Cost and Revenue Glossary

Total Procedures

The sum of “Medical procedures conducted inside the practice,” “Medical procedures conducted outside the practice,” “Surgery/anesthesia procedures conducted inside the practice,” “Surgery/ anesthesia procedures conducted outside the practice,” “Clinical laboratory and pathology procedures,” and “Diagnostic radiology and imaging procedures.”

Patients

The total number of individual patients who received services from the practice during a 12-month reporting period.

Included:

• Fee-for-service and capitation patients. A patient is simply a person who received at least one service from the practice during the 12-month reporting period, regardless of the number of encounters or procedures received by that person. If a person was a patient during the most recent fiscal year but did not receive any services at all during that fiscal year, that person would not be counted as a patient. A patient is not the same as a covered life. The number of capitated patients, for example, could be less than the number of capitated covered lives if a subset of the covered lives did not utilize any services during the 12-month reporting period.

Relative Value Units (RVUs)

Relative value units (RVUs), are measured by the Resource Based Relative Value Scale (RBRVS), not weighted by a conversion factor, and are attributed to all professional services. An RVU is a nonmonetary standard unit of measure that indicates the value of services provided by physicians, advanced practice providers, and other healthcare professionals.

• The total RVUs for a given procedure consist of three components:
  • Physician work RVUs;
  • Practice expense (PE) RVUs; and
  • Malpractice RVUs.

Thus, total RVUs = physician work RVUs + practice expense RVUs + malpractice RVUs. For the current year, there are two different types of practice expense RVUs: 1. Fully implemented nonfacility practice expense RVUs; and 2. Fully implemented facility practice expense RVUs.

“Facility” refers to RVUs associated with a hospital affiliated medical practice that utilizes a split billing fee schedule where facility (hospital) charges and professional charges are billed separately. “Facility” also refers to services performed in a hospital, skilled nursing facility, or ambulatory surgery center. Total RVUs that are a function of “facility” practice expense RVUs are not reported.

“Non-facility” refers to RVUs associated with a medical practice that is not affiliated with a hospital and does not utilize a split billing system that itemizes facility (hospital) charges and professional charges. “Non-facility” also applies to services performed in settings other than a hospital, skilled nursing facility, or ambulatory surgery center.

Total RVUs

Included:

• RVUs for the “physician work RVUs,” “practice expense,” and “malpractice RVUs,” including any adjustments made as a result of modifier usage;
• RVUs for all professional medical and surgical services performed by physicians, advanced practice providers, and other physician extenders such as nurses and medical assistants;
• RVUs for the professional component of laboratory, radiology, medical diagnostic, and surgical procedures;
• For procedures with either no listed CPT code or with an RVU value of zero, RVUs can be estimated by dividing the total gross charges for the unlisted or unvalued procedures by the practice’s known average charge per RVU for all procedures that are listed and valued;
• RVUs for procedures for both fee-for-service and capitation patients; and
• RVUs for all payers, not just Medicare.

Not included:

• RVUs for other scales such as McGraw-Hill, California;
• The technical component (TC) associated with any medical diagnostic, laboratory, radiology, or surgical procedure; or
• RVUs where the Geographic Practice Cost Index (GPCI) equals any value other than one. The GPCI must be set to 1.000 (neutral).

Work RVUs

Included:

• RVUs for the “physician work RVUs” only; including any adjustments made as a result of modifier usage;
• Work RVUs for all professional medical and surgical services performed by providers;
• Work RVUs for the professional component of laboratory, radiology, medical diagnostic, and surgical procedures;
• Work RVUs for all procedures performed by the medical practice. For procedures with either no listed CPT code or with an RVU value of zero, RVUs can be estimated by dividing the total gross charges for the unlisted or unvalued procedures by the practice’s known average charge per RVU for all procedures that are listed and valued;
• Work RVUs for procedures for both fee-for-service and capitation patients;
• Work RVUs for all payers, not just Medicare;
• Work RVUs for purchased procedures from external providers on behalf of the practice’s fee-for-service patients;
• Anesthesia practices should provide the physician work component of the RVU for flat fee procedures only such as lines, blocks, critical care visits, intubations, and postoperative management care;
• All RVUs associated with professional charges, including both medically necessary and cosmetic RVU; and
• Work RVUs produced from physician-administered chemotherapy drugs.

Not included:

• RVUs for “malpractice RVUs”;
• RVUs for other scales, such as McGraw-Hill, California;
• RVUs for purchased procedures from external providers on behalf of the practice’s capitation patients;
• RVUs that have been weighted by a conversion factor. Do not weigh the RVUs by a conversion factor;
• RVUs where the Geographic Practice Cost Index (GPCI) equals any value other than one. The GPCI must be set to 1.000 (neutral),or
• Work RVUs produced from the administration of chemotherapy drugs by someone other than the physician (i.e. nurses, techs, etc.).

Total ASA Units

Anesthesiology practices report American Society of Anesthesiologists (ASA) units. The ASA units for a given procedure consist of three components:

• Base unit;
• Time in 15-minute increments; and
• Risk factors.

Total Encounters

A documented interaction, regardless of setting (including tele-visits and e-visits), between a patient and healthcare provider(s) for the purpose of providing medical services, assessing illness or injury, and determining the patient's health status. If a patient sees two different providers on the same day for one diagnosis, it is one encounter. If a patient sees two different providers on the same day for two unrelated issues, then it is considered two encounters. Encounters are procedures from the evaluation and management chapter (CPT codes 99201-99499) or the medicine chapter (CPT codes 90281-99607) of the Physicians’ Current Procedural Terminology, Fourth Edition, copyrighted by the American Medical Association (AMA).

