The RUC is a multi-specialty committee that provides medicine with a powerful voice in describing the resources required to provide physician services. Since 1991 the RUC has submitted numerous recommendations to the Centers for Medicare & Medicaid Services (CMS) that enhance the underlying data used to create relative values units (RVUs). The RUC, in conjunction with the Current Procedural Terminology (CPT) Editorial Panel, has created a process where specialty societies can develop relative value recommendations for new, revised and potentially misvalued codes as well as update RVUs to reflect changes in medical practice.
The AMA manages the RUC although its activities are a collaborative venture between the AMA, national medical specialty societies, limited license and allied health provider organizations and the Centers for Medicare and Medicaid Services (CMS).
The RUC has 32 seats, with 22 seats consisting of representatives from major national medical specialty societies, including the AAOS. Most of these seats are held on a permanent basis by the participating specialty societies. Four seats are rotating seats with 2-year terms. The RUC chair, the co-chair of the RUC’s HCPAC Review Board, the chair of the Practice Expense Subcommittee and representatives of the American Medical Association, the American Osteopathic Association and the CPT Editorial Panel hold the remaining six seats.
RUC Advisory Committee
There are approximately 125 specialty societies represented in the AMA House of Delegates. Each of these societies has the option of appointing a representative to the RUC Advisory Committee; however not all specialty societies have appointed a RUC advisor.
Advisory Committee members represent the interests of their specialty societies when codes used by their societies' members are being presented to the RUC for valuation. In essence, the "Advisors" help manage the process through which proposals are presented to the RUC before its meetings and then orally presented in person at the meetings.
Practice Expense Review Committee (PERC)
The AMA continues to participate and monitor all phases of the refinement of the practice expense relative values and continues to advocate that they be based on valid physician practice expense data. Since there is not a single universally accepted cost allocation methodology, it is especially important that CMS base its methodology on actual practice expense data. The decisions reached by CMS have enormous implications for physicians and all their patients, not just those on Medicare. Since many other payment systems use the Medicare RBRVS, the change to resource-based practice expense relative values has broad implications for the entire health care system.
Due to the significance of this issue, the RUC established a special subcommittee called the Practice Expense Advisory Committee (PEAC) to monitor this process. The PEAC was charged with the review of direct expense inputs (clinical labor activities, medical supplies and equipment) used to calculate practice expense relative values and made code-specific recommendations to the RUC. The RUC then made the final recommendation to CMS. The PEAC reviewed the practice expense inputs of essentially the entire Medicare Payment Schedule by submitting recommendations for more than 6,500 medical procedures. The composition of the PEAC mirrored the RUC with additional representation from nursing. The PEAC review process was similar to the RUC process, relying on specialty societies to make recommendations that were reviewed by a panel of medical experts and then forwarded to CMS. While the PEAC concluded its work in March 2004, the RUC continues to work closely with specialty societies and CMS to maintain the practice expense component of the RBRVS. The RUC, through its current Practice Expense Subcommittee, addresses any practice expense policy issues that arise. The Practice Expense Subcommittee also assists the RUC in its review of practice expense inputs for new and revised codes and codes identified through the relativity assessment process or by CMS.
The RUC process for developing relative value recommendations is as follows:
Step 1: The CPT Editorial Panel’s new or revised codes and CMS and RUC identified potentially misvalued services are transmitted to the RUC staff, who then prepare a “Level of Interest” form. This form summarizes the panel’s coding actions and specific CMS requests.
Step 2: Members of the RUC Advisory Committee and specialty society staff review the summary and indicate their societies’ level of interest in developing a relative value recommendation. The societies have several options: (1) they can survey their members to obtain data on the amount of work involved in a service and develop recommendations based on the survey results; (2) they can comment in writing on recommendations developed by other societies; (3) in the case of revised codes, they may decide that the coding change does not require action because it does not significantly alter the nature of the service; or (4) they may take no action because the codes are not used by physicians in their specialty.
Step 3: AMA staff distributes survey instruments for the specialty societies. The societies are required to survey at least 30 practicing physicians. The RUC survey instrument asks physicians to use a list of 10 to 20 services as reference points that have been selected by the specialty RVS committee. Physicians receiving the survey are asked to evaluate the work involved in the new, revised or potentially misvalued code relative to the reference points. The survey data may be augmented by analysis of Medicare claims data and information from other studies of the procedure, such as the Harvard RBRVS study.
Step 4: The specialty RVS committees conduct the surveys, review the results and prepare their recommendations to the RUC. When two or more societies are involved in developing recommendations, the RUC encourages them to coordinate their survey procedures and develop a consensus recommendation. The written recommendations are disseminated to the RUC before the meeting and consist of physician work, time and practice expense recommendations.
Step 5: The specialty advisors present the recommendations at the RUC meeting. The RUC Advisory Committee members’ presentations are followed by a thorough question-and-answer period during which the specialty advisors must defend every aspect of their proposal(s).
Step 6: The RUC may decide to adopt a specialty society’s recommendation, refer it back to the specialty society or modify it before submitting it to CMS. Final recommendations to CMS must be adopted by a two-thirds majority of the RUC members. Recommendations that require additional evaluation by the RUC are referred to a Facilitation Committee.
Step 7: The RUC’s recommendations are forwarded to CMS. CMS medical officers and contractor medical directors review the RUC’s recommendations.
Step 8: The Medicare Physician Payment Schedule, which includes CMS’s review of the RUC recommendations, proposals are published in July and finalized in November each year.
Five Year Review Process
By law, CMS is required to conduct a comprehensive review of all relative values at least every 5 years and make needed adjustments. The changes resulting from the four RBRVS five-year reviews became effective in January of 1997, 2002, 2007 and 2012.
In the 2012 Medicare Physician Fee Schedule Final Rule, CMS announced they would no longer use the five-year method for evaluating existing code values but will instead conduct annual reviews as part of the comment process on the Final Rule. Public nominations must be submitted by February 10th of each year.