Thank you so much, Gary. I would like to welcome all of you to our next installment of our FAMRS Fellows Virtual Forum Web-based Lecture Series. This is a series of presentations by experts in our sub-specialties from across the country developed exclusively for the FAMRS Fellows. This presentation will then be captured and made available for view at any time on the AUG's website. Upon completion of this program, you will be given the opportunity to provide some feedback which we value greatly as we plan future programming. For this evening's presentation, it is my pleasure to introduce Cedric Oliveira. He is Clinical Assistant Professor at NYU School of Medicine and he is joined by Jill Ratburn, Health Policy Consultant for AUG. And their presentation today will be the ins and outs of RVUs. So thank you, Dr. Oliveira and Jill. All right. My pleasure. So what we're going to talk about today are the ins and outs of RVUs and really what this talk is about is just getting us all familiar with terminology that's going to be important for how we're compensated as physicians moving forward as the healthcare market changes and as job descriptions and requirements change. So to just jump right into this. So Medicare basically pays physicians based on services that they provide. And as you all know, we give them CPT codes and we'll go through some examples later on. But each CPT code has what's called a relative value unit assigned to it. And when the RVU or relative value unit is multiplied by the geographical adjustment factor or GIPC and then by a conversion factor, and I'll show you how to actually utilize that formula, then that will create the compensation level for a particular service. And as many of you know, we're currently as physicians being paid by our productivity and RVUs. So basically the RVU has three different components to it. It has a physician work component, it has a practice expense component, and it has a malpractice expense component. The breakdown is about 52% for physician work, 44% for practice expense, and about 4% for malpractice expense. So that's an important thing to know because the malpractice portion is actually the smallest portion of the whole formula. And so the relative RVU for work is the level of skill, time, training, and intensity that's provided by a given service. Each CPT code may be reviewed at least every five years to determine the work RVU for a particular service and consider whether or not it remains the same and whether or not it needs to be changed. And I'll talk to you later on about when you get surveys to determine what the value is of the work that you're doing, how you should fill out that survey. And it should be based on your average time to do something or i.e. provide a certain amount of work versus the best time. But we'll go over that a little bit later. So there are various different code values that can increase or decrease the value or component of the service that you provide. And a code with a higher work RVU obviously takes more time, has more intensity, or some combination of the two. In some radiological codes, as we'll talk about, they have no associated physician work or they're reimbursed, their facility and non-facility reimbursement for practice expense, which I'll show you, will change whether or not it's done in the hospital or in their private freestanding office or non-facility area. All right, so we talked about work RVU. Now we'll talk about practice expense RVU. So remember, the formula is work RVU, practice expense RVU, medical malpractice RVU. And then that's all going to be combined and then multiplied by a conversion factor. And I'll show you how each one of those components, work, practice expense, and malpractice are multiplied by what's called a geographical practice cost index, or GIPC, for short. But so just moving forward, so the practice expense RVU is the component that addresses the cost of maintaining a practice, including rent, equipment, supplies, and non-physician staff costs. The practice expense RVU is calculated from a bottom-up methodology where the direct costs of providing a service are calculated, which are staff time, supplies, and equipment time. And then you have indirect costs. And we'll talk about that. But basically, direct costs are things that are tangible. And indirect costs are things that are somewhat intangible. An example of an indirect cost would be like a billing service or having a waiting room. But the direct costs are things such as actual supplies, equipment, staff time, et cetera. So again, a lot of this talk is just to get you familiar with some of the terminology that's utilized out there regarding RVUs so that you understand all that there is to know about them. And then also to initiate an investigative process on your part to figure out how your institution is actually paying you because, or will be paying you for some of you that are looking to get into the job market because it can vary from institution to institution. All right. So to continue with the practice expense RVU, frequently a CPT code that we're all familiar with will be assigned a practice expense RVU for facility settings such as a hospital and a different practice expense RVU for non-facility settings such as a freestanding center or physician office. And when you think of the word non-facility, it's linked with this term freestanding. So whether it's the freestanding physician's office or some other freestanding clinic or office area, then that's associated with the non-facility portion of the calculation. When a procedure is performed in the hospital, the hospital receives their fees through two different fee models. One is known as the HOPPS, which is the Hospital Outpatient Prospective Payment System, or the Hospital Inpatient Prospective Payment System, which is the IPPS. In terms of malpractice RVUs, as we noted before, they're the smallest component of the calculated formula, usually about 4%, and represents payment for the professional liability expenses. The Relative Value Scale Update Committee, which is something that you're going to hear a lot about, what is this committee? It's the RUC committee. And basically, the RUC committee and the Centers for Medicare and Medicaid Services, which you also have heard of, CMS, they basically suggest the rules that determine what expenses are going to be allocated to the RVUs and how the RVUs are going to be calculated. And they usually, depending on which