Renee Kinder
Renee Kinder

If there is a buzzword being used in our industry right now, it would be “data.”

Much has been said and predicted about data review and trending analysis for Medicare Part A.

We know what was stated in the final rule. We have all reviewed the updates in CMS Program Integrity Manual. And now we wait… 

What is the Centers for Medicare & Medicaid Services going to review?

How are they going to analyze shifts in volume of services?

How will they integrate volume and quality to look holistically at care assess and care trends?

While we all wait and wonder about Part A, let us not forget about Part B.

Part B? Why, Renee, should we keep a pulse on Medicare Part B usage? Weren’t the caps/thresholds repealed?

I heard a unique perspective on this recently, which is why I decided to write about Medicare Part B and our responsibility to appropriately access the benefit. 

The exact perspective I heard went something along the lines of this … Yes, our therapy provider has reduced volume (i.e. minutes) in Part A, but we are just “picking it up” on the B side.

Picking it up. Interesting.

To begin, I am a firm believer that we as therapists and nursing teams have a responsibility to identify changes in function for the individuals who reside in our communities as their homes. 

As such, formalized screening and patient identification procedures can be beneficial in noting changes in early phases, allowing us to meet the OBRA 1987 requirements to support our residents’ ability to attain or maintain the highest practicable physical, mental and psychosocial well-being.

I also appreciate the updates we have seen with Phase II ROPS Survey changes, the use of critical element pathways to assess specific care areas, and the overarching move to more person-centered care. 

So, do we need to “pick up” or improve our identification processes? Perhaps. This, of course, will depend on your individual community and their practices.

With that said, the “pick up” should not be as a result of financial goals, tied to arbitrary operational benchmarks or shifts in payer volume in your community. 

Aside from my opinion, Medicare Part B, CPT codes specifically, are under continual review from the American Medical Association as part of the CPT and RUC processes.

CPT ® = Current Procedural Terminology and is a registered trademark of the American Medical Association.

In a prior blog post, I spoke to the history of the process of how codes are created and valued. 

Today, I want to bring to light how data is used as part of the process to track trends in various areas.

So, how is data reviewed and by whom? 

Data is reviewed, in part, for CPT codes by the RAW.

The RAW is the Relativity Assessment Workgroup, was formed in 2006 by the American Medical Association Relative Value Scale Update Committee (AMA RUC) and has an aim to review potentially misvalued services using objective mechanisms for reevaluation. 

The workgroup was established following comments from the Medicare Payment Advisory Commission urging CMS to be more diligent in the identification of both potentially over- and

undervalued services within the payment schedule for review during the Five-Year reviews.

What specifically does the RAW review? 

The Relativity Assessment Workgroup continues to identify and review services. The workgroup’s identification screening process to date includes:

  • Bundled CPT services — services often billed together
  • Site-of-Service anomalies — services with site-of-service shifts (i.e. services that were typically in the inpatient setting and are now typically performed in the outpatient setting or physician office)
  • Harvard-Valued — services performed more than 30,000 times a year that still have the original Harvard established value
  • CMS/Other Source — services performed more than 100,000 times a year that were not reviewed by either Harvard or the RUC, but are assigned by CMS
  • Services surveyed by one specialty but are now predominantly performed by a different specialty
  • High Volume Growth — services with a utilization increase of 100% or more in a five-year period
  • High Intra-service Work Per Unit of Time (IWPUT) — services with high intensity relative to other services
  •  Negative Intra-service Work Per Unit of Time (IWPUT) – services with negative intensity for the intra-service period per minute, indicating possible mis-valuation.
  • High Level E/M in Global Period — services with Medicare utilization greater than 10,000 units that have a level 4 (99214) or level 5 (99215) office visit included in the global period.
  • Services with low work RVUs that are billed in multiple units per patient
  • Services with low work RVUs that have high utilization
  • Services identified on the RUC Multi-Specialty Points of Comparison (MPC) List — a list of common services performed by specialties and used for comparison during the RUC survey procedure
  • High Expenditure Procedural Codes — codes under the Medicare Physician Payment Schedule that have not been reviewed in the last five years with the highest payments per specialty
  • Services with Stand-Alone PE time — codes with PE time assumptions not based on physician time
  • Pre-Service Time Analysis — codes with pre-service time greater than the standard pre-service time package 4 Facility Difficult Patient/Difficult Procedure (63 minutes)
  • Post-Operative Visits — 010 and 090-day global period services with more than six postoperative office visits
  • 000-Day Global Services Reported with an E/M with Modifier 25 — services with a 000-day global period billed with an E/M fifty percent of the time or more, on the same day of service, same patient, by the same physician, that have not been reviewed in the last five years with Medicare utilization greater than 20,000 units.
  • Contractor-priced High Volume — contractor-priced Category I
  • CPT codes performed more than 10,000 times a year.
  • CPT Modifier -51 exempt — services on the services on the CPT Modifier -51 Multiple Procedures exempt list performed more than 10,000 times a year.

In closing, I hope this piece has been informational to provide insight into the intense effort used to evaluate code usage and trending. 

Furthermore, RUC’s potentially misvalued codes review project accounts for approximately $45 billion in Medicare allowed charges.

Remember: The data speaks for itself. What will your trending data say about you? 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).