Hot Topics of Interest: AUC & RUC Reviews

Where the money comes from, and notes from the reimbursement battlefield.

Most Mohs patients have insurance, and therefore someone else is deciding what you get paid for what you do. That payment is determined by two numbers, and two numbers only: the RVU (relative value unit) and the CF (conversion factor). The RVU for any given CPT code is ultimately determined by CMS (the Center for Medicare and Medicaid Services). The conversion factor is determined by either the government or private insurers, and translates the RVU into a dollar amount. Almost all private insurers use the RVU value as determined by CMS.

Here's the secret, and the reason you should care. CMS gets advice (and usually takes it) on RVU's from a private American Medical Association committee called the RUC (the Resource-based relative value system Update Committee). So, for the most part, one unpublicized committee determines how much you get paid for any given code, relative to all other codes.

So who is this "RUC"?

The RUC is comprised of 31 members, with 21 of those appointed by major national medical specialty societies, and it meets 3 times a year. At these meetings, existing code values are reviewed and refined and new codes are assigned a value. The RUC determines work RVU's, determines practice expense RVU inputs, and comments on professional liability insurance (PLI) costs. CMS takes the work RVU, converts the practice expense inputs into an RVU value, and determines a PLI RVU value. These are added together to produce the total RVU for the code (so work RVU + practice expense RVU + professional liability insurance RVU = total RVU). It is important to note that the RUC does not define codes (that is the job of the AMA CPT committee) nor determine whether codes are paid or not paid (that is the purview of CMS and private insurers). The RUC is the only portal that physicians have for direct input into payment guidelines. More importantly, Dermatology has one of the RUC seats.

Dermatology codes have been called before the RUC recently for review, and the values have been refined (i.e. changed). Recently, the following codes were reviewed: lip biopsy (40490), eyelid biopsy (67810), ear biopsy (69110), regular and frozen section pathology (including 88304, 88305, 88331, 88332), intermediate linear closures (12031 through 12057) and malignant lesion destruction (17260-17286). In addition, other codes of importance to Mohs have been looked at this year. Value recommendations suggested by the RUC to CMS are confidential until CMS publishes any changes in the federal register, and thus can't be discussed. There were also some proposed refinements in the definitions of some of these codes (such as the eyelid biopsy having to include a portion of the lid margin, which is that portion of the eyelid between the lash line and the palpebral conjunctiva), but it is unknown at this point whether CMS will accept the proposed refinements.

Additionally the Federal Register indicates that the actinic keratosis destruction codes (17000-17004) and the Mohs codes (17313-17315) are scheduled for review soon. And here is an important bit about all of this. In general, codes values don't tend to go up. This is because the work RVU component of the code value can only go up if certain RUC standards (known as compelling evidence) are met. Compelling evidence includes such things as a technology change in the procedure, a different specialty doing the procedure now, versus when it was last valued, a change in the patient population, or evidence that the existing value is incorrect (such as having failed to include certain components of physician work). Rarely is compelling evidence met. However, values can also go up or down when practice expense is refined. Practice expense includes both the supplies and staff needed to do any given procedure.

Codes are valued at the RUC using survey data. Likely, you have been asked to participate in a RUC survey. If asked, participation is critical (we need to have a minimum of 30 completed surveys) and the more surveys we have, the more robust and valid our data is assumed to be. As you might imagine, careful completion of the survey is critical, as the data is looked at quite closely. Good surveys do not always mean good values, but bad surveys always lead to bad values. In some cases, the surveys are good and merely show that there is less work in the code than previously thought. In other cases, the surveys appear good but the RUC determines that the values are not believable. But whatever values are ultimately accepted by the RUC may not be accepted by CMS.

The Mohs codes have been a particular challenge when previously looked at by the RUC. Other specialties have difficulty conceiving of the surgeon and the pathologist being the same person. Mohs surgeons get paid to both remove the tumor and repair the defect, which is not true of all similar codes. Due to the outpatient nature of the procedure, there are no operating room logs to refer to. And lastly, utilization of the Mohs codes is increasing every year. While this is at least partially explained by increasing skin cancer incidence, there is concern about "indication creep". While the RUC can't control this, it can try to moderate utilization increases through valuation decreases. In fact, it would be fair to say that CMS and many at the RUC view consistent increases in usage as indication of an overvalued code based on the thinking that if doctors find a code that is relatively lucrative relative to other codes they may use it more.

This is why the recently published Mohs Appropriate Use criteria are so critically important. For the first time Dermatology has taken a public and proactive step based on a well-vetted methodology to insure that utilization of this procedure is consistent with published studies. Hopefully this is a first step toward moderating that portion of the utilization increase that can be moderated. This is critical not only for the good of medicine in general (and Mohs specifically) in a resource limited world, but also to pull the Mohs codes off of CMS screens for procedures that show significant utilization increases. This preserves the Mohs codes for the challenging cases in which Mohs surgery is absolutely needed.

Scott A. B. Collins, MD