term, whether it's the GYPSI or the work RVU or the conversion factor, they meet on various different, either annually or every three years or every five years, et cetera. All right, so talking about the RUC committee a little bit more, it's an expert panel that develops recommendations for work RVUs and practice expense inputs for consideration by CMS. It involves the American Medical Association and the National Medical Specialty Societies. The AMA is responsible for staffing the RUC. So obviously, there's a direct interest there, and providing logistical support for the RUC committees. Basically, the RUC committee, so that you understand the process, is a 31-member committee. Twenty-one of those members are appointed by major national medical specialties, and ten of those seats are reserved. Of those ten seats that are reserved, four of them are rotating every two years. So two internal medicine subspecialties, one for primary care, and one for another specialty. Of the six remaining seats of those ten, you have one for the RUC chair, one for the RUC co-chair, one for the representative of the AMA, one for the representative of the American Osteopathic Association, one for the chair of the Practice Expense Review Committee, and one for the chair of the CPT editorial board. In terms of that geographic practice cost index, or GIPC, it accounts for the geographical differences in the cost of practices across the country. So the GIPC in New York or in the Northeast may be different from the GIPC in the South, in Georgia, for example. CMS calculates an individual GIPC for each of the RVU components, physician work, practice expense, and malpractice. I'm going to show you a formula how to calculate this, and there's two different ways of looking at it. I'll point that out to you later. But the GIPC is reviewed every two years. So there's something called budget neutrality. One of the formulas, just as we're talking, is, remember, the RVU comprises of the work RVU, the practice expense RVU, and the malpractice expense. So one formula is to take the work RVU and multiply that by the work GIPC, and then you take the practice expense RVU, whether it's a non-facility or facility, and you multiply that by the practice expense GIPC, and then you could take the malpractice RVU and multiply that by the malpractice GIPC, and then when you multiply all of that, after you've added those three up, time the conversion factor, which is also known as the reason for budget neutrality. And so what is the conversion factor? It's a dollar amount that's multiplied, and it's updated on an annual basis to a specific formula. The problem is that the government or CMS, they only have X amount of dollars, right? So basically, they have to fall within the guidelines of balancing their budget or budget neutrality, and they only have a $20 million bracket that they can utilize. So therefore, if they're going to be over that $20 million, then they're going to readjust the conversion factor. So in 2016, the conversion factor adjusted for budget neutrality was $35.08, basically. So CMS is prohibited from changing its overall budget by more than $20 million. So should RVU shift in a way that the CMS budget is impacted by over $20 million, then must use a budget neutrality factor or that conversion factor to bring its total payment back in line. In 2009, CMS changed its budget neutrality application, moving it to the conversion factor. The facility and non-facility fees we talked about, but it basically identifies where the services are being provided. The facility pricing amount generally covers services to inpatients or in a hospital outpatient clinic setting, but can include other settings. Off-site hospital-owned sites are also considered as facility. So if your hospital has a clinic in the hospital or multiple clinics in the community, those would be considered facility fees that CMS would pay them versus a freestanding physician's office, and that would be the non-facility fee. And I'll show you why that's important, because depending on whether it's a non-facility or facility, the RVUs will change. So what about female public medicine reconstructive surgery and how we're going to be impacted moving forward? This is just an example of some of the common codes that we use, some of the common CPT codes that we use. So 10120, transvaginal simple removal of a foreign body from the skin in the clinic. And let's say you were just going to remove something in the vagina or maybe a piece of mesh that's extruded, et cetera. You'll see that the total RVU amount for the non-facility is higher than the facility. And why is that? So basically, if you remember that formula where it's work RVU is work times the gypsy plus practice expense times gypsy for practice expense times, or plus the malpractice expense times its gypsy, the practice expense in the office is higher than it would be in the hospital. So that translates into Medicare saying, okay, we're going to give you more total RVU value if you do this in your office. If it's a non-facility freestanding physician's office, then it would be in the hospital. So because you have to cover that cost of the expense of doing it in your office. But it also translates into being rewarded, if you will, for doing something in your office instead of taking the patient to the hospital, which for CMS is going to be more expensive. Other areas that I wanted to point out here, if you do a cystoscopy in your office, it's 5.67 RVUs versus 3.59 in the hospital or the facility. Some things you can see, obviously you can only do it in the hospital. So a code 53500 only has a facility fee because that can't be done in a freestanding physician's office. The other thing you need to understand is if you use the code 57240, which is an anterocoporophy, that's worth 19 RVUs. If you use 57250, that's a posterocoporophy, that's worth 19 RVUs also, so almost 40 RVUs. But if you use the code 57260, well then you've combined a cystocele and rectocele repair, and they only pay you 24 RVUs. So a significant difference, especially when every single RVU counts. And later on, I'll talk to you about when you're coding in the office with E&M coding and you're trying to figure out whether you've met meaningful use or not, each of those parameters will increase your ability to bill at a higher level, but that higher coded level is also associated with a rewarded RVU. And it may not be by much, one or two RVUs, depending on