The Resource-Based Relative Value Scale and Neuroradiology: ASNR’s History at the RUC

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Introduction

Before 1992, professional payment for Medicare services in the United States was fragmented, usually administered on a local or regional basis. There was significant geographic variation in reimbursement of doctors’ fees. With health care cost outlays accelerating rapidly in the 1980s, there was a call by Congress for greater oversight of distribution of government revenue for medical services. This led to the creation of the Resource-Based Relative Value Scale (RBRVS), which remains in force, with continual evolution, to the current day. The radiology community played a critical role, perhaps more than any other single medical specialty, in the acceptance of the relative value scale (RVS) system by the greater medical community. The neuroradiology community, despite its small numeric footprint nationwide, has participated actively in the evolution of this payment system.

Section snippets

Brief history of the RBRVS

The Medicare program was created by the Social Security Act of 1965, signed into law by then-President Lyndon B. Johnson (Fig. 1). It reimbursed physicians for both their professional work and their direct practice expenses on an as-billed basis. There was a modest oversight program to confirm that reimbursement requests were in line with “customary, prevailing, and reasonable” charges, but no organized national basis or guidelines to maintain uniformity. The Health Care Financing

The role of radiology in the adoption of the RVS

Less well known than Hsaio’s arrival on the national payment scene is the key role played by the radiology community in the adoption of the RVS system. Radiology’s efforts to establish an RVS actually predated Hsaio; and during the 1980s, radiology’s RVSs were being revised and updated contemporaneous with Hsaio’s efforts.

Radiology initially established an RVS of its own as early as 1963 in response to a request from the Department of Defense for its own insurance program for military and

The rise of component coding

In the establishment of the radiology RVS, and the nascent establishment of the national RBRVS for Medicare, local discrepancies in the coding of interventional procedures were uncovered. Specifically, some Medicare carriers reimbursed interventional procedures in a bundled manner, whereas the radiology RVS and the ACR advocated billing on a component basis; that is, separate codes for supervision and radiologic interpretation (S and I) of interventional procedures apart from the billing of the

The RUC

One of PPAC’s recommendations to Congress made during consideration of a national Medicare RBRVS was to establish an expert multispecialty consensus panel that would be charged with ongoing review of the accuracy of the RBRVS, and that would determine appropriate rank-order placement of newly introduced procedures into the system.8 Thus was born the RUC, an acronym for the American Medical Association/Specialty Society RVS Update Committee, which continues its work on an advisory basis to CMS

The ASNR at the RUC

The ASNR was founded in 1962.11 Throughout its history, the mission of the Society was focused on education and dissemination of information to its members, and to the rest of the medical community.12 An emphasis on socioeconomic and political activity in the ASNR beginning in the 1990s is directly attributable to the work of one man: J. Arliss Pollock, MD (Fig. 3).

Arliss Pollock was a native of Texas. After 4 years of military service, he completed a radiology residency and a fellowship in

ASNR at the RUC, 2004 to the present

Dr Patrick A. Turski assumed chairmanship of the ASNR CPC in 2004, serving until 2010. Barr became the ASNR’s RUC advisor in 2002, serving until 2008 (see Table 1). He has recently assumed chairmanship of the CPC. These individuals have continued the active presence in matters of payment policy, quality assurance, appropriateness and standards, and intersocietal activity that Dr Pollock established. The Government Affair subcommittee was folded into the ACR Neuroradiology Commission during Dr

Radiology in the crosshairs

Evolutionary changes at the RUC over the past 5 years, however, have caused the ASNR and the other radiology societies to assume a more defensive posture.

As one of the founding principles of the RUC, Congress mandated a program to review codes already vetted in an effort to maintain legitimacy and relativity in the face of changing technology and its use. A new technology or procedure, it was assumed, may be more efficiently performed as a physician’s experience increases, and/or with equipment

The fall of component coding

One of the most perturbing screens that ASNR, ACR, and SIR have been and are still being forced to work through is the “Codes frequently reported together” screen. The rationale for this screen was to identify “physician efficiencies”; that if services are routinely reported together (ie, by the same provider, for the same Medicare beneficiary, on the same day), they effectively represent a single complex service, rather than discrete services, and that their valuation should reflect these

Summary

The RBRVS has defined the professional reimbursement strategies of CMS, and secondarily of private payors, since its inception in 1992. Radiology groups had a significant influence on the acceptance of this system when it was first introduced, thanks to extraordinary efforts largely through the ACR and its practice leaders, who had been working through various RVS formats before that time. Their success resulted in an entire body of RVU values being accepted in the original Medicare RBRVS, with

Acknowledgments

I am indebted to ASNR CPC staff Michael Morrow for research work. Additional thanks to ASNR CEO James Gantenberg and ASNR staff Bonnie Mack. The following physicians provided insights and remembrances: David Seidenwurm, MD; Robert M. Barr, MD; Patrick A. Turski, MD; James M. Moorefield, MD; Eric J. Russell, MD; Blake A Johnson, MD; James Borgstede, MD; Bibb Allen, MD; Suresh K. Mukherji, MD. Many thanks for their time and effort.

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