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Data Insights

Understand the past and present to propel your practice into the future.

Make informed decisions for your practice through insights and benchmarks from industry-leading data analysis, reports and surveys.

Production

Medical procedures conducted inside the practice’s facilities

When reporting procedure counts and gross charges for practice activities, it is necessary to identify whether the activity occurred inside or outside the practice’s facilities. This inside/outside distinction enables the proper assignment of operating costs to develop cost per unit output statistics. The Centers for Medicare and Medicaid Services (CMS) “place of service” codes are used to make this inside/outside distinction. There is one “place of service” code, the “office” code (11), which indicates activity inside the practice’s facilities. All other place of service codes (12-81) are for activities occurring outside the practice’s facilities. Examples of “outside” locations are the patient’s home, inpatient or outpatient hospital, psychiatric or rehabilitation facility, emergency room, freestanding ambulatory surgery center, birthing center, skilled nursing or custodial care facility, hospice, ambulance, independent laboratory or radiology and imaging center, ambulatory emergency
center, etc.
Include:

  • Procedures performed by all practice physicians, advanced practice providers, and other healthcare professionals such as nurses, medical assistants, and technicians; and

  • Purchased procedures from external providers and facilities on behalf of the practice’s fee-for- service patients for which revenue is reported as a subset of “Total net fee-for-service collections/ revenue” and for which costs are reported as a subset of “Clinical laboratory,” “Radiology and imaging,” and “Other ancillary services.”

Do not Include:

  • Purchased procedures from external providers and facilities on behalf of the practice’s capitation patients for which costs are reported as “Purchased services for capitation patients.”

**If the observed medical practice uses CMS Procedural Coding System (CMS PCS) codes, please use your best judgment to assign the G, H, M, Q, S, and T code counts and gross charges to the appropriate categories.

The five digit numbers in the following lists are the Current Procedural Terminology (CPT) codes published in Current Procedural Terminology CPT 2020 (American Medical Association, 2020).
 

Medical procedures conducted inside the practice’s facilities

Include:

Evaluation and Management Services (given an appropriate location code)

  • 99201-99215, office or other outpatient services;

  • 99241-99245, office or other outpatient consultations;

  • 99354-99360, prolonged and standby services;

  • 93792-93793, 99366-99368, 99441-99449, case management services;

  • 99374-99375, 99377-99380, care plan oversight services;

  • 99381-99387, 99391-99397, 99401-99404, 99406-99409, 99411-99412, 96160, 99429, preventive medicine services;

  • 99450, 99455-99456, special evaluation and management services; and

  • 99460-99465, newborn care. Radiology Services (given an appropriate location code)

  • 77261-77799, radiation oncology; and

  • 79005-79999, therapeutic nuclear medicine. Medicine Services (given an appropriate location code)

  • 90281-99091; and

  • 99170-99199, other services/procedures.

Do not Include:

  • 10021-69990, surgery procedures. These procedures are reported as “Surgery and anesthesia procedures”;

  • 70010-76499, diagnostic radiology. These procedures are reported as “Diagnostic radiology and imaging procedures”;

  • 76506-76999, diagnostic ultrasound. Report in “Diagnostic radiology and imaging procedures”;

  • 78012-78999, diagnostic nuclear medicine. Report in “Diagnostic radiology and imaging procedures”; or

  • 80047-89398, clinical laboratory and pathology. These procedures are reported as “Clinical laboratory and pathology procedures.”
     

Medical procedures conducted outside the practice’s facilities

Include:
The same items listed under “Medical procedures conducted inside the practice’s facilities,” given an appropriate location code:

  • 99217-99226, hospital observation services;

  • 99221-99223, 99231-99236, 99238-99239, hospital inpatient and observation services;

  • 99251-99255, inpatient consultations;

  • 99281-99285, 99288, emergency services;

  • 99291-99292, critical care services;

  • 99466-99467, 99471-99472, 99475-99476, pediatric critical care services;

  • 99468-99469, 99477-99480, neonatal critical and intensive care services;

  • 99304-99310, 99315-99316, 99318, nursing facility services;

  • 99324-99328, 99334-99337, domiciliary, rest home, or custodial care services;

  • 99354-99360, prolonged and standby services;

  • 99341-99345, 99347-99350, home services;

  • 99460-99465, newborn care; and

  • 99500-99602, home health services.