which code you're able to bill at and level of E&M service. But if it's just a one RVU difference, over a hundred patients, well all of a sudden that's a hundred RVUs. So each RVU counts. Cedric, this is Leslie. Can I ask you a question on that last slide? Sure. Are you, you know, there's the whole, some procedures are bundled. So if you did an anterior and a posterior repair, do you have to bill them combined or would you bill them separately? Well so it all depends on what's called NCCI edits. And basically, as I'll go through an example later, there was the bundling of their various different services for prolapse repair and enter corpora fees and then they became unbundled. So if the rule, so we have to understand what the rule is at the time. If the rule says you can submit all these codes you want, but we're going to bundle it, then that's the way it has to be submitted. But then as you'll see later, they allowed us to unbundle them and therefore we can then bill them separately. Yeah. This is Jill too, Leslie. The other thing is that the rule of code selection is that physicians are supposed to select the code that most accurately describes what they did. So if there is a combined code like 57260 that accurately describes what was done, that is the code that needs to be selected. If there was not a combined code of 57260 and you did both an anterior and posterior repair, then you might be able to bill a 57240 plus a 57250-51. But since there is a more accurate code, 57260, if you did a combined cystocele and rectocele repair, then you would actually bill that code. Okay. Thank you. Yep. All right. So, and then again, if you look at transvaginal mesh removal for interocele, abdominal interocele repairs, you can see that the value of the RVUs assigned to them can range from 13 to 23 to 27. Can you still hear me? Hello? Yes. Okay. Great. So, but if you move forward, what I wanted to show you that a sling, a midurethral sling, 57288, which is something that we all commonly do, well, that's worth 20 RVUs. And that's almost, in fact, it's worth more than mesh removal for an interocele, but it's much as doing a sacrocopalpexy or a paravaginal defect repair, where the time and the work that is required for us as pelvic reconstructive surgeons may vary depending on that code and that procedure. So, just understand what procedures you're doing, what RVUs are usually assigned to them so that you can make the most of utilizing your time and effort. All right. So, in summary, RVUs, relative value units, are used to provide relative comparisons between CPT codes. The conversion factor is adjusted for budget neutralities, which is the dollar amount used to convert RVUs into payment amount, which is adjusted for budget neutrality. We talked about that $20 million that CMS has and Medicare payments have, and they can't exceed that. The facility is where the services are being performed. It's either inpatient or outpatient. The GIPC is the Geographic Practice Cost Index, so you'll understand that they vary throughout the country. And then there's the medical malpractice portion, the non-facility portion, and the practice expense portion. And remember, the medical malpractice portion is usually about 4% of the RVUs, so it's the smallest component of all three. In terms of coding, reimbursement is not public knowledge, except for Medicare and CMS rates, because that's a common denominator for all of us. And it is illegal for us to discuss our private payer reimbursements amongst ourselves, because there are contracts that we have with the various different companies, and that falls under the Sherman Antitrust Act. So we can only discuss reimbursement rates by CMS, because that's the common denominator for us all, and that's the model that we all look to to set the rates. The current state of affairs, as far as RVUs are concerned, is that basically the historical value of the RVU came from a radiologist reading one chest X-ray, but we can appreciate that now it's so important to understand the RVUs, because many of us are being compensated based on the RVU model. We're incentivized for doing high-value products, or I'm sorry, high-value procedures that have a high RVU value associated with it, and the volumes that we can generate, if we do more cases, then we're going to be compensated for that. But remember that the problem is that there's a set amount of dollars for the whole process, so the budget neutrality can't exceed that $20 million. So in terms of RVUs, the RUC and surveys, CPT codes get reviewed and reevaluated by the RUC every five years. High-frequency services are revalued more frequently, and your professional society representatives, they'll contact you, whether it's AUGS, AUA, SUFR, and ACOG. And so basically when you get these surveys, it's incumbent upon us all to remember that we don't want to do the fastest time that we've ever done, which shows that we're doing the work, but it's really not as much work as CMS thought it was. So basically what you want to do is when you fill out the surveys, just bear in mind that you want to use your average time, the average amount of work that it takes, because we all know that some cases take us not as long as others, and some cases take us much longer. So you want to, you know, be balanced when you're filling out the surveys so that it accurately reflects the work that we're doing. All right, so here's that formula. I gave you a different version of it, but another version is if you take the relative value of work plus the relative value unit of practice expense plus relative value unit of malpractice expense, and you multiply all that by the GIPC, because the conversion factor has been built into the GIPC and some calculations of the formula, that'll give you a total RVU. Most employers nowadays are using the work RVU as a barometer of your productivity. And remember the work RVU component is about 54 percent, 52 percent rather. All right, so how many RVUs do you need to support your salary? Well, that depends on your conversion factor, pay and mix, and expenses. A quick estimate is to find your average reimbursement conversion rate, that's dollar per RVU. Take your total annual RVUs, whether it's $6,000, $7,000, $8,000, multiply the dollar amount per RVU times RVU, and that'll give you an annual salary or annual revenue. And then you subtract the annual revenue minus your annual expenses, and that'll give you your annual salary. As a ballpark, around 