Included:

• Pre- and post-operative visits and other visits associated with a global charge;
• Visits that resulted in a coded procedure;
• The total number of procedures or reads for diagnostic radiologists and pathologists, regardless of place of service;
• For obstetrics care, where a single CPT-4 code is used for a global service, each is counted as a separate ambulatory encounter (e.g., each prenatal visit and postnatal visit is one encounter). A delivery is a single encounter; and
• Encounters that include procedures from the surgery chapter (CPT codes 10021-69990) or anesthesia chapter (CPT codes 00100-01999).

Not included:

• Encounters with direct provider to patient interaction for the specialties of pathology or diagnostic radiology (see #3 above under "Include”);
• Visits where there is not an identifiable contact between a patient and a physician or advance practice provider (i.e., patient comes into the practice solely for an injection, vein puncture, EKGs, EEGs, etc. administered by an RN or technician);
• Administration of chemotherapy drugs; or
• Administration of immunizations.

Panel Size

The “set of patients cared for by a physician” as the number of individual, unique patients that have been seen by any provider within the practice over the past 18 months. The following methodologies are used to calculate panel size:

• If a patient has only seen one physician in the practice, assign the patient to that physician.
• If a patient has seen more than one physician in the practice, assign the patient to the physician seen most frequently.
• If a patient has seen more than one physician in the practice the same number of times, assign the patient to the physician who did the patient's last physical.
• If a patient has not had a physical, assign him/her to the physician seen most recently.

Number of Exam/Treatment Rooms

The number of exam/treatment rooms located in the practice.

• This is available for per FTE Physician and per FTE Provider data cut selections only.

Square Footage

The total number of finished and occupied square feet within outside walls for all the facilities (both administrative and clinical) that comprise the practice. Hallways, closets, elevators, stairways and other such spaces are included. For anesthesia practices, any leased or rented administrative office space are included, regardless of whether it is inside or outside the hospital setting.

Number of Hospital, Same-Day Surgery Center, Surgeon Offices and Other Facilities Staffed

The number of facilities an anesthesiology practice covered in each facility type category. Any facilities not physically in the same location as separate facilities are counted. For example, if the practice provides services (inpatient and outpatient) at one hospital in the same block of operating rooms, this is counted as one facility. If the outpatient department is sufficiently removed that a separate staff is assigned to cover that “facility” on any given day, that is counted as a separate facility (hospital or same day surgery center, as appropriate).

Number of Hospital, Same-Day Surgery Center, Surgeon Offices and Other Anesthetizing Locations

The number of anesthetizing locations including cath lab, ESWL, MRI, or OB suite, a practice covers at 7:30 AM (or another time that represents a typical first case of the day) in each facility type category.

Surgical Anesthesia

Included:

• Any case with base and time units where anesthesia services such as general, regional or MAC are provided, regardless of whether or not there were multiple providers on the case. Generally, these are the “0” anesthesia codes or services which cross over to these codes. Obstetrical cases, critical care, chronic and acute pain services, as well as flat fee procedures are each listed as a separate category for which you will give separate counts.
• Listed base units and minutes for surgical anesthesia cases only. For the “Charge per ASA unit,” the monetary fee that is applied to an American Society of Anesthesiologists (ASA) unit is included.

Labor Epidurals (CPT Codes 59409, 01960, 01967)

Included:

• Labor epidurals (59409, 01960 or 01967). If a labor epidural was started and then a C-section was performed, one of each is counted.

C-Sections (CPT Codes 59514, 01961, 01968)

Included:

• C-sections (59514, 01961 or 01968). If a labor epidural was started and then a C-section was performed, one of each is counted.

Epidurals (CPT Codes 62324, 62326)

Included:

• The epidural (62324, 62326) for the day that the procedure was performed and each day of subsequent follow-up is counted as one follow-up visit (01996). For example, if patient A has an epidural placed for post-op pain on Monday and you visit him/her on Tuesday, Wednesday, and Thursday, one epidural and three days of follow-up visits are listed.

Follow-Up Visits (CPT Codes 01996, 99231-99233)

Included:

• The epidural (62318, 62319) for the day that the procedure was performed and each day of subsequent follow-up is counted as one follow-up visit (01996). For example, if patient A has an epidural placed for post-op pain on Monday and you visit him/her on Tuesday, Wednesday, and Thursday, one epidural and three days of follow-up visits are listed.

Nerve Blocks for Post Op Pain (CPT Codes 64400-64530)

Included:

• Nerve blocks for post op pain (CPT codes 64400-64530).

Critical Care Services (CPT Codes 99291, 99292)

Included:

• Critical care services (CPT codes 99291, 99292).

Other (Lines, Intubations, etc.) (CPT codes, 36555-36558, 36568-36569, 36620, 93503, 93312-93318, 31500)

Included:

• Central venous lines (36555-36558, 36568-36569), arterial lines (36620), and Swan Ganz catheters (93503) placed by members of your group;
• TEEs (93312-93318) that are performed and/or monitored by your group. Each separate CPT code billed is counted as one service;
• Intubations (31500) that are not associated with anesthetic cases; and
• Other flat fee procedures that are not applicable to any other category. For example, if an E/M visit has been included under critical care, acute or chronic pain, it is not double count here.