Physician Payment for 2007: A Description of the Process by Which Major Changes in Valuation of Cardiothoracic Surgical Procedures Occurred  Peter K. Smith, MD, John E. Mayer, MD, Kirk R. Kanter, MD, Verdi J. DiSesa, MD, James M. Levett, MD, Cameron D. Wright, MD, Francis C. Nichols, MD, Keith S. Naunheim, MD  The Annals of Thoracic Surgery  Volume 83, Issue 1, Pages 12-20 (January 2007) DOI: 10.1016/j.athoracsur.2006.11.058 Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Frequency distribution of intraservice (skin-to-skin) time for 6,222 mitral repair patients (CPT® code 33430). The distribution curve is asymmetric (right shifted) due to the occurrence of more long procedures than short ones. Thus, the mean time (includes all patients) is greater than the median time (excludes outliers) and is therefore preferred to account for all physician work. The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The difference between the STS database intraservice time and the intraservice time determined by RUC survey (and employed in current code valuation) is illustrated as a percent difference for all cardiothoracic codes submitted for revaluation, sorted in descending percent difference. Many codes are severely under- and overestimated by the RUC survey estimation process, with the majority to the right and actually overestimated. (RUC = Relative Value Update Committee; STS = The Society of Thoracic Surgeons.) The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 The survey results for the intensity of physician intraoperative work for the submitted Adult Cardiac codes is shown, in ascending order of intensity. The ordinate is IWPUT multiplied by 1000. Two methods were used (an Intensity Survey using magnitude estimation, and a Rasch paired analysis comparison) and are displayed as the lower and upper lines, respectively. The average of the two methods is the third line, and these values were used in the RUC recommendations. For clarity, only selected CPT® code numbers are shown on the abscissa. (CPT® = current procedural terminology; IWPUT = intraservice work per unit time; RUC = Relative Update Committee.) The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 The frequency distribution of length of stay for mitral valve repair (N = 7,985) is shown, with the relative value for E&M services provided each day for a typical patient superimposed. Solid E&M value is the current assigned value, and the hash marked component indicates additional value approved by the RUC. On day 0, the additional value is due to the assignment of a critical care code 99291. On day 7, the value represents an additional E&M service, allocated because the mean LOS was one day higher than the median LOS for this code. (E&M = Evaluation and Management; LOS = length of stay; RUC = Relative Update Committee.) The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 The relative value work units for all submitted Cardiothoracic codes are illustrated here, in ascending order of the RUC recommendations. Also shown are the current (2006) RVWs, and the CMS values suggested in the June 2006 proposed rule. The lack of relativity and generally lower total value of the current code values and those proposed by CMS are apparent, compared to the RUC recommendations, as is a general failure to acknowledge the physician work in more complex and longer procedures. The RUC recommended values are identical to those now accepted by CMS and used to value these codes for 2007. (CMS = Centers for Medicare & Medicaid Services; rvu = relative value units; RUC = Relative Update Committee; STS = The Society of Thoracic Surgeons.) The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Change in RVW and for 2007 Medicare payment discount. The change in RVW for each code is illustrated arranged in descending value change for the revalued codes and the remaining codes used by Cardiothoracic surgeons but not addressed in this 5-year review. The upper line for each code group is all positive, indicating increased assigned work value units. Increases were higher for revalued codes due to the process described in this article. There were also small increases for the remaining codes due to the “pass through” of the increase in E&M services to all procedural global periods. The lower line for each code group shows the value change that will be used to determine Medicare payment only. The difference is due to an internal adjustment of the RVWs to effect budget neutrality. (AATS = American Association for Thoracic Surgery; E&M = Evaluation and Management; RVU = relative value units; RVW = relative value work units; STS = The Society of Thoracic Surgeons.) The Annals of Thoracic Surgery 2007 83, 12-20DOI: (10.1016/j.athoracsur.2006.11.058) Copyright © 2007 The Society of Thoracic Surgeons Terms and Conditions