READER QUESTIONS:
Office Codes Usually Pay More Than Facility
Published on Wed Apr 06, 2005
Question: What is the difference between facility and non-facility relative value units (RVUs)?
Kansas Subscriber
Answer: CMS assigns codes facility and non-facility RVUs. To find out how much Medicare pays nationally for a code, you multiply the code's RVUs by the year's conversion factor ($37.8975 for 2005). Medicare will reimburse you based on non-facility RVUs when the otolaryngologist performs the procedure in the office or in a clinic. If he provides the procedure in the hospital or in a nursing facility, CMS would pay you at the facility rate.
Non-facility RVUs usually pay at a higher rate than facility RVUs because they include office expenses, such as rent and equipment. When an otolaryngologist performs the procedure in a hospital, the facility is responsible for those fees.
Comparison: For instance, Medicare assigns 31511 (Laryngoscopy, indirect; with removal of foreign body) 5.47 non-facility RVUs and 3.41 facility RVUs. If the otolaryngologist performs foreign body removal from the larynx in the office, you would report 31511 and receive payment for 5.47 RVUs ($207.30). But if the surgeon performs the procedure in the hospital, CMS would reimburse 31511 at 3.41 RVUs ($129.23).
Quick tip: If the National Physician Fee Schedule Relative Value File shows a procedure has equal facility and non-facility RVUs, assume you must perform the procedure in the hospital.
Tympanostomy with general anesthesia (69436, Tympanostomy [requiring insertion of ventilating tube], general anesthesia) contains 4.44 RVUs ($128.26), regardless of location. The otolaryngologist would have to perform this procedure in the hospital because most offices do not offer general anesthesia.
But tympanostomy using local anesthesia (69433, Tympanostomy [requiring insertion of ventilating tube], local or topical anesthesia) has 4.74 nonfacility RVUs ($179.63) and 3.29 facility RVUs ($124.68). In this case, the otolaryngologist could perform the procedure in either location and Medicare would pay you accordingly.
Answers to You Be the Coder and Reader Questions answered/reviewed by Barbara Cobuzzi, MBA, CPC, CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Brick, N.J.; Charles F. Koopmann Jr., MD, MHSA, professor and associate chair at the University of Michigan's department of otolaryngology in Ann Arbor; and Tara R. Ritter, CPC, billing and reimbursement specialist at Robert A. Gadlage, M.D., P.C. in Duluth, Ga.
