Question: I saw that relative value units (RVU) changed for 2023. Does this mean I will get a raise or increased payment for my services?
You are correct: The relative value units of CPT codes were adjusted, as they are each year; for 2023, that was about a 1-2% change in the common codes used by licensed acupuncture providers. For example, in 2021 and 2022, 97810 had a relative value of 1.06 and 1.16, respectively, meaning about a 10% increase. For 2023, the value was reduced slightly to 1.14.
For 97811, the values for 2021 and 2022 were 0.80 and 0.87 – a 7% increase. In 2023, the value is 1% less at 0.86. These changes for 2021-2022 had a decidedly positive impact on reimbursement for acupuncture on most plans. For 2023, acupuncture relative values are flat, but other common services, such as evaluation and management services and physical medicine services, saw a 1-4% increase.
Getting Paid More or Less? Medicare vs. Other Insurance
These small increases may result in reimbursement increases, but are not always that simple, as the conversion factor for the services may increase or decrease. There is no better evidence for this than with Medicare.
For example, Medicare sets a conversion factor that is multiplied by the RVU to provide the Medicare rate for that service. However, in 2023 in most regions, although the RVU is flat, the conversion factor was reduced. You are seeing this in Medicare rates, as you have likely noticed about a $1-$3 reduction for acupuncture and 25-50 cents for therapies if you bill Medicare. (Note that the value of evaluation and management services RVU was increased by a few dollars higher based on RVU.)
Many insurance plans may maintain the same conversion, meaning when a code's RVU is increased or decreased, there will be a commensurate increase or decrease in reimbursement. Medicare lowered its conversion, which results in a lower payment for acupuncture; but due to increases in RVU, other services are flat or slightly higher.
However, many plans and commonly, workers' compensation fee schedules, will increase their conversion year to year. For example, in 2022 Texas had a conversion of $61.17 and in 2023 it is $64.83. Plans of this nature will pay higher allowances. But this is not the only use for RVU.
Understanding RVU
RVU is your best tool for understanding the value of one service compared to another. Every code has a relative value, meaning a comparison of one vs. another. For example, if a code is valued at 0.75 and another code is valued at 1.0, then the codes are 25% different.
For example, the RVU for 97810 is 1.14 and for 97811 it is 0.86, meaning the value difference between them is about 28%. You see this reflected with non-per-diem plans, where you will note that the allowed rate of a 97810 compared to a 97811 is about 28 percent higher.
Note that you will see this ratio reflected in non-PPO/HMO, personal injury, workers' compensation, Veterans Administration, and Medicare rates among all common acupuncture, physical medicine, and evaluation and management services.
Using RVU to Set Fair and Reasonable Fees
Using the logic of relative value can aid you in establishing a fair and reasonable fee for all your services. If you know the fee of one code, you can then establish the fees for any other code based on the primary service fee and set a ratio based on the relative value.
For example, if you charge $60 for 98940 and have established that is the fair and reasonable fee allowed and payable, you can use that value to establish the same for other codes based on relative values. To do this follow this algorithm:
If, for example, the fee you set for 97810 is $75, divide $75 by 1.14 = 65.79, which becomes your conversion factor. Simply multiply that number by another service RVU to determine the price based on the $75 fee for 97810. (Note: This means you have established that the $75 for 97810 is fair, reasonable and customary in your region, but also what you are being paid or is allowed.)
For example, here are the values of other services based on a $75 fee for 97810:
This is how plans determine fees (exception: ASH does not), including Medicare, workers' comp, personal injury, and non-PPO plans. In using the above, you will often find you have been undervaluing what is reasonable for certain codes; but also may find you have some that are not reasonable and too high.
Value Your Services – Insurance Isn't Going to Do It For You
All businesses, including yours, should make a fiscal review of fees. When there are increased expenses for that business, there should be increases in their charges. An acupuncture office should not be dependent solely on the increasing volume of patients, but also on the value and price of their services to match the cost of business and inflation.
My big lament is how an insurance plan can charge higher premiums year to year, pay their executives very high salaries and bonuses, and their workers cost-of-living increases ... but never raise the rates paid to the providers.
Yet they indicate to the general public that the reason for increased premiums is due to the increased costs of the services. How can that be true when they never pay the provider more in many instances?
If you accept insurance, when was the last time you saw a true increase year to year (or any year) in reimbursement for your services? (I have to admit due to RVU it was 2021, but that was a long- overdue adjustment for acupuncture.) Use RVU to help determine whether you should make changes to your fees.
Editor's Note: Have a billing question? Submit it to Sam via email at sam@hjrossnetwork.com. Submission is acknowledgment that your question may be the subject of a future column.
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