6,000 RVUs is generally a salary of about $300,000. And you're able to create a linear graph. So if you look at this graph, you see take-home pay on the left, total RVUs on the right, and you'll see that 19,000 total RVUs is about $250,000 in terms of take-home pay. But again, that's total RVUs, so you need to understand when you're negotiating with your hospitals, what number are they using? Are they using work RVUs? Are they using total RVUs? You need to also understand what the average RVU is that's generated from most Uruguayans in the country. Some of us are in our academic practices. Some of us are in private practices. Some of us are in a hybrid. So you need to understand when you're negotiating with your hospital, what RVU number they're going to utilize. All right, so the problem is that the future is a little problematic for us because our salaries are probably going to go down unless we're able to be creative and advocate for women's public health coverage and reimbursement and show that it's more than just quality of life issues, even though we know that's what it is, but it's actually necessary. And that's based on the evidence. That's why research is so important, because it can actually validate the work that we're doing from a health perspective standpoint. Financial incentives for high volume, high RVU procedures are there. That's volume-based medicine. And we also know that patients are going to ultimately be the losers in this situation if high-value, high-volume services are translated into decreased care. So we have to make sure that we maintain excellence in our healthcare so that doctors aren't cutting corners just so that they can have a high turnover rate for the RVUs. All right, so the future for us as specialists are basically either alternative payment models, capitated payments. We can potentially form our own IPO, and we have to continue to be creative so that we can be profitable moving forward as a subspecialty and still make sure that we're able to provide high-quality care. Our value-based reimbursement models, in 2018, 50% of CMS monies were tied to quality measures. So when I mention things like meaningful use, when you're doing your history, your physical examination, are you touching on all the portions that are important? Review of systems, history of present illness, impression, plan, smoking cessation, whether or not that's involved in your social history taking. So you need to go through all of those various different parameters of your EMN coding so that you're making sure that not only are you providing high-quality care, but you're able to utilize a higher RVU amount if it's necessary and if you can actually do that. Right now, as you know, there's about 1,000 boarded female public medicine reconstructive surgeons around the country, about 50 new graduates per year. Obviously we're a tiny subspecialty, but in huge demand, and so as I was mentioning before, we need to be creative in terms of our reimbursement models so that we can show that high-quality outcomes should be rewarded, and it's not just the RVU that counts. Some of you may know that there's an ongoing issue with the taxonomy code. Basically, anybody that takes the female public medicine and reconstructive surgery boards and you pass that, all of a sudden you can get a new taxonomy code, and that taxonomy code says, okay, you're a certified FPMRS specialist, however, that does not give us the two-digit subspecialty code, which is what we need to go on the claims. So it doesn't change the claims that we're having submitted to CMS. We're still viewed and lumped together with general OB-GYN and or urology, because we don't have a separate subspecialty code at this point in time, and it's an ongoing issue that we're trying to fix. In terms of how you bill in your offices, because we don't have that two-digit subspecialty code, if you are an OB-GYN in an OB-GYN practice and one of your colleagues sends you a patient, you can't bill the patient as a new patient at a higher E&M, because we don't have our own subspecialty code, so it's going to be lumped with the tax ID from the practice. And if we try to bill it separately, okay, OB-GYN did their part or urology did their part and we're FPMRS specialists, sometimes none of it is paid, because CMS will deny both claims. So it's really important to understand what your tax ID number is and understand that we do not have a two-digit, at this point, a two-digit subspecialty code, even though many of us are board certified. And so when you're placing those claims into CMS, if you're doing it yourself, if you have a billing company, just make sure that they're up to speed with how they're submitting the claims for you. E&M, as we talked about before, as we all know, our evaluations and management codes for clinic hospital visits, either new, established, or sometimes we are consultants for individuals. And as you know, the codes will vary based on whether or not you're coding at a high level or a lower level based on the history of present illness, physical exam, medical decision making, and whether or not you've gone through your review of systems. So again, that just falls into meaningful use parameters so that you understand that if you're doing meaningful use, you're going to be rewarded for it because you can bill at a higher level, but you're also going to be compensated by having a higher RVU amount associated with it. I'm going to skip over how you bill for a sphincter of plastic, but the important part of this slide is that if there are questions that you have, you can always go to the website, and OGS has a website. We're part of the coding committee, and basically we're trying to make sure that our membership understands how to utilize codes and how RVUs are going to impact their bottom line. And so the website is www.ogs.codingtoday.com, and please feel free to use that. And there also, as I showed you before, there are different ways to code, and so you just need to understand the proper way, whether you're using enteric porophy, posteric porophy, if you're using both, if you've done both, et cetera. There's also modifiers that are important to utilize depending on what you're doing at the time, and most of us have systems that either automatically crosswalk or convert to ICD-10 by this point. Obviously, ICD-9 is obsolete, but again, if you have questions about it, you can always go to the website. This is what I was talking about before