Free
Payment & Practice Management  |   April 2019
ASA Relative Value Guide (RVG): Updates to Keep it Relevant, Valuable and Germane to Your Practice
Author Affiliations
  • Neal H. Cohen, M.D., M.P.H., M.S.
    Chair, Section on Professional Practice
  • Christopher A. Troianos, M.D., FASE
    Chair, Committee on Economics
Article Information
Practice Management / Payment & Practice Management
Payment & Practice Management   |   April 2019
ASA Relative Value Guide (RVG): Updates to Keep it Relevant, Valuable and Germane to Your Practice
ASA Monitor 4 2019, Vol.83, 42-44.
ASA Monitor 4 2019, Vol.83, 42-44.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
×
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
×
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
×
The Relative Value Guide® (RVG™) and CROSSWALK®, the premier coding resources of ASA are updated on an annual basis. The changes are made to ensure that the guides are consistent with annual updates to other coding and billing documents and address specific issues of importance to anesthesia practices. The 2019 edition of the AMA Current Procedural Terminology (CPT®) includes over 300 changes involving new, revised and deleted codes. It also includes changes to instructions and guidelines found within the code set. The 2019 edition of ICD-10-CM includes over 400 changes reflecting new, revised and deleted diagnosis codes along with updates to its official guidelines.
Each year, the ASA Committee on Economics (COE) thoroughly reviews and edits the contents of the RVG so that it remains current, provides updated information and continues to be valued by practices and payers as an authoritative source of information for anesthesia billing. The annual review of the RVG typically addresses new, revised or deleted codes, any applicable updates to the base unit assignments and the addition or revision of RVG comments that offer additional information to help clarify use of the associated code. The COE recently undertook a more overarching approach to its review of the RVG. Some of the results of that review appear in the 2019 edition with an updated definition of anesthesia time and new guidance on field avoidance. For more information, please review the December 2018 Timely Topic 2019 Relative Value Guide Updates Include Anesthesia Time and Field Avoidance.
In addition to the changes to the RVG that will be described in more detail, the 2019 CROSSWALK includes new entries to correspond to new CPT codes. The updated CROSSWALK also describes revisions to the previous year’s CROSSWALK entries when information and/or changing practice support such a revision.
Preview of Change to Come in the 2020 RVG
By nature of the medical practice of anesthesiology, anesthesiologists perform a variety of services, some specifically related to delivery of anesthesia care and some that are provided by anesthesiologists and other physicians. Specific anesthesia services are valued according to the “Base+Time” formula. The other services provided by anesthesiologists (and other providers) are valued and paid under the Resource-Based Relative Value System (RBRVS). The RVG includes information about billing for all the services provided by anesthesiologists in all subspecialties by including the codes that describe the services they provide in the Consultative, Diagnostic and Therapeutic Services section of the RVG. There are subsections for Evaluation and Management (E/M), pain medicine, intravascular catheterization, transesophageal echocardiography, pulmonary function testing, neurological monitoring and other procedures.
A limited number of non-anesthesia procedures first appeared in the RVG in the early to mid-1970s. Over the years, more non-anesthesia procedures were added, corresponding to the expanding role and scope of the physician anesthesiologist. Assignment of anesthesia base unit values to those procedures dates to those initial listings when payers may have relied on those base unit assignments to determine payment to anesthesiologists for those services. Much has changed since then. The RBRVS, implemented in the early 1990s, bases payment of the procedure without any differentiation as to the specialty of the physician who performs it. Base units are a valid and accurate way to assign value to anesthesia care, but they do not serve that same purpose for RBRVS codes. Except for a small (and decreasing) number of contracts, payers determine payment for non-anesthesia services performed by physician anesthesiologists via the work, practice expense and professional liability relative value units (RVUs) assigned to the procedure under the RBRVS.
Over the past few years, providing base unit values for non-anesthesia codes has created scenarios where practices may be misreporting services notwithstanding the clarification found in the introduction to the CROSSWALK:
