The AMA / RUC Physician Work Survey
The Centers for Medicare and Medicaid Services (CMS) has requested review of the physi...
START HERE
When you have completed this survey, please save and return via email to:
RUCsurvey@aol.com
Please Complete Sur...
Introduction
"Physician work" includes the following elements:
• Physician time it takes to perform the service
• Physicia...
SURGERY 090 Global Period Discussion
Pre-service period
The pre-service period includes physician services provided from t...
Please consider these “typical patients” when completing this survey
Survey Code 60220 Total thyroid lobectomy, unilateral...
Question 1: Which ONE Reference Service below is most similar to each procedure and patient described
above? You may choos...
Question 2A. How much of your own time is required per patient treated for each of the
following steps in patient care rel...
Question 2B: Post-Operative Work – Please respond to the following questions based on your
typical experience for each sur...
Background for E&M Services: Please review this Table and use it as a guide when answering Question 2C
on the next page ab...
indicate the number of typical E/M services through the 90-day global period for the typical patient for each survey
code....
QUESTION 3: For the Surveyed CPT code and for the reference service you chose in Question 1, rate the
AVERAGE pre-, intra-...
QUESTION 4: For the Surveyed CPT code and for the reference service you chose in Question 1, rate
the intensity for each c...
QUESTION 6: The RUC is also interested in determining whether the physician work for the survey
service has changed over t...
QUESTION 7: Is your typical patient for each code similar to the typical patient described on Page 5 at
the beginning of t...
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The AMA / RUC Physician Work Survey

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The AMA / RUC Physician Work Survey

  1. 1. The AMA / RUC Physician Work Survey The Centers for Medicare and Medicaid Services (CMS) has requested review of the physician work for intermediate wound repair procedures. The American College of Surgeons, American Academy of Otolaryngology – Head and Neck Surgery, and AMA/Specialty Society RVS Update Committee (RUC) need your help to assure relative values will be accurately and fairly presented to CMS during this review process. This is important to you and other physicians because these values determine the rate at which Medicare and other payers reimburse for procedures. Survey Codes 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy 60240 Thyroidectomy, total or complete 60500 Parathyroidectomy or exploration of parathyroid(s); Financial Disclosure: Do you or a family member have a direct financial interest in the procedure(s) shown above, other than providing these procedure(s) in the course of patient care? [Family member means spouse, domestic partner, parent, child, brother, or sister. Disclosure of family member’s interest applies to the extent known by you.] For purposes of this survey “direct financial interest” means: For each question Check Yes or No 1. A financial ownership interest in an organization* of 5% or more? Yes No 2. A financial ownership interest in an organization* which contributes materially** to your income? Yes No 3. Ownership of stock options in an organization*? Yes No 4. A position as proprietor, director, managing partner, or key employee in an organization*? Yes No 5. Serve as a consultant, researcher, expert witness (excluding professional liability testimony), speaker or writer for an organization*, where payment contributes materially** to your income? Yes No * Organization means any entity that makes or distributes the product that is utilized in performing the procedure/service and not the physician group or facility in which you work or perform the procedure/service. ** Materially means income of $10,000 or more (excluding any reimbursement for expenses) for the past 24 months. CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 1
  2. 2. START HERE When you have completed this survey, please save and return via email to: RUCsurvey@aol.com Please Complete Survey Areas Shaded in Green (Demographic information is kept confidential.) Physician's NAME Last: First: Physician’s Primary Office (STATE) E-mail address SPECIALTY (check all that apply) General surgery Otolaryngology – Head and Neck surgery Surgical oncology Other (specify)  YEARS Practicing Specialty Primary Geographic Practice Setting: (check one) Rural Suburban Urban Primary Type of Practice: (check one) Solo Practice Single Specialty Group Multispecialty Group Medical School Faculty Practice Plan Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 2
