Relative Values for Physicians Relative values based on physician survey data from Relative Value Studies, Inc.
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Contents
Introduction ...................................................................1User Guide ............................................................................ 1Definitions of Terms in Relative Values for Physicians ............ 1The Global Period ................................................................. 3Services With Significant Direct Costs .................................. 3Historical Background .......................................................... 3Relative Value Studies — Legal and Fair ............................... 4The Research Behind Relative Value Units ........................... 4Relative Values for Physicians with CPT Codes ....................... 4How to Use This Relative Value Scale ................................... 5Determining Fees .................................................................. 5Conversion Factor Development ........................................... 5Productivity Measurement .................................................... 6Cost and Profitability Analysis .............................................. 7Capitation ............................................................................. 8RVUs and the Capitation Contract ....................................... 8Modifiers ............................................................................ 10
Anesthesia .....................................................................15Guidelines ........................................................................... 15Calculations of Total Anesthesia Values .............................. 22Anesthesia Section ............................................................... 23
Surgery ..........................................................................33Guidelines ........................................................................... 33Surgery Section ................................................................... 37
Radiology ....................................................................251Guidelines ......................................................................... 251Radiology Section .............................................................. 253
Pathology and Laboratory ...........................................297Guidelines ......................................................................... 297Pathology and Laboratory Section...................................... 299
Medicine ..................................................................... 397Guidelines ......................................................................... 397Medicine Section ............................................................... 399
Evaluation and Management ...................................... 451Guidelines ......................................................................... 451Evaluation and Management Section ................................. 456
Category II Codes ....................................................... 475Guidelines ......................................................................... 475Category II Section ............................................................ 476
Category III Codes ..................................................... 499Guidelines ......................................................................... 499Category III Section........................................................... 500
HCPCS ....................................................................... 513HCPCS Disclaimer ........................................................... 513Level II (HCPCS/National) Modifiers .............................. 513HCPCS Section ................................................................. 521
R Code Crosswalk ...................................................... 747Guidelines ......................................................................... 747
Services with Significant Direct Costs ......................... 749
Conversion Factor Development ................................ 759Developing a Conversion Factor ....................................... 759Gross Conversion Factor Worksheets ................................ 760Conversion Factors by Payer ............................................. 766Conversion Factor Percentiles ........................................... 768
Procedural Index ........................................................ 771
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© 2016 Optum360, LLC CPT © 2016 American Medical Association. All Rights Reserved.
Intro
duct
ionIntroduction
User GuideIts long history and careful development make Relative Values for Physicians the most accurate and comprehensive relative value system available. Use of Relative Values for Physicians spans North America and several European countries. In this relative value system, values are provided for physician services contained in the American Medical Association’s (AMA) Physicians’ Current Procedural Terminology (CPT®) system, as well as Medicare’s HCPCS Level II (National) codes. Additional codes, as recommended by physicians, have been
included in this system and assigned relative values to address special reimbursement issues.
Relative Values for Physicians provides a user-friendly listing of physician services with unit values. The accompanying instructions, guidelines, and modifiers explain the application and use of relative value units in the medical practice. All sections of the book may be used by any or all physicians or other qualified health care professionals. For example, codes found in the surgical section are not confined to use by a surgeon. Likewise, codes found in the medicine section are not limited to use by internists or primary care providers.
Definitions of Terms in Relative Values for PhysiciansColumn Descriptions
(1) UPD This column indicates the date the procedure was updated for Relative Values for Physicians. For the year 2016 the update stamp will read 160; for 2015, 150; etc. Mid-year updates are posted to the web site during the preceding year. The update stamp 151 would indicate a value that was changed mid-year 2015. The update stamp is removed after three years.
(2) TYPE Indicates code type or AMA icon
M Indicates a code that has been deleted from the CPT book or HCPCS code set. The CPT copyright remains with the AMA. This publication contains those codes which have been deleted within the past year for CPT codes and HCPCS codes. One year of deleted codes is maintained for both CPT and HCPCS codes.
s The triangle indicates a change in the code description.
l The circle indicates that the code was added to the CPT book or HCPCS code set.
: The plus indicates an add-on code. Add-on codes describe additional intra-service work associated with
the primary procedure. They are performed by the same physician on the same date of service as the primary service/procedure, and must never be reported as a stand-alone code.
* Indicates the procedure is modifier 51 exempt. Codes identified as exempt from modifier 51 are not subject to multiple procedure rules. No reimbursement reduction or modifier 51 is applied.
B Codes identified by this Optum360 icon indicate that the procedure should not be reported with modifier 51 (multiple procedures). Any code with this icon is backed by official AMA guidelines but is not identified by the AMA with their modifier 51 exempt icon.