“ One should note that anesthesiologists may report codes for diagnostic or therapeutic procedures in addition to the anesthesia code for the primary operative procedure and that the ASA Relative Value Guide includes ASA base unit values for many of these non-anesthesia procedures. These base unit values reflect the effort involved in performing the diagnostic/therapeutic procedure itself. When one provides anesthesia in support of procedures like a sympathetic block, the appropriate anesthesia code should be reported. For example, when the anesthesiologist performs a celiac plexus block, s/he would report 64530; however, if an anesthesiologist provides anesthesia for this block when it is performed by a different physician, the anesthesiologist should report 01992 (5 base units + time) if the patient is prone or 01991 (3 base units + time) if the patient is not prone for the procedure.”
Reporting of base units for non-anesthesia codes listed in the RVG creates confusion and misrepresents the actual services provided in some cases. For example, the RVG lists eight base units for code 64415 – Injection, anesthetic agent; brachial plexus, single. Some are submitting claims that list the number of units as eight. While unintentional, this is claiming that the block was performed eight times and typically results in a denial due to an excessive number of units of service. Continued misreporting (intentional or not) can flag a practice for audit.
Reducing the number of non-anesthesia codes listed in the RVG will help ensure that the RVG is focused on current practice. For example, at some point there was likely good reason to include code 99199 – Unlisted special service, procedure or report – in the RVG, but it is hard to find reason to do so in 2019.
Based on this review and implications of some of the information in the previous versions of the guide, the COE has recommended and the ASA Board of Directors and House of Delegates approved the following changes for the 2020 RVG:
  • ■ To trim the number of non-anesthesia codes included in the RVG down to those most relevant to current practice and coding, while retaining those that are specific to anesthesia and perioperative medicine.
  • ■ To remove anesthesia base unit values for non-anesthesia services (services other than those described by CPT codes 00100-01999). For these services, the base unit values will be replaced with work RVUs as finalized by CMS in the Final Rule for the corresponding fee schedule year as published in late October/early November.
Key Points to Remember
As you prepare for 2020 and this change to the RVG, it is important to understand that:
  • ■ The ASA RVG continues to provide timely and accurate information about anesthesia billing practices and associated base unit values. This change to the 2020 RVG has no impact on the codes and values associated with anesthesia care (CPT codes 00100-01999).
  • ■ Codes that may be removed from the RVG may still be valid CPT codes and, if that is the case, anesthesiologists may continue to report those codes when they provide the service for medical necessity and the clinical conditions comply with the rules for reporting the service.
  • ■ A base unit value and a work RVU are not the same! The change to listing work RVUs in the RVG are not the result of any ASA action regarding anesthesia coding and valuation. This change is not an ASA action or recommendation to reduce the value of a service. As an example, the 2019 RVG lists eight base units for code 64415 while the 2019 work RVU assigned to that code per RBRVS valuation is 1.48. An RVG listing of 1.48 will not represent a reduction of 6.52 units but instead will accurately reflect the approved work RVU for that code.
Please review Figure 1 for an example of how payment for anesthesia care is typically determined. Private payers usually use the same “Base+Time” formula (with a different conversion factor than CMS). They may also allow for physical status and qualifying circumstances while CMS does not. Figure 2 demonstrates how payment for services under the RBRVS is determined.
This preview of the 2020 RVG is provided to help guide billing practices and to allow time for your practice to modify any in-house use of base units for non-anesthesia services that some groups may still be using to internally define productivity metrics.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
Neal H. Cohen, M.D., M.P.H., M.S., is Professor of Anesthesia and Perioperative Care and Medicine, and Vice Dean, University of California, San Francisco, School of Medicine.
×
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
Christopher A. Troianos, M.D., FASE, is Professor and Chair of the Anesthesiology Institute, Cleveland Clinic, Lerner College of Medicine of Case Western Reserve University.
×
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
Sharon K. Merrick, M.S., CCS-P is ASA Director of Payment and Practice Management.
×
0 Comments
Submit a Comment
Submit A Comment

Contributors must reveal any conflict of interest. Comments are moderated.

Name
Affiliation & Institution
I have a potential conflict of interest
Comment Title
Comment


This feature is available to Subscribers Only
ASA Member Login or Create an Account ×