There is no such thing as RBRVS…

Yes, the title is an incomplete sentence. The rest of this discussion will complete the thought. Chances are that if you're a physician or work on behalf of a physician's revenue cycle, one of your managed care contracts has language in it that references RBRVS. The most common use of 'RBRVS' in contracting language is for the payor and physician to agree on a % of RBRVS as a fee schedule. Additionally, the parties probably understand this % of RBRVS to mean the payment method used by Medicare. Well, there is no such thing as an 'RBRVS' fee schedule in the Medicare program.

Sure, we all know the history of the Resource Based Relative Value Scale (RBRVS). Passed into law by Congress in 1989 it has been the payment method for professional services. But it is NOT the payment method used for all services paid to physicians under the Medicare program.

If you search the CMS website you won't find 'RBRVS' associated to any fee schedule used to pay physician services. What you will find are terms like:

MPFS - Medicare Physician Fee Schedule
PFS - Physician Fee Schedule
PFS Relative Value Files
PFS National Payment Amount File
National Physician Fee Schedule Relative Value File

All of these descriptions are for payment information that has its basis in the RBRVS methodology. But RBRVS should not be used as a contracting term.

The source that is probably understood to mean RBRVS is really the 'National Physician Fee Schedule Relative Value File'. So, out of the 5 letters in the RBRVS acronym, only 2 really match the actual payment file used to calculate the fee schedule. In fact, most physician practices will bill for services from the four (4) main Medicare fee schedules used to pay physician groups. They are:

• National Physician Fee Schedule Relative Value File


• ASP Drug Pricing


• Clinical Laboratory Fee Schedule


• Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule

Why does this semantic discussion matter? Well here are some reasons based on our implementation of contract language.

One of the most common codes billed for in office lab work is 36415 (Routine venipuncture). The MPFS fee schedule has 0 RVU's for this service and using the MPFS fee schedule you will get $0 as the fee. However, the Medicare Clinical Laboratory Fee Schedule does have a flat dollar payment amount for 36415 (@ $3.00).

So, if you have a rate of 150% of RBRVS, what is the payment amount for 36415? Ask the payor, the person who negotiated the contract for the physician, and the reimbursement analyst for the physician and you're likely to get as many answers. Taken literally, the only RBRVS fee schedule that I know of is 'Ingenix Essential RBRVS'. Interestingly, the Ingenix Essential RBRVS file shows 0.7 work RVU's and using the Ingenix file you can calculate a rate greater than $0. (but Medicare does not follow Ingenix). Now we all understand that Ingenix Essential RBRVS is almost never the RBRVS that the payor and the physician had in mind. Add to this the fact that RBRVS is commonly mis-understood to mean ANY Medicare payment amount found in one of the four Medicare fee sources I mentioned above and you understand quickly why you should avoid the use of RBRVS.

The bottom line is that when it comes to negotiating a fee schedule, ambiguity is expensive. Don't use % of RBRVS in any fee schedule agreement. Be specific. We are fans of using the four Medicare fee schedules as a basis. (Public access to the 13,000 plus codes, easy to compare notes between payor and physician, physician's tend to know their primary Medicare rates well, etc.) Pick the year (preferably within one or two years of current to insure a current HCPC code set), and the locality (Medicare Drug schedules are not locality specific).

The language would look like this:

150% of Medicare National Physician Fee Schedule Relative Value File for 2007 California, Locality 99 effective 12/31/2007.
150% of Medicare ASP Drug Pricing effective 12/31/2007.
150% of Medicare Clinical Laboratory Fee Schedule for California effective 12/31/2007.
150% of Medicare Durable Medical Equipment, Prosthetics/Orthotics, and Supplies Fee Schedule for California effective 12/31/2007.

If a rate is found in more than one of the above schedules, the highest rate shall apply.
For any valid HCPC code billed that is not found in one of the above schedules, or does not have a rate > $0 in any of the above schedules, the fee shall be 80% of the billed charges.