RBRVS

The RBRVS reimbursement tool lets you calculate reimbursements based on Resource Based Relative Value Systems or Scales (RBRVS), including the following:

• Medicare
• National
• St. Anthony's (Ingenix)

With the RBRVS tool, you can specify a percentage of the reimbursement amount in a particular RBRVS to apply to a specific range of procedure codes. You can use the standard conversion factor or enter any conversion factors applicable to the contract. For example, you can specify that a particular range of codes should be reimbursed at 125% of the Medicare RBRVS, using a conversion factor of 45.5.

In addition, you can also apply a Geographical Pricing Cost Index (GPCI) to further refine your calculations to a specific carrier and locality. By default, the GPCI is determined by the zip code of the location of service from the claim, but you can also override this by entering specific carrier and locality codes to apply to the reimbursement calculation. The GPCI effective date is determined by the effective date entered in the RBRVS tool for a specific code range. If there is no effective date entered for a specific code, the GPCI effective date is determined by the date of service on the claim.

Note: This tool performs its calculations based on Relative Value Unit (RVU) and GPCI master tables so that the reimbursement is calculated as the claim is being repriced rather than being based on a pre-calculated fee schedule.

• The Code Exclusions section lets you ignore codes found in the following tables:
  • To ignore CMS DME codes, select CMS DME.
  • To ignore CMS drug codes, select CMS Drug.
  • To ignore CMS lab codes, select CMS Lab.
  • To ignore codes in the MPFSRVU table, select NOTUSEDMED.
• The RBRVS Percent field sets the percent of the RBRVS at which the range of procedure codes entered in the Codes From and Codes To fields is reimbursed.
• The Of field lets you select an RBRVS: Medicare, National, or St. Anthony's (Ingenix).
• If you leave the Conversion Factor field blank, the calculation uses the default conversion factor for the selected RBRVS
• The Effective Date field lets you enter the effective date for the RBRVS. If you leave this field blank, the calculation uses the RBRVS that was in effect on the date of service on the claim.
• The POS Override field lets you override the place of service to either a facility or non-facility.
• If you leave the Codes From and the Codes To fields blank, the calculation is applied to all codes.
  • A procedure code matches an entry in a lookup table according to standard matching rules.
• The Carrier and Locality fields are only active if you select the Apply GPCI check box.
  • If you select the Apply GPCI check box and leave the Carrier and Locality fields blank, the RBRVS tool determines the carrier and locality from the zip code of the location of service from the claim.
  • The GPCI effective date is determined by the effective date entered in the RBRVS tool for a specific code range. If there is no effective date entered for a specific code, the GPCI effective date is determined by the date of service on the claim.
  • The Carrier and Locality fields must both be blank or both be populated. You cannot enter information in one and not the other.
• The Apply work budget neutrality adjustor check box allows you to apply the 2007 Work Budget Neutrality Adjustor to Medicare and national reimbursements.