Last week, ACEP held its annual Leadership and Advocacy Conference, where emergency physicians (including many of you) came together from across the country to learn new leadership skills, share stories and advocacy ideas, and build relationships with policymakers and fellow advocates while tackling priority emergency medicine issues. A key component of the conference was advocates’ meetings on Capitol Hill with legislators and staff. On Tuesday, 400 ACEP members from 46 states participated in 298 meetings with federal legislators or their health care staff, sharing their unique and vital perspective with Congress on three pressing issues: the boarding crisis, protecting emergency physicians from workplace violence, and stabilizing Medicare reimbursements (for more information on all three issues, please click here).
While Tuesday was the “big day,” on Monday, attendees were able to hear from a number of policymakers, fellow ACEP members, and other thought leaders about key issues and learn how ACEP, through work by our own volunteer members, advocates on behalf of the specialty. During one session, Jordan G. R. Celeste, MD, FACEP; Nicholas Cozzi, MD, MBA; and Jay Mullen, MD, MBA, FACEP took the stage to discuss what determines your paycheck and explain ACEP’s work at the “RUC” and “CPT” (both explained below) to help ensure that you all are appropriately reimbursed for the services you provide.
Dr. Celeste, ACEP’s RUC Advisor, provided an excellent overview of the “ABCs” of emergency physician reimbursement and our advocacy work, so I thought it would be useful to hand the reins over to her this week to let her share her insights with you all as well. Without further ado, here is Dr. Celeste:
Thank you, Jeffrey. This is really going to just scratch the surface of many complex topics, so if you have questions or need more information, be sure to check out the ACEP Reimbursement webpage.
RVUs
We’re going to start with the basics. RVU stands for relative value unit, and this is the basis of physician payment. Every physician encounter and procedure have a CPT code, and these have assigned RVUs.
For emergency medicine, we have codes for our visits, the procedures we perform, and for critical care. Our patient encounters in the emergency department (ED) are captured with CPT codes 99281-99285 that you’re probably familiar with – these are Evaluation and Management (or E/M) codes – that make up approximately 85% of what we do, and represent cognitive work, moving from lowest to highest. Procedures make up about 11% of what we do – most procedures are separately billable, so it is important to make sure that you’re documenting these correctly. For emergency medicine, critical care makes up about 4%.
CPT stands for Current Procedural Terminology. This is developed by the American Medical Association (the AMA, but specifically the CPT Editorial Panel) and is published annually. The CPT Advisory Committee is the body that reviews and comments on code change applications and other CPT business. It’s important to understand that for emergency medicine, the CPT Advisory Committee members are from ACEP, and they are supported by our fantastic staff. This is arguably one of the most important external roles for ACEP.
CPT codes make the uniform language used in medical billing. They’re five numbers (or G followed by four numbers…but that’s for another time), but behind that there is a description of the unique work that goes into performing that code.
After CPT defines the work with a code, the value for the code is then determined by the RUC by assigning RVUs. Briefly, RVUs have three parts: Physician Work + Practice Expense (PE) + Professional Liability Insurance (PLI) = Total RVU. Each component is also adjusted for geographic variations in the cost to provide care by the Geographic Practice Cost Index, or GPCI. The final RVU amount is multiplied by the Medicare conversion factor (more on this later…but remember, conversion factor!).
RUC
In 1992, the RBRVS, which is the Resource Based Relative Value Scale, was implemented, and this led to the formation of the Resource Based Relative Value Scale Update Committee…thankfully shortened to “the RUC.”
As with CPT, the RUC is a committee of the AMA. It is composed of 32 members, and emergency medicine has a permanent seat on the RUC. And again, ACEP fills this seat. In addition to the RUC Representative, there’s another role that ACEP fills at the RUC, and that’s the Advisor (me!). This person makes the actual presentations and arguments to the RUC using survey data in a process I’ll outline briefly below. I cannot underscore the importance of this process, though, as 90% of all ED physician payments are based on RVUs! Seemingly small victories actually translate to millions and millions of dollars. So, if you ever find yourself wondering why you should pay your annual ACEP dues, or why you should be very proud of your ACEP membership, the answer is easy – it’s ACEP’s representation in the CPT and RUC processes by a team of dedicated staff and volunteer leaders.