  3. 3. Introduction "Physician work" includes the following elements: • Physician time it takes to perform the service • Physician mental effort and judgment • Physician technical skill and physical effort, and • Physician psychological stress that occurs when an adverse outcome has serious consequences All of these elements will be explained in greater detail as you complete this survey. "Physician work" does not include the services provided by support staff who are employed by your practice and cannot bill separately, including registered nurses, licensed practical nurses, medical secretaries, receptionists, and technicians; these services are included in the practice expense relative values, a different component of the RBRVS. Background for Question 1 The Table in Question 1 presents reference services that have been selected for use as comparison services for this survey because their relative values are sufficiently accurate and stable to compare with other services. The “work RVU” column presents current Medicare fee schedule work RVUs (relative value units). In Question 1 you will be asked to select one code from this list which is most similar to the surveyed CPT code descriptor and typical patient/service. It is very important to consider the global period when you are comparing the survey code to the reference services. A service paid on a global basis includes: • visits and other physician services provided within 24 hours prior to the service; • provision of the service; and • visits and other physician services for a specified number of days after the service is provided. The global periods listed refer to the number of post-service days of care that are included in the payment for the service as determined by CMS for Medicare payment purposes. 090 90 days of post-service care are included in the work RVU Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 3
  4. 4. SURGERY 090 Global Period Discussion Pre-service period The pre-service period includes physician services provided from the day before the operative procedure until the time of the operative procedure and may include the following: • Hospital admission work-up. • The pre-operative evaluation may include the procedural work-up, review of records, communicating with other professionals, patient and family, and obtaining consent. • Other pre-operative work may include dressing, scrubbing, and waiting before the operative procedure, preparing patient and needed equipment for the operative procedure, positioning the patient and other “non- skin-to-skin” work in the OR. The following services are not included: • Consultation or evaluation at which the decision to provide the procedure was made (reported with mod-57). • Distinct evaluation and management services provided in addition to the procedure (reported with mod-25). • Mandated services (reported with modifier -32). Intra-service period The intra-service period includes all “skin-to-skin” work that is a necessary part of the procedure. Post-service period The post-service period includes services provided on the day of the procedure and within 90 days and may include the following: • Day of Procedure: Post-operative care on day of the procedure is divided into “Immediate Post-Service Time” and any subsequent visit on the day of the operative procedure. [Immediate Post-Service Time includes non "skin-to-skin" work in the OR after the procedure, patient stabilization in the recovery room or special unit, and communicating with the patient and other professionals (including written and telephone reports and orders).] • Other follow-up care before the patient is discharged: Post-operative visits in ICU, other in-hospital visits, and discharge day management services. • Office visits within the assigned global period of 90 days. The following services are not included: • Unrelated evaluation and management service provided during the postoperative period (reported with modifier -24) • Return to the operating room for a related procedure during the postoperative period (reported with mod -78) • Unrelated procedure or service performed by the same physician during the postoperative period (reported with modifier -79) Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 4
  5. 5. Please consider these “typical patients” when completing this survey Survey Code 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy Global Period 90 days Typical Patient A 37-year-old female presents with dysphagia and a 1.5 cm palpable thyroid nodule in the lower pole of the right lobe that is cold on radionuclide scan, solid by sonography, and by fine needle aspiration cytology is non-diagnostic. At operation, the right lobe of the thyroid and a portion of the isthmus are resected. Frozen section reveals thyroid adenoma. Survey Code 60240 Thyroidectomy, total or complete Global Period 90 days Typical Patient A 50-year-old female presents with an enlarged thyroid and symptoms. Ultrasound evaluation reveals multiple nodules with one dominant. At operation, a total thyroidectomy is performed. Survey Code 60500 Parathyroidectomy or exploration of parathyroid(s); Global Period 90 days Typical Patient A 40-year-old female presents with persistent elevated levels of serum calcium and PTH, as well as mild osteoporosis. Nuclear medicine and ultrasound imaging are non- diagnostic. At operation, she undergoes four gland exploration, with tissue submitted for frozen section, followed by resection of parathyroid(s) to reduce excess parathyroid activity. Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 5