K Indicates the procedure includes moderate sedation as an inherent part of the service. Because these services include moderate sedation, the provider performing the diagnostic or therapeutic service that the sedation supports should not report moderate sedation codes 99143–99145 in addition to the basic procedure code. In rare instances a second provider other than the provider performing the diagnostic or therapeutic
(1) (2) (3) (4) (5) (6) (7)
UPD Code Description Units Anes Global
150 S K 10030 Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous
3.7 (I) 3 XXX
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GlobalAnesUnitsDescriptionCodeUPD
09069.5with thrombectomy, autogenous or nonautogenous dialysis graft(separate procedure)
36833
090615.6Insertion of Thomas shunt (separate procedure)36835
090611.6 (I)Distal revascularization and interval ligation (DRIL), upper extremityhemodialysis access (steal syndrome)
36838
00061.0External cannula declotting (separate procedure); without balloon catheter36860140
00062.0with balloon catheter36861
09067.0Thrombectomy, percutaneous, arteriovenous fistula, autogenous ornonautogenous graft (includes mechanical thrombus extraction andintra-graft thrombolysis)
36870.S
0901531.0Venous anastomosis, open; portocaval37140
0901530.0renoportal37145
0901531.0caval-mesenteric37160
0901531.0splenorenal, proximal37180
0901540.0splenorenal, distal (selective decompression of esophagogastricvarices, any technique)
37181
000713.1 (I)Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS)(includes venous access, hepatic and portal vein catheterization,portography with hemodynamic evaluation, intrahepatic tractformation/dilatation, stent placement and all associated imaging guidanceand documentation)
37182
00076.2 (I)Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS)(includes venous access, hepatic and portal vein catheterization,portography with hemodynamic evaluation, intrahepatic tractrecanulization/dilatation, stent placement and all associated imagingguidance and documentation)
37183.S
00069.1Primary percutaneous transluminal mechanical thrombectomy,noncoronary, non-intracranial, arterial or arterial bypass graft, includingfluoroscopic guidance and intraprocedural pharmacological thrombolyticinjection(s); initial vessel
37184.sS160
ZZZ03.3 (I)second and all subsequent vessel(s) within the same vascular family(List separately in addition to code for primary mechanicalthrombectomy procedure)
37185.+sS160
ZZZ05.0 (I)Secondary percutaneous transluminal thrombectomy (eg, nonprimarymechanical, snare basket, suction technique), noncoronary,non-intracranial, arterial or arterial bypass graft, including fluoroscopicguidance and intraprocedural pharmacological thrombolytic injections,provided in conjunction with another percutaneous intervention otherthan primary mechanical thrombectomy (List separately in addition tocode for primary procedure)
37186.+sS160
00068.5Percutaneous transluminal mechanical thrombectomy, vein(s), includingintraprocedural pharmacological thrombolytic injections and fluoroscopicguidance
37187.S
00066.1Percutaneous transluminal mechanical thrombectomy, vein(s), includingintraprocedural pharmacological thrombolytic injections and fluoroscopicguidance, repeat treatment on subsequent day during course ofthrombolytic therapy
37188.S
Surg
ery
(I) Interim ValueR RVSI CodeS SDC CodeM Deleted from CPTl New Codes Revised CodeNote: For a complete explanation of each icon, please see the Introduction
CPT © 2016 American Medical Association. All Rights Reserved.
m Reinstated Code
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Surgery — 1452016 Relative Values for Physicians
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GlobalUnitsDescriptionCodeUPD
XXXRNEObstetric panel (includes HIV testing)0080081#l160RNE26RNETC
XXX3.7Amikacin00801501.2262.5TC
XXX3.2 (I)Caffeine00801551401.1 (I)262.1 (I)TC
XXX3.2Carbamazepine; total00801561.0262.2TC
XXX2.0free00801570.7261.3TC
XXX3.2Cyclosporine00801581.1262.1TC
XXX3.2 (I)Clozapine00801591401.1 (I)262.1 (I)TC
XXX3.0Digoxin; total00801621500.9262.1TC
XXXRNEfree0080163150RNE26RNETC
XXX4.0Valproic acid (dipropylacetic acid); total0080164#1501.3262.7TC
XXXRNEValproic acid (dipropylacetic acid); free0080165#150RNE26RNETC
XXX4.0Ethosuximide00801681.6262.4TC
XXX3.2 (I)Everolimus00801691401.1 (I)262.1 (I)TC
XXX4.1Gentamicin00801701.4262.7TC
XXX3.2 (I)Gabapentin, whole blood, serum, or plasma0080171#1501.1 (I)262.1 (I)TC
XXX3.0Haloperidol00801731.0262.0TC
+ Add-on Code , AMA Mod 51 Exempt B Optum Mod 51 Exempt a Mod 63 Exempt . Moderate Sedation # Resequenced Code Note: For a complete explanation of each icon, please see the Introduction
CPT © 2016 American Medical Association. All Rights Reserved. © 2016 Optum360, LLC
2016 Relative Values for Physicians300 — Pathology and Laboratory
Path/Lab
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