens at a Large Academic Cancer Center: Identification of Targetable Variants and Experience with Reimbursement. J Mol Diagn 2016; 19:277-287. [PMID: 28024947 DOI: 10.1016/j.jmoldx.2016.10.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/23/2016] [Accepted: 10/05/2016] [Indexed: 12/11/2022] Open
Abstract
Large cancer panels are being increasingly used in the practice of precision medicine to generate genomic profiles of tumors with the goal of identifying targetable variants and guiding eligibility for clinical trials. To facilitate identification of mutations in a broad range of solid and hematological malignancies, a 467-gene oncology panel (Columbia Combined Cancer Panel) was developed in collaboration with pathologists and oncologists and is currently available and in use for clinical diagnostics. Herein, we share our experience with this testing in an academic medical center. Of 255 submitted specimens, which encompassed a diverse range of tumor types, we were able to successfully sequence 92%. The Columbia Combined Cancer Panel assay led to the detection of a targetable variant in 48.7% of cases. However, although we show good clinical performance and diagnostic yield, third-party reimbursement has been poor. Reimbursement from government and third-party payers using the 81455 Current Procedural Terminology code was at 19.4% of billed costs, and 55% of cases were rejected on first submission. Likely contributing factors to this low level of reimbursement are the delays in valuation of the 81455 Current Procedural Terminology code and in establishing national or local coverage determinations. In the absence of additional demonstrations of clinical utility and improved patient outcomes, we expect the reimbursement environment will continue to limit the availability of this testing more broadly.
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Affiliation(s)
- Anthony N Sireci
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Vimla S Aggarwal
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Andrew T Turk
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Tatyana Gindin
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Mahesh M Mansukhani
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Susan J Hsiao
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.
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Donovan WD, Leslie-Mazwi TM, Silva E, Woo HH, Nicola GN, Barr RM, Bello JA, Tu R, Hirsch JA. Diagnostic carotid and cerebral angiography: a historical summary of the evolving changes in coding and reimbursement in a complex procedure family. J Neurointerv Surg 2014; 6:712-7. [PMID: 25179635 DOI: 10.1136/neurintsurg-2014-011416] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Carotid and cerebral angiography have been a mainstay of neurointerventional and neuroradiologic practice for years. Centers for Medicare and Medicaid Services (CMS) and Relative Value Scale Update Committee (RUC) initiatives have compelled the professional societies to bundle component codes under threat of unilateral CMS revision and revaluation. Code bundling usually results in a decrease in the professional Relative Value Unit (RVU) valuation, and thus the MD reimbursement. The year 2013 saw a dramatic revision to the Current Procedural Terminology (CPT) code set that defines carotid and cerebral procedures. This paper reviews the process that led to that code set being revised and estimates the impact on professional reimbursement. We show the current and previous carotid angiography CPT codes and use clinical examples to assess professional RVU valuation before and after code revision.
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Affiliation(s)
| | - Thabele M Leslie-Mazwi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ezequiel Silva
- South Texas Radiology Group, Department of Radiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Henry H Woo
- Department of Neurological Surgery and Radiology, Cerebrovascular Center, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Gregory N Nicola
- Department of Radiology, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Robert M Barr
- Mecklenburg Radiology Associates P.A., Charlotte, North Carolina, USA
| | - Jacqueline A Bello
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Raymond Tu
- Department of Progressive Radiology, The George Washington University, Falls Church, Virginia, USA
| | - Joshua A Hirsch
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hirsch JA, Donovan WD, Nicola GN, Barr RM, Schaefer PW, Silva E. Alphabet soup: our government "in-action". AJNR Am J Neuroradiol 2013; 34:1887-9. [PMID: 23811971 PMCID: PMC7965411 DOI: 10.3174/ajnr.a3672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/07/2013] [Indexed: 11/07/2022]
Affiliation(s)
- J A Hirsch
- Neurovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Donovan WD. The Resource-Based Relative Value Scale and Neuroradiology. Neuroimaging Clin N Am 2012; 22:421-36. [DOI: 10.1016/j.nic.2012.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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