  6. 6. Question 1: Which ONE Reference Service below is most similar to each procedure and patient described above? You may choose one reference code for all procedures being surveyed or a different reference code for each survey procedure. Multispecialty Reference Service List Place "X" in each column to indicate your reference choice for each survey code. Only one "X" per column for your reference choice. CPT Code DESCRIPTOR work RVU global period60220 60240 60500 38520 Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad 7.03 090 21556 Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 cm 7.66 090 38542 Dissection, deep jugular node(s) 7.95 090 14060 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 9.23 090 38740 Axillary lymphadenectomy; superficial 10.70 090 60210 Partial thyroid lobectomy, unilateral; with or without isthmusectomy 11.23 090 38700 Suprahyoid lymphadenectomy 12.81 090 38745 Axillary lymphadenectomy; complete 13.87 090 69714 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 14.45 090 21557 Radical resection of tumor (eg, malignant neoplasm), soft tissue of neck or anterior thorax; less than 5 cm 14.75 090 60212 Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including isthmusectomy 16.43 090 60271 Thyroidectomy, including substernal thyroid; cervical approach 17.62 090 42415 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve 18.12 090 60260 Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion of thyroid 18.26 090 15732 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (eg, temporalis, masseter muscle, sternocleidomastoid, levator scapulae) 19.90 090 38720 Cervical lymphadenectomy (complete) 21.95 090 60252 Thyroidectomy, total or subtotal for malignancy; with limited neck dissection 22.01 090 38724 Cervical lymphadenectomy (modified radical neck dissection) 23.95 090 60600 Excision of carotid body tumor; without excision of carotid artery 25.09 090 60254 Thyroidectomy, total or subtotal for malignancy; with radical neck dissection 28.42 090 CPT five-digit codes, two-digit number modifiers, and descriptions only are copyright by the American Medical Association. No payment schedules, fee schedules, relative value units, scales, conversion factors, or components thereof are included in CPT. The AMA is not recommending that any specific relative values, fees, payment schedules, or related listings be attached to CPT. Any relative value scales or relative listings assigned to CPT codes are not those of the AMA, and the AMA is not recommending use of these relative values. Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 6
  7. 7. Question 2A. How much of your own time is required per patient treated for each of the following steps in patient care related each procedure? 60220 60240 60500 Day Before Procedure Pre-service evaluation time: minutes Day of Procedure Pre-service evaluation time: minutes Pre-service positioning time: minutes Pre-service scrub, dress, wait time: minutes Intra-service time (skin-to-skin): minutes Immediate post-service time* minutes * Immediate post-operative care on day of the procedure, includes non "skin-to-skin" work in the OR, patient stabilization in the recovery room or special unit and communicating with the patient and other professionals (including written and telephone reports and orders). Include patient visits on the day of the operative procedure (eg, in their hospital room or in the ICU) in Question 2c below. Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 7
  8. 8. Question 2B: Post-Operative Work – Please respond to the following questions based on your typical experience for each survey code. Typical for purpose of this survey means more than 50% of the time. What is “Typical”? 60220 60240 60500 (Check only one row for each code) Do you typically (>50%) perform this procedure in a hospital, ASC or in your office? Typically performed in a hospital Typically performed in an ASC Typically performed in my office (Check only one row for each code, if applicable) If you typically perform this procedure in a hospital, is your patient discharged the same day, kept overnight but less than 24 hours, or admitted to the hospital? Same-day discharge Overnight, but stays less than 24 hrs Admitted, stays more than 24 hrs N/A – typically in ASC / office (Check only one row for each code, if applicable) If your patient is typically kept overnight in a hospital, will you perform an E&M service later on the same day? Yes – E/M later same day No – first E/M is next day Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 8
  9. 9. Background for E&M Services: Please review this Table and use it as a guide when answering Question 2C on the next page about post-operative facility and office care through the global period. CPT Code Physician Total Time (min) Typical Physician Total Face-to-Face Time (min) History: Examination Complexity of Medical Decision Making NON-Critical Care Hospital Visits 1,2 99231 20 15 Problem focused Low or straightforward 99232 40 25 Expanded Moderate 99233 55 35 Detailed High Critical Care Hospital Visits 1,3 99232 or 99233 LESS than 30 minutes total for day 99291 30-74 minutes total for day 99292 Each additional 30 min after first 74. Use multiples added to 99291, as needed. Discharge Day Management 99238 38 < 30 99239 55 > 30 Office Visits 1 99211 7 5 99212 16 10 Problem focused Straightforward 99213 23 15 Expanded Low 99214 40 25 Detailed Moderate 99215 55 40 Comprehensive High Prolonged Services 4 99354 30-74 minutes total for day. Performed in the office or other outpatient setting 99355 Each additional 30 min after first 74. Use multiples added to 99354, as needed. 