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Pathway to endosurgery and third-space endoscopy reimbursement: understanding the past to get payment in the future

      By the 1960s the proliferation of physician services after decades of accelerating innovation required development of a common language to describe medical services for modern health care. The American Medical Association (AMA) in partnership with medical specialties developed Current Procedural Terminology (CPT) to specify nomenclature describing physician procedures and services to facilitate documentation and third-party billing. In 1991 the Relative Value Scale Update Committee (RUC) was established to develop a standard method to advise the Centers for Medicare & Medicaid (CMS), which sets service payments for physician services within the Resource-Based Relative Value Scale (RBRVS). The elements of the RBRVS that CMS adopted based on research work carried out by Hsiao et al
      • Hsiao W.C.
      • Braun P.
      • Yntema D.
      • et al.
      Estimating physicians’ work for a Resource-based Relative Value Scale.
      at Harvard involved determination of relative value units (RVUs) for work, practice expense (PE) RVUs, and liability expense.
      • Hsiao W.C.
      • Braun P.
      • Yntema D.
      • et al.
      Estimating physicians’ work for a Resource-based Relative Value Scale.
      The resulting total RVU is then translated into a dollar value using a conversion factor determined by the CMS and historically modified frequently by Congress.

      Abbreviations:

      AMA (American Medical Association), CMS (Centers for Medicare & Medicaid), CPT (Current Procedural Terminology), GPCI (geographic practice cost index), PE (practice expense), RBRVS (Resource-Based Relative Value Scale), RUC (Relative Value Scale Update Committee), RVU (relative value unit)
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      References

      1. American Medical Association History.
        (Available at:)
        • RVS Update Committee
        RBRVS overview.
        (Available at:)
        • Hsiao W.C.
        • Braun P.
        • Yntema D.
        • et al.
        Estimating physicians’ work for a Resource-based Relative Value Scale.
        N Engl J Med. 1988; 319: 835-841
        • CPT Editorial Panel
        The CPT code process.
        (Available at:)
      2. CPT code applications.
        (Available at:)
      3. RVS Update Committee.
        (Available at:)
      4. 2019 RVS updated process.
        (Available at:)
        • American Medical Association
        Summary: 2019 Medicare physician fee schedule.
        (Available at:)