As the knowledge, education, and training of our profession progresses, so do the services that we can offer our patients. As these services expand, it is important for us to understand how they are valued. This article will serve mainly to provide background about how services are valued and provide insight into specifically what diagnostic services have a higher value and thus a greater reimbursement.
Relative Value Units (RVU)
In order to assign a reimbursement to a procedure or service, Medicare will create a standard value for each Current Procedural Terminology (CPT) code. These codes represent services that will necessitate a significant amount of training, effort, time, staff, and equipment but also represent services that require relatively few resources.
In an effort to define how much total value each service has, Medicare breaks down the total RVUs into three components. These include:
- Physician Work
- Professional Liability
- Practice Expense
Each of these can be further defined.
Physician Work (PW RVU)
Physician Work RVUs account for the time, training, and experience required to perform a service. The work RVUs for a level five Evaluation and Management office visit (99205) are more than 3.5 times the work RVUs for a level two office visit (99202) because 99205 requires more physician time and effort than the 99202. The 99205 is estimated to require 60-74 minutes of physician time and the 99202 is estimated to take between 15 and 29 minutes of physician time.
Professional Liability (PL RVU)
Professional Liability RVUs account for the cost of malpractice liability coverage for a specific provider group. Providers who perform procedures that carry more risk or who are more likely to be sued will have a higher liability insurance cost, and likely perform procedures that have a higher Professional Liability RVU. One very clear example of this would be to look at the Professional RVU of a trabeculectomy (66172) and the professional liability of a level 2 office visit (99202). The 66172 has a professional liability that is 12 times greater than the 99202.
Practice Expense (PE RVU)
Practice Expenses RVUs include resources like staff time, equipment, and consumables that are used for a procedure or service. If we use the trabeculectomy and level two office visit example above, we will see that the practice expense for the 66172 is forty-five times greater than the 99202.
How do we calculate Total RVU?
Calculating total RVU is simple. You add the RVU for each, and the resulting equation would look like this:
Once you have a Total RVU, then you multiply that by a conversion factor to get a reimbursement dollar amount.
So what common diagnostic procedures have the highest Total RVU and subsequently the highest reimbursement?
While the top reimbursing diagnostic procedures are at the top of scope for most states, it means that optometrists whose patients are benefiting from the highest level of their knowledge, education, and training are subsequently ordering tests that carry higher RVUs. It is also important to understand that the following values are based on Medicare national average non-facility price. Below are the top reimbursing diagnostic procedures with the corresponding codes.
5 Highest Reimbursing Optometry Diagnostic CPT Codes
- Fluorescein angiography (92235) - $119.33
- Anterior segment UBM (76513) - $79.91
- Threshold visual field (92083) - $64.20
- A-scan (76511) - $58.62
- B-scan (76512) - $49.90
Do exactly what the patient needs for that specific encounter.
Of course, diagnostic tests are ordered because there is a medical necessity based on patients’ specific complaints so that the physician can evaluate for specific conditions, not because those tests pay well. Be sure to document the order for the diagnostic test and provide appropriate interpretation and report for each test in the patient's chart.
Whether you’re a new grad or an experienced practice owner, it’s crucial to understand how your diagnostic skills are valued when it comes time to code and bill. As best practices change, stay on top of how your patient care services will be reimbursed, no matter how complex the procedure!
Eyes On Eyecare has partnered with EyeCode Education to bring our members the best in coding and billing education!