99356 30-74 minutes total for day. Performed in the inpatient setting 99357 Each additional 30 min after first 74. Use multiples added to 99357, as needed. 1) When counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face-to- face time or floor/unit time), then time may be considered the key or controlling factor to qualify for a particular level of E/M service. This includes time spent with parties who have assumed responsibility for the care of the patient or decision making, whether or not they are family members. 2) Services for a patient who is not critically ill but happens to be in a critical care unit are reported using hospital visit codes as appropriate to the circumstances. 3) Critical care codes are used to report the total duration of time spent by a physician providing constant attention to an unstable critically ill or injured patient, even if the time spent by the physician providing critical care services on that date is not continuous. These codes should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code. Critical care code 99292 is used to report each additional 30 minutes beyond the first 74 minutes and may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes, beyond the first 74 minutes, is not reported separately. 4) Prolonged services are used when a physician provides prolonged service involving direct (face-to-face) patient contact that is beyond the usual service in either the inpatient or outpatient setting. These services are used to report the total duration of face-to-face time spent by a physician on a given date providing prolonged service, even if the time spent by the physician is not continuous. Code 99354 or 99356 is used to report the first hour of prolonged service of 30-60 minutes on a given date depending on site of service. Either code should be used only once per date, even if the time spent by the physician is not continuous. Prolonged service of less than 30 minutes total duration beyond the typical CPT time on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes. Code 99355 or 99357 is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately. Please continue to next page  Question 2C: Post-operative services by day: For these codes, post-op work includes physician visits from the conclusion of the operation until the end of the 90-DAY global period. Applicable CPT codes are listed in the table below. Descriptions for these CPT codes are shown above for your reference. In the table below, please CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 9
  10. 10. indicate the number of typical E/M services through the 90-day global period for the typical patient for each survey code. Only one E/M code may be reported on any calendar day regardless of the number of patient visits. (It may also be helpful to think of this exercise as listing the type and frequency of all the evaluation and management codes for which you would submit claims, if there was no global period for these codes.) In The Right Columns, Enter The Total Number Of Post-Operative Visits Through The 90-Day Global Period History: Exam Complexity of Medical Decision Making E/M CPT Codes Survey Codes 60220 60240 60500 Number of Facility visits (if applicable): ICU 30-74 minutes (time is total for day) 99291 ICU Each add'l 30 min after first 74 99292 Problem focused Low 99231 Expanded Moderate 99232 Detailed High 99233 Facility Discharge <36 min total / < 30 face-to-face 99238 Facility Discharge >36 min total / > 30 face-to-face 99239 Number of Office visits (if applicable): 99211 Problem focused Straightforward 99212 Expanded Low 99213 Detailed Moderate 99214 Comprehensive High 99215 Number Prolonged Services (if applicable): 30-74 minutes (time is total for day)(non-facility) 99354 Each add'l 30 min after first 74 (non-facility) 99355 30-74 minutes (time is total for day) (facility) 99356 Each add'l 30 min after first 74 (facility) 99357 Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 10
  11. 11. QUESTION 3: For the Surveyed CPT code and for the reference service you chose in Question 1, rate the AVERAGE pre-, intra-, and post service complexity/intensity on a scale of 1 to 5 (1 = low; 3 =medium; 5 = high). Please base your rankings on the universe of codes your specialty performs. (Reference codes were chosen on Page 6 above.) INSERT Complexity Rating of 1, 2, 3, 4, or 5 in each green cell (rating scale: 1=low; 5=high) Rate 60220 Rate Ref Code Rate 60240 Rate Ref Code Rate 60500 Rate Ref Code PRE-service complexity INTRA-service complexity POST-service complexity Discussion of Physician Work Complexity and Intensity In evaluating the work of a service, it is helpful to identify and think about each of the components of a particular service. Focus only on the work that you perform during each of the identified components. The descriptions below are general in nature. Within the broad outlines presented, please think about the specific services that you provide. Physician work includes the following: Time it takes to perform the service. Mental Effort and Judgment necessary with respect to the amount of clinical data that needs to be considered, the fund of knowledge required, the range of possible decisions, the number of factors considered in making a decision, and the degree of complexity of the interaction of these factors. Technical Skill