Commentary: The Kidney Community’s and Renal Physician Association’s Role in Valuing Nephrologists’ Work

  • 1 Adam Weinstein, MD, is Chief Medical Information Officer for DaVita and is a part-time clinical nephrologist with the University of Maryland Shore Medical Group. He has been an RPA advisor to the AMA RUC since 2011, an alternate for the RUC internal medicine rotating seat from 2014 to 2016, and was elected to the RUC internal medicine rotating seat for 2022−2024. Eileen Brewer, MD, is Medical Director of Kidney Transplant at Texas Children's Hospital in Houston and Professor of Pediatrics at Baylor College of Medicine. Dr. Brewer has been an alternate to the RUC for the American Academy of Pediatrics since 2013.
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Health care providers eagerly anticipate the Centers for Medicare & Medicaid Services (CMS) updates to the physician fee schedule (PFS) in the Federal Register each fall. The PFS, which assigns relative value units (RVUs) to Current Procedural Terminology (CPT) codes, is CMS's price list for physician services. The published CPT values result from thousands of hours of work by specialty society representatives (called advisors) and the 32 members of the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) (1).

Per AMA bylaws, specialty societies that meet requirements for representation in the AMA House

Health care providers eagerly anticipate the Centers for Medicare & Medicaid Services (CMS) updates to the physician fee schedule (PFS) in the Federal Register each fall. The PFS, which assigns relative value units (RVUs) to Current Procedural Terminology (CPT) codes, is CMS's price list for physician services. The published CPT values result from thousands of hours of work by specialty society representatives (called advisors) and the 32 members of the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) (1).

Per AMA bylaws, specialty societies that meet requirements for representation in the AMA House of Delegates may appoint representatives to the RUC. For the last 30 years, the Renal Physicians Association (RPA) has qualified to have RUC advisors advocating for the value of nephrology-related CPT codes (2). RVUs are the basis of most physician payments, including employment contracts and parts of value-based care programs, such as the Chronic Kidney Disease Quarterly Capitated Payment (CKD QCP) in the Comprehensive Kidney Care Contracting (CKCC) model.

Before establishing the relative value system, CMS paid physicians at “usual and customary” rates, which proved to be fiscally untenable. In 1989, Congress mandated the use of the Harvard resource-based relative value scale (RBRVS) study methodology for all Medicare payments (3). Establishing a work- and intensity-based relative value for every medical procedure (from removing a glioblastoma to providing psychotherapy) proved complex and led in 1991 to regular RUC meetings at which AMA-participating medical society RUC advisors present typical physician work and practice expense RVUs to the 32 members of the RUC through a fair and structured methodology (4). A 2011 study, the most recent peer-reviewed article on this topic, found that CMS, on average, accepts 85%–95% of CPT values recommended by the RUC (1).

As seen in Figure 1, both new and existing CPT codes are referred for RUC review. Societies representing specialties that most frequently submit bills for the reviewed CPT code are expected to survey their members to establish typical physician work RVUs and practice expense values to ensure appropriate relativity compared with similar CPT codes.

Figure 1
Figure 1

Steps in the CPT valuation process and RPA participation

Citation: Kidney News 14, 6

The RUC holds triannual meetings, where specialty society advisors present survey findings and recommend CPT valuation, defending their recommendations with survey data and precedent valuations of similar RUC-reviewed CPT codes. After each meeting, the RUC sends its recommendations for work RVUs and practice expenses to CMS for internal deliberation, finalization, or further alteration before inclusion in the PFS. The RUC may recommend 200−400 CPT code values to CMS in a typical year.

Among the 32 members of the RUC, there are six AMA representatives, 22 permanent specialty society seats, and four rotating seats for 2-year, non-repeating terms. Two of the rotating seats are for internal medicine subspecialties, one is for primary care, and one is for any specialty (5). Specialty society-nominated physician candidates for the rotating seat are elected by RUC members. Nephrologists who are members of RPA were elected to an internal medicine rotating seat in 2014 and 2022.

Although far from perfect, the RUC process influences how most CPT codes obtain absolute and relative values in the United States. Having physicians experienced in the RUC process and with backgrounds in CPT coding who establish and agree on these values is critical (6, 7). RPA's RUC advisors have defended multiple CPT code values, including establishing values for 90950−90970 in 2008 and various interventional nephrology procedures in recent years. Nephrologists can participate in several ways:

  1. Maintain both RPA and AMA membership. RPA relies on having at least 20% of its members maintain AMA membership to be a voice for nephrology at the RUC.

  2. Participate in RPA member surveys to establish a CPT code's typical time, work, intensity, and practice expense. Review and respond appropriately to any email from RPA titled “RUC Survey.”

  3. Review the AMA literature on the relative value system.

The lingua franca of physician work in the American medical system is the RVU. All physicians must think about our time and effort in these terms, as it is the best means to ensure a robust workforce to care for our patients.

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