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Fam Pract Manag. 2000 Mar;7(3):60.

RVUs and established patient visits

Q

How many relative value units (RVUs) are there in a level-III established visit?

Relative Value Scale (RBRVS) Under the Resource-Based used by Medicare and many other third-party payers to determine physician reimbursement, a level-III established patient office visit (i.e., code 99213) has a total of 1.29 RVUs assigned to it.

Under RBRVS, a code's total RVUs is the sum of three components: work RVUs, practice-expense RVUs and malpractice RVUs. The component RVUs for established patient office visits are as follows:

View/Print Table

CodeWork RVUsPractice expense RVUsMalpractice RVUsTotal RVUs

99211

0.17

0.37

0.01

0.55

99212

0.45

0.47

0.02

0.94

99213

0.67

0.60

0.02

1.29

99214

1.10

0.85

0.04

1.99

99215

1.77

1.13

0.07

2.97

CodeWork RVUsPractice expense RVUsMalpractice RVUsTotal RVUs

99211

0.17

0.37

0.01

0.55

99212

0.45

0.47

0.02

0.94

99213

0.67

0.60

0.02

1.29

99214

1.10

0.85

0.04

1.99

99215

1.77

1.13

0.07

2.97

The Health Care Financing Administration (HCFA) maintains the RBRVS and assigns RVUs to each code with the advice of the public and organized medicine. You can find all the RVUs for the 2000 edition of the RBRVS in the Nov. 2, 1999, Federal Register.

Treating family members

Q

I treat my wife and children for minor coughs, colds, etc. My concern is about ordering tests for my family (e.g., ultrasounds, labs) and performing routine check-ups and Pap smears. Is there any legal reason this can't be done? Also, is there any reason why an insurance company would not pay for tests I ordered for a family member?

Your medical license does authorize you to treat family members, and insurance companies should pay for the tests you order. However, there are legal risks associated with treating family members.

Blending the vastly different roles of physician and family member can deprive the patient of the confidential relationship that's so important in medicine. It also can lead to fragmented care, with some records being in the physician-family member's office and others in the possession of someone else. Often the family member's medical record is incomplete or doesn't exist at all.

These circumstances can put the physician at risk if payment is challenged by a third-party payer or if the physician's narcotic prescribing practices are questioned by a regulatory body.

While I'm aware that many physicians routinely treat family members, to do so except for the most minor of conditions may present unnecessary exposure to risk for both patient and doctor. In these difficult times, why should you volunteer for such problems?

Unlawful restraint of trade?

Q

A third-party payer is refus ing to pay the stated charge, reducing my billings by a 30-percent, non-negotiable discount. Isn't that a violation of restraint of trade? HCFA and insurance companies seem to be in collusion; they fix prices and are non-negotiable price vendors within dollars of each other.

A single payer's refusal to pay a physician's stated charge or its decision to reduce the amount it pays a physician is not an unlawful restraint of trade or any other violation of the federal antitrust law. However, a payment reduction could constitute a breach of contract by the payer if the stated charge is in a contract between the payer and physician and the contract does not provide that the payer may unilaterally change the terms of payment.

In general, the antitrust laws provide a purchaser with the right to purchase goods and services at the lowest price it's able to negotiate. An unlawful restraint of trade and a violation of the antitrust laws would occur if the fee reduction resulted from an agreement involving more than one payer. In that case, the payers participating in the agreement would have entered into an unlawful horizontal price-fixing agreement.

The fact that HCFA and other payers refuse to negotiate with physicians and that their prices are close to each other's does not mean that collusion is occurring. Each may have observed the behavior and fees of the other and then made independent decisions not to negotiate or to pay the fees they set.


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Copyright © 2000 by the American Academy of Family Physicians.
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