in terms of bundling. So CMS proposed bundling edits for pelvic organ prolapse repair and vaginal hysterectomy, which was effective October 1st, 2014, and then OGS fought hard to reverse and revise those suggestions, and then we were successful because in April 1st, 2015, we were able to resubmit claims that were previously bundled and be reimbursed for them. All right, so that's basically what I wanted to talk about in the allotted time, and that'll leave us some time for questions, so let's see. So do I answer the questions, Leslie, or are you gonna moderate that? Sorry, hey, so I, let's see, right now, I don't see any questions up right now. Okay. If anybody has them, they can type them in, and then I can kinda just notify you if one pops up. And there may be some questions at the end, too, for either one of you once we've heard everything. Okay. Maybe we'll give people a few minutes to type a question. Okay. Okay, so we have one. What is the average work RVU for FPMRS? Okay, so I don't know that there's an average work RVU for FPMRS specifically, but remember that on average, the work RVU is about 52% of the total. And a general way of looking at it, if the mean is about $300,000 for the year, it's about $6,000, it's about 6,000 RVUs. So that's probably it, about 6,000 is, but I don't know specifically the number, but it's probably somewhere around there, around $6,000. 6,000 RVUs, rather. Cedric, I have another question. Can you give an example of how to bill for a combined VAD shift, uterine sacral suspension, anterior posterior pair with sling? Okay. You wanna tackle that one, Jill? Okay. Actually, I think that's a really good question to go on the OGS website, as we have answered that coding question before for folks. And so Leslie, if we take Megan's information, we can send her that answer from the website. Yeah. Great, yeah. Megan, so I don't know the best way to email. Will might be able to jump in, but maybe info at OGS.org if there's a way to direct her questions. Yeah, we actually have a library of archived coding questions that are already pre-answered on the OGS website, as well as a series of fact sheets for coding, such as how to code for InterStim, how to code for urodynamics, how to code for surgical scenarios, like Megan just mentioned, how to code for, we have a couple others on there as well, as well as an ICD-9 to ICD-10 crosswalk. So there's a lot of good coding information on the OGS website that is right there at your fingertips so you can download. Yeah. And then the other- And Jill, this is Leslie. Oh, go ahead, Cedric, sorry. Oh, I'm sorry. The other thing I was just gonna add is basically what has changed are modifiers. So basically there's a 51 modifier that can be utilized. There's a 59 modifier that can be utilized. And depending on, there's a 78 modifier. And then now, ever since January 2015, the 59 modifier has changed to either XE or SXP modifier. So you just need to be familiar. When you're going to the coding website, you just need to understand that the way we bill has changed and there are different modifiers that can now be used that we didn't use before just to make sure that the billing goes through smoothly and that you're compensated based on what you've done. There's another question from Jane Baker. Do diagnoses have anything to do with RVU? So RVU is, as we went over, it's work. It's practice expense and malpractice expense. And so the ICD-9 and now ICD-10, which are the diagnoses, don't have anything to do with the RVU. It's the CPT code that is valued based on what you've done or the E&M code that's valued based on what you've done. So if in your E&M coding, you have more diagnoses, that might change, not the specific diagnoses, but the complexity of the diagnoses might change how much time you either need to spend with the patient or how much work was required in working up that diagnosis. So it might actually be affected, but not the diagnosis specific, but how much work goes into taking care of that patient and how you do your E&M coding. And then Cedric, there's also a question. The average number of work RVUs needed per year, I think you said about 6,000 you think is average. I don't know what you did exactly. Yeah, I think the number that I have in my head is about 6,000 is about $300,000 a year. And that's about where most of us fall. Most of us fall between 250,000, take home, 250,000 to 400,000, 450,000, that's about the range. But 300,000 is about 6,000 RVUs. That's a number that you can kind of hold on to. All right, I don't see any other questions popping up. I can tell you that there's some models, for example, where you may see patients in the clinic and you may also see patients in your office. And if you see patients in the clinic, sometimes in some models, the RVUs that you see patients in the clinic isn't attached to your total RVU package. It may be just the surgeries that you do, for example. And in those instances, it's okay to go to your healthcare administrator or your chairman and say, hey, listen, the average in the country is 6,000, but I'm only collecting 3,000 RVUs even though I'm doing the same amount of work because some of the work that I do is not being contributed to my overall package. So I think that I should get $300,000 based on 3,000 RVUs. And that might be a valid argument if you can justify it based on the work that you're actually doing and how the RVUs are being calculated towards your bottom line. There's one other question, I'm sorry, about kind of just explaining the difference again between work RVU and total RVU. Yeah, so the total RVU is, you take the work RVU and you multiply it by the work RVU GIPSY or geographic practice cost index plus the practice expense RVU times the practice expense geographic practice cost index plus the malpractice expense times the malpractice expense geographic cost index. And then you add those guys up and you multiply it by a conversion factor for budget neutrality and that will give you your total. So when you think total RVUs, it's gonna be a much bigger number, somewhere around 19, 20, 25,000, which is gonna translate into your salary. But remember, total RVUs is much higher than the work RVU because the work RVU is only 52% of the total. The practice expense RVU is 44% of the total RVUs and the malpractice expense is 4% of the total RVUs. Any other questions? I think we are good right now, so we can probably go on to build slide deck. Okay. So thank you all