required with respect to knowledge, training and actual experience necessary to perform the service. Physical Effort can be compared by dividing services into tasks and making the direct comparison of tasks. In making the comparison, it is necessary to show that the differences in physical effort are not reflected accurately by differences in the time involved; if they are, considerations of physical effort amount to double counting of physician work in the service. Psychological Stress – Two kinds of psychological stress are usually associated with physician work. The first is the pressure involved when the outcome is heavily dependent upon skill and judgment and an adverse outcome has serious consequences. The second is related to unpleasant conditions connected with the work that are not affected by skill or judgment. These circumstances would include situations with high rates of mortality or morbidity regardless of the physician’s skill or judgment, difficult patients or families, or physician physical discomfort. Of the two forms of stress, only the former is fully accepted as an aspect of work; many consider the latter to be a highly variable function of physician personality. Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 11
  12. 12. QUESTION 4: For the Surveyed CPT code and for the reference service you chose in Question 1, rate the intensity for each component listed on a scale of 1 to 5. (1= low; 3=medium; 5 = high). Please base your rankings on the universe of codes your specialty performs. (Reference codes were chosen on Page 6 above.) INSERT Complexity Rating of 1, 2, 3, 4, or 5 in each green cell (rating scale: 1=low; 5=high) Rate 60220 Rate Ref Code Rate 60240 Rate Ref Code Rate 60500 Rate Ref Code Mental Effort and Judgment The number of possible diagnoses and/or the number of management options that must be considered The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained reviewed and analyzed Urgency of medical decision making Technical Skill/Physical Effort Technical skill required Physical effort required Psychological Stress The risk of significant complications, morbidity and/or mortality Outcome depends on skill and judgment of physician Estimated risk of malpractice suit with poor outcome QUESTION 5: Experience - How many times in the past 12 months have you performed each survey code procedure and each reference code procedure? What is your experience in the past 12 months for each Survey code and each Reference code*  60220 Ref Code* 60240 Ref Code* 60500 Ref Code* *Reference codes were chosen on Page 6 above. Please continue to next page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 12
  13. 13. QUESTION 6: The RUC is also interested in determining whether the physician work for the survey service has changed over the previous five years. 6a. Has the work of performing this service changed in the past 5 years? 60220 60240 60500 Yes No If YES, please also complete Questions 6b-6f. 6b. Does this service represent new technology. 60220 60240 60500 Yes No 6c. If this service represents new technology, how has this new technology affected the work of this service. 60220 60240 60500 Less Work Same Work More Work 6d. This service represents new technology that has become more familiar. 60220 60240 60500 I agree I do not agree 6e. Compared with 5 years ago, patients requiring this service are now: 60220 60240 60500 More complex Less complex No Change 6f. The usual site-of-service has changed over the past 5 years: 60220 60240 60500 From outpatient to inpatient From inpatient to outpatient No Change Please continue to LAST page  CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 13
  14. 14. QUESTION 7: Is your typical patient for each code similar to the typical patient described on Page 5 at the beginning of the survey? 60220 YES? NO? If "No," please describe your typical patient below: 60240 YES? NO? If "No," please describe your typical patient below: 60500 YES? NO? If "No," please describe your typical patient below: *************************VERY IMPORTANT QUESTION************************* QUESTION 8: Based on all previous survey questions that compare the survey code(s) and reference code(s), please provide your estimated physician work RVU for each survey code. Please keep in mind the RANGE of work RVUs for the reference codes listed in the table for Question 1 on page 6 above when providing your estimate. For example, if the survey code involves the same amount of physician work as the reference service you choose in Question 1, you would assign the same work RVU. If the survey code involves less work than the reference service you would estimate a work RVU that is less than the work RVU of the reference service and vice-versa. This methodology attempts to set the work RVU of the survey service “relative” to the work RVU of comparable and established reference services. Your Estimated work RVU: 60220 Total thyroid lobectomy, unilateral; with or without isthmusectomy 60240 Thyroidectomy, total or complete 60500 Parathyroidectomy or exploration of parathyroid(s); Please email your completed survey to: RUCsurvey@aol.com THANK YOU! CPT five-digit codes, two-digit modifiers, and descriptions only are copyright by the American Medical Association. Page 14

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