So, let’s walk through the RUC process (briefly and fairly superficially as well). Surveys are used to generate data for codes under review. If you get a survey, please fill it out! The RUC advisor then takes this data and creates a presentation laying out arguments for proposed values and times. Sometimes this involves work with multiple other specialties. It always requires a lot of preparation and careful thought. The advisor then sits at the front of the room like they’re in a congressional hearing and lays out their case. The RUC deliberates and votes, and then makes recommendations to CMS regarding the values and times for codes under review (CMS sits in on both the CPT and RUC processes, by the way). CMS then assigns RVUs to the codes. In most years they accept about 90% of the RUC recommendations. The initial decision made by CMS comes out in the form of a proposed rule, which is then followed by a comment period. And then a final rule is issued, which will then go into effect the following year. This can be a LONG process. So if you present in April, that won’t be put into a proposed rule until July OF THE NEXT YEAR. Then the final rule is usually issued that November for implementation in January – so over 1.5 years after the presentation at the table! This is one of the reasons why there are strict confidentiality agreements in place.
Outcomes
Let’s circle back to the conversion factor that we mentioned before. Again, this is the value (a dollar amount) that total RVUs are multiplied by to calculate reimbursement.
First, we need to put this into some historical context. Back in 1997, the Balanced Budget Act tied the conversion factor to the sustainable growth rate (SGR). In VERY basic terms, they were trying to make sure that the annual increase in Medicare spending per beneficiary did not exceed the growth in the gross domestic product (GDP). So, the “SGR formula” would set an expenditure target for spending, and then they’d mess with components of the formula to meet this – specifically, they’d decrease the conversion factor. This was problematic for many, many reasons. It linked physicians' payments to fluctuations in the GDP instead of the true costs of providing care to Medicare patients – who are not famed for being simple, healthy, and low utilizers of the health care system. We will not be going into all of the nitty gritty here – but after MANY years of advocacy and congressional “patches,” the SGR formula was finally “fixed” in 2015. This was a fight that many of you remember…going up to the Hill in DC over and over again and asking for a solution. It was ultimately the Medicare Access and CHIP Reauthorization Act (MACRA) that did away with the SGR formula…which gave us the Merit-based Incentive Payment System (MIPS)…and a new batch of challenges as well.
The celebrations were brief, though, and the next issue was already at hand. Through the Budget Control Act of 2011, we got to meet the “sequester,” which called for a 2% cut to Medicare rates through the conversion factor from 2013-2021. The solution to this was congressional action again, and Congress passed a delay of the sequester through the end of 2021. BUT it didn’t happen in 2022…AND then yet another challenge reared its head…
In 2021, Budget Neutrality was triggered when office visits went up, as this broke a set threshold and meant that “adjustments” had to be made. In a budget neutral environment, everyone is fighting over the same amount of pie – so with a set of codes going up, everyone had to get paid less via a decrease in the conversion factor.
The increased office visit RVUs also meant that the ACEP RUC Team wins with the E/M codes in 2018 were short-lived (as they only went into effect in 2020 due to that long process I described above). Fortunately, ACEP staff – Mr. Jeffrey Davis and Mr. David McKenzie – lobbied CMS directly and successfully to keep the previous relativity between office and ED E/M codes in place and increase YOUR reimbursement.
Yet another issue we continue to face is that the conversion factor does NOT keep up with inflation. Specifically, CMS does NOT adjust physician payments for inflation. Hospitals, skilled nursing facilities, and other components to the health care system get inflationary adjustments, but not the docs. This was one of the three major advocacy issues we took to the Hill during the Leadership and Advocacy Conference this year.
All in all, here are some take home points:
- The CPT and RUC processes are crucial for our specialty, and ACEP represents the interests of emergency physicians at these tables.
- There are lots of external and bureaucratic forces exerting pressure on physician reimbursement, and a strong specialty society is crucial in these fights.
- Even if you are not interested in learning more about the topics touched on in this article, understand that ACEP is taking care of you so you can continue to take great care of your patients!
Until next week, this is Jordan (and Jeffrey) saying, enjoy reading regs with your eggs!
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