for getting on our webinar this evening. As Cedric mentioned in his slides, CPT codes and their RVUs can get reassessed on a somewhat routine basis now every three to five years. And OGS has some, OGS and ACOG will be surveying some codes starting next week. And so we wanted to take this opportunity of having you all with us to just run through some slides about the survey instrument that you will be receiving via an email probably on Friday, February 26th. And as Cedric said in the slides, we really encourage you if you receive this email from OGS and ACOG to please complete the survey and to please spend time to think about every question you're answering in the survey, which will go through some of the steps that you'll be asked to answer questions on right now. So this will be important to us as you fill out the survey so that we get accurate data. So first of all, we're gonna talk about the survey basics, then the purpose of the survey, i.e. what your responses are gonna get used for, who does what, how the seven easy steps that you'll need to go through to fill out the survey, and then how that data again is used, i.e. the purpose. So why does OGS and ACOG have to conduct surveys when one of our codes gets up for review? Well, we need to still reassess whether the RVUs, particularly in this instance, the work RVUs and the practice expense RVUs are still accurate. And are they truly representative of the time and the intensity it takes you to do the procedure? And so that is why surveys are conducted. Many times things about codes change. Like for instance, these codes that we're gonna survey, they're being reassessed because no longer does the patient stay as an inpatient. The typical patient now is as an outpatient. And so we need to reassess if the RVUs are accurate because some of the services for an inpatient aren't done for an outpatient. So as I mentioned, everyone needs to be on the lookout in their email on Friday, February 26, or close to it, there will be a email that you will receive. And in that email, it will give a deadline for when we need the survey response back from you. And that will be probably around 10 days after. And it's very important that we get timeliness of surveys because we have to have a minimum number of surveys for our effort to be considered. And if we don't, then there's consequences to that. So again, as I said, we do the survey because we need to collect time. We need to collect the amount of time it takes you to do the procedure. We need to collect how complex you think the procedure is. And we need you to give us a recommended work value, i.e., work RVU like we talked about tonight for the code that's being surveyed. So we'll need three things in the survey and the questions that are asked are to get those three results. So how does the survey work? The survey asks you a series of questions. First, the questions are about your time. How much time does it take you to do the procedure for a typical patient? Then it asks you to compare the complexity of the case versus other procedures that you do. And then it asks you to give a proposed work RVU number relative to the other procedures you do. The survey will also contain what's called a reference list, which will have lists of other codes and procedures you do that the survey will ask you to compare the code being surveyed to those reference list codes. And you'll select two codes off the reference list that you believe it's most similar to. So who works on the surveys? So as Cedric said, the RUC oversees the survey process and they meet and they review the results from the survey and they decide if they agree with them or not and then they send those results to the Medicare program. Medical societies like AUGS, ACOG, AUA, SUFU, et cetera, actually do the surveys. And then we analyze the survey results and we submit a form to the RUC to be reviewed. So as I said, we have to do these recommendation forms off of your survey results. And three times a year, the RUC meets and we are doing these surveys for the RUC meeting at the end of April, that weekend, the first, last weekend in April, first weekend in May. And then the RUC, as I said, sends their recommendations in. These recommendations will be in the proposed rule in July of 2017, and they would be making changes in the codes for January 1, 2018. So here's how, when you get the survey tool and you open it up in the email, you first wanna look at the actual CPT code that's being listed as being surveyed. And then you wanna look at the descriptor for that code. Then there will be a short paragraph, which we call a patient vignette, that is a description of the patient. And so you wanna take the time to really think about that patient relative to your typical patient that represents the code that we're looking at for the survey. Then you're gonna read the instructions for the survey, complete your contact information. And then the very first thing you do is look at that reference list of codes and select a code off that reference list that you think is like the patient that you're looking at. Select a code off that reference list that you think is like the code that's being surveyed in regards to the same amount of time, intensity, work RVUs, et cetera. Then you're gonna have a series of questions where you're gonna think about your time, the time it takes you to do the procedure. And it's so important, as Cedric said in his slides, so important that you think about every little piece of work that you do. There's no points for being the fastest surgeon, there's points for being the most complete surgeon to think about all the time you take for your typical patient. As Cedric said, it's not your most easy patient, it's not your most complicated patient, it's sort of the typical patient that you see every day in your practice. And that's what you're thinking about when you're putting down the answers for the time estimates that the survey asks you for. Then you compare that survey procedure to the reference procedure on multiple questions around complexity. These surveys that we're gonna have out to you don't involve moderate sedation, so you don't have to worry about that. And then you actually wanna look at the reference codes, think about this code, think about how much the code's paying today, and estimate a work RVU for the new surveyed amounts. So as I mentioned, the vignette is for a typical patient. You wanna perform, think about your typical