In 1992, the American Medical Association (AMA) was tasked to help Medicare determine appropriate CPT code relative values for physician work, liability, and direct practice expenses when Congress transferred payments from the market based usual, customary and reasonable (UCR) fee schedule to a resourced-based relative value scale (RBRVS).
The AMA-RBRVS Update Committee, casually known as the “RUC,” includes representatives from all of the American Board of Medical Specialties (ABMS), who debate physician survey data that ultimately provides CPT code values recommended to the Center for Medicare and Medicaid Services (CMS). Those values, multiplied by a “conversion factor” determined annually by Congress, become the payments made to physicians.
When Congress initiated RBRVS, they mandated a process to maintain accurate values for CPT codes. The process that evolved includes widespread code reviews every five years, as well as targeted reviews based on screens for utilization, common code pairings, new technology, spikes in utilization, and new concepts such as medical home models and chronic care management.
These reviews, developed from a very specific and lengthy process, may have substantial impacts on direct reimbursement from Medicare and commercial insurance by adaptation.