patient and think about that patient and the one described in the vignette. You wanna really think about how the typical patient is defined. You also can say on the survey tool if you think that the vignette about the typical patient is not correct. So if you think that, please put that on your survey. And then of course, as I said, we want you to complete your contact information. So then it's really important that you look at the reference code list and really look at other procedures besides the one being surveyed that you think is accurately similar to the procedure that's being surveyed in regards to time and work. And so there'll be other codes on that reference list that you do quite a bit, and there'll be this code that's being surveyed, and you wanna pick the one that's most like the one being surveyed. And so it's important to really think about that reference code list before you make a selection. And also you wanna look at the global period for the code that's being surveyed and the global periods on the reference list codes. And if it's a 90-day global period code that's being surveyed, it's really important to pick a 90-day global period code as your reference code. So then as I mentioned, the next part is about estimating your time for the code that's being surveyed. And this is about your personal time and thinking about everything it takes you to do the procedure and then put those time amounts down on the questions that it asks you. But it's important to be complete when you think about your time because it's gonna ask you for time for the pre-service period, the intra-service period, and the immediate post-service period. And so the pre-service period, that's the time provided on the day before the operative procedure until the time that you start the operative procedure. So you have to think through how much time that is and what you're doing in that day before to day of and all of your different activities and how many minutes you're spending on all those activities. And this is what you the physician are spending, not your clinical staff. Jill, this is Leslie. I have a question real quick because I've done some of these before. So this, I mean, because you're not seeing the patient the day before, typically. Right, you might be doing some paperwork. You might be getting all the consent forms ready or you might be looking at their test results again, anything like that. Okay, so- So this is not face-to-face time. The patient may not be with- And so it doesn't include the entire pre-operative evaluation. It just takes into account what you're gonna be looking over the day before to make sure everything's straight. Right, and then if you see the patient before you go into the OR to get consent or to talk to the patient and their family one more time before you start the procedure, it includes that time too. Okay, thank you. So again, here it gives a little more specificity. So the hospital admission workup, the pre-op evaluation, I was just talking about when you see the patient right when they come in, dressing, scrubbing, waiting, positioning the patient, et cetera. What it doesn't include, as we were just, Leslie and I were just talking about, is any distinct evaluation and management services that are for other issues, not this code that you're doing the procedure on. And it doesn't include any evaluation management visits that you did a couple of days earlier where you made the decision to go to surgery. Doesn't include any of that. But what about, so you've decided to go to surgery but you spent maybe 30 minutes talking to them about the surgery, but it was three days before and not the day before. Does that doesn't count? That's a separately billable E&M. That's separate. Okay. Okay. So then the next big piece of the time that you're gonna be collecting and putting on the survey is what we call interest service time. And this is really important. This is what we call skin to skin time. So this is when you first touch the patient when you go into the OR to start the procedure to when you very last touch the patient, including any stitches or final wound care, anything in the OR, you need to think about all those minutes that you're spending and put that in the interest service time period. And so this is really important to take a minute when you get the survey and to think through a typical patient case and all the things you do and all the time you spend once you start the procedure, from when you touch the patient's skin to when you finally end the procedure and the patient's totally ready to go to the recovery room. Hey, Jill, this is Cedric. I had a quick question. So if who the audience of the telephone line now is our fellows, I guess how would they, first of all, how long do you think it might take for them to fill out the survey in general when we get it or when they get it? And then the other thing is how would they estimate how long it would take for them to do a procedure when they're doing it with their attending physicians? You have to assume that you're doing the procedure by yourself. So when you fill out a survey, if you're an attending or if you're a fellow, you have to think about how long it would take you to do the procedure if you were doing it as a solo surgeon. So if you're an attending and you don't do the final stitching, et cetera, if it's a stitching required procedure, let's say your fellow does it, you have to think through how much time it would take you if there was no fellow with you. Yep, and how long do you think it might take for them to fill out the survey? To do the survey, we really hope that people will take the time to think about what they're doing as they fill it out. But even then, this is probably a 20-minute survey to fill out. It doesn't take very long, but we want people to be thoughtful and to be complete as they're thinking through the answers that they're gonna put down. Great, thanks. It doesn't take long. That's why we hope everybody will take the time to do it. So the post-op period, the immediate post-service period, is that time after the patient goes to recovery until the patient is discharged home. And so this is where you have to think about how many times do you round on the patient, do you do a discharge visit, et cetera, and the survey will ask you to put that down. Then we have the, and this gives you more examples. So any post-operative care on the day of the procedure, if you're visiting the patient in the recovery room, if you're talking to the patient and their family, if you're doing all the discharge notes so the patient can take them home, all of that is in the minutes that you would count in the post-service period. And then, as I said, there's a series of questions on the survey where you're comparing the complexity or the intensity of the procedure that's being surveyed to the procedure that you picked off the reference list. Is it harder than that procedure? Is it easier than that procedure? Is it the same as that procedure, et cetera? And these are sort of Likert scale questions. So again, as Cedric mentioned, when we're thinking about physician work, we're thinking about the time it takes to do the procedure, the mental effort it takes to do the procedure, and the technical skill. How much technical skill does it take to do the procedure? And so that, you have to think about all those things when you're doing the survey. And so physical effort, that's required to perform the procedure. Physical effort can be compared into tasks, and you can think about direct comparison to the task. That's some of these comparative questions. Stress of doing the procedure relative to the reference service. So you must remember when you're thinking about your time that it doesn't include any of your staff's time, nurse time, reception time, secretary time. That time is all accounted for in the practice expense RVUs. So this is just time that you as a physician spend that you're counting up and you're reporting on the survey. Our surveys don't include really moderate sedation. So then the last step that's really important is to think about the current code that's being surveyed and it's our work RVUs, the code on your reference, the RVUs on your reference procedure, and then it's gonna ask you to give an estimate of how many work RVUs you think the procedure that's being surveyed should be assigned. And so again, this is important to think through. Is it the same procedure you, if it's a procedure that's established, it's just being resurveyed, should it be the same number of RVUs? Should it be the same as your reference procedure RVUs? Should it be less RVUs? What is the current appropriate estimate of work RVUs, total work RVUs? And they'll ask you that as the last question on the survey. So that's a little bit about the survey and we will be getting the surveys. So again, in your email inbox, probably on Friday, February 26th, and actually you'll be getting surveys for four codes if you are selected to do a survey. So please check your inbox on Friday the 26th. If you don't get a survey, let OGS know. And again, as I said, there'll be an email link to go to the survey and there'll be four surveys in there because we have four codes that are up for review, all in the repair part of the work that OGS members do. So we do hope that you will take the time to thoughtfully and completely fill out the survey and think through the amount of time you take, as well as the complexity of the procedure and the appropriate comparison code and or reference code to select. Thank you. Any questions about the survey? Jill, this is Leslie. I may have missed this. Is this automatically going out to all OGS members or is it a selected group? It's probably gonna be a random sample, but even in that case, it will be a large poll. So it might be like, we send the entire OGS physician member list to ACOG for the survey. So even if it's one out of every two, that would be about 600 OGS members that would receive a survey. So that's why if you don't receive a survey in your inbox on Friday, please let us know because it's possible it went to your spam folder. That's the other thing you could check your spam folder because it is sent out as a broadcast email. And we know some particularly academic email addresses have blockers up. So we hope that you all check your emails on Friday for the survey. There was a question previously, just to circle back when you had mentioned the coding questions that were on the OGS website. I logged into OGS and just correct me, Jill, if this is correct, but I logged into OGS and I went to the member center and then I went to coding Q&A and they had general coding questions and answers. Is that there? It looked like Mitra had answered a bunch. That's where we're talking about, right? Okay. Yeah, so that's one great resource. And if you also on the OGS website, if you go to the dropdown menu under, I want to say practice, and there's a bunch of, there's a coding link into there too. So any questions for Jill or Dr. Oliveira right now? Everybody's tapped out. They're full of RVU information. Okay. I don't think I'm seeing anything else right now. So we're going once. Anybody? Last minute questions? There were a bunch already. We kind of did them in the middle instead of at the end. So, okay. So well, a big thank you to Dr. Oliveira and Jill Ratford for those great presentations. We learned a lot from some of our great educators in our subspecialty. I know some of these practice topics are things that we don't get formal presentation or education on often. It's something that the fellows and not just the fellows, but all members really like to hear. So I think this is a great addition to our live webinar forums. So I also have to thank all the participants for being on the call today and for carving time out of your schedules also to participate. Again, upon completion of this program, you will be prompted to provide feedback. So please do share your thoughts and impressions with us. Again, thank you so much to our presenters. Really appreciate you guys putting together that presentation and answering the questions. It was super helpful and informative. We are also, just to remind everybody, looking forward to our next program on March 23rd. It's going to be Geriatric Considerations for Women with Urinary Incontinence and Lower Urinary Tract Symptoms by Dr. Elaine Marklin from UAD. So again, that's March 23rd at 7 p.m. Eastern time. And that is everything. I think that's a wrap. All right, Leslie, thank you. Again, thank you, Dr. Oliveira and Jill. On behalf of AUGS, I'd like to thank our listeners as well for your participation in today's event. This concludes our program for today. Again, thank you and have a great rest of the day.

RVUs

relative value units

Medicare

physician payment

CPT codes

geographical adjustment factor

conversion factor

physician work

practice expense

malpractice expense