 

Surgery and anesthesia procedures conducted inside the practice’s facilities

Include:

  • 00100-01999, anesthesia procedures;

  • 10021-36410, 36420-69990, surgery procedures;

  • 99100-99140, anesthesia procedures; and

  • Surgery and anesthesia procedures performed in the practice’s own ambulatory surgery unit.

Do not Include:

  • 36415 and 36416, venous and capillary blood collection.
     

Surgery and anesthesia procedures conducted outside the practice’s facilities

Include:

  • Surgery and anesthesia procedures performed in an inpatient hospital or a freestanding ambulatory surgery center.

  • 00100-01999, anesthesia procedures;

  • 10021-36410, 36420-69990, surgery procedures;

  • 99100-99140, anesthesia procedures; and

Do not Include:

  • 36415 and 36416, venous and capillary blood collection.
     

Clinical laboratory and pathology procedures

Include:

  • 36415 and 36416, venous and capillary blood collection;

  • 80047-89398, a panel of tests represented by a single CPT code is considered to be one procedure;

  • HCPCS P codes;

  • All clinical laboratory and pathology procedures conducted by laboratories outside of the practice’s facilities as long as the practice pays the outside laboratory directly for the procedures and the procedures are only for the practice’s fee-for-service patients. The cost for these purchased laboratory services should be reported as a subset of “Clinical laboratory;” and

  • All procedures done either at the practice (where the practice bills at a global rate for both the technical and professional components) or procedures done at an outside facility (where the practice bills at a professional rate only).

Do not Include:

  • Purchased laboratory services from external providers and facilities on behalf of the practice’s capitation patients for which costs are reported as “Purchased services for capitation patients.”
     

Diagnostic radiology and imaging procedures

Include:

  • 70010-76499, diagnostic radiology;

  • 76506-76999, diagnostic ultrasound;

  • 78012-78999, diagnostic nuclear medicine;

  • All diagnostic radiology and imaging procedures conducted by laboratories outside of the practice’s facilities as long as the practice pays the outside laboratory directly for the procedures and the procedures are only for the practice’s fee-for-service patients; and

  • All procedures done either at the practice (where the practice bills at a global rate for both the technical and professional components) or procedures done at an outside facility (where the practice bills at a professional rate only).

Do not Include:

  • 77261-77799, radiation oncology;

  • 79005-79999, therapeutic nuclear medicine. Radiation oncology and therapeutic nuclear medicine activity is included in “Medical procedures,” depending on location code; or

  • Purchased radiology services from external providers and facilities on behalf of the practice’s capitation patients for which costs are reported as “Purchased services for capitation patients.”
     

Total procedures and procedural gross charges

Add “Medical procedures conducted inside the practice's facility,” “Medical procedures conducted outside the practice's facility,” “Surgery and anesthesia procedures conducted inside the practice's facility,” “Surgery and anesthesia procedures conducted outside the practice's facility,” “Clinical laboratory and pathology procedures” and “Diagnostic radiology and imaging procedures” for both Total procedures and Procedural gross charges.
 

Nonprocedural gross charges (include chemotherapy drug charges)

Other charges not reported in “Medical procedures conducted inside the practice’s facilities” through “Diagnostic radiology and imaging procedures” in the Gross Charges column.
Include:

  • Facility fee charges for the operation of an ambulatory surgery unit;

  • Facility fee charges in a hospital-affiliated practice that utilizes a split billing system where both facility fees and professional charges are billed;

  • Charges for drugs and medications, administered inside the practice’s facilities, such as chemotherapy drugs; and

  • Charges for HCPCS A, J, R, and V codes.

Do not Include:

  • Charges for the sale of medical goods and services. Such charges are not reported anywhere on this survey.
     

Total gross charges

Add “Total procedures and procedural gross charges” and “Nonprocedural gross charges.”
 

How many Resource Based Relative Value Scale (RBRVS) total and physician work relative value units (RVUs) units did your practice produce?

If you are an MGMA member and would like assistance in calculating your RVUs, please visit http://data.mgma.com/DataTools/rdPage.aspx to use the RVU calculator.

Report the relative value units (RVUs), as measured by the Resource Based Relative Value Scale (RBRVS), not weighted by a conversion factor, attributed to all professional services. An RVU is a nonmonetary standard unit of measure that indicates the value of services provided by physicians, advanced practice providers, and other healthcare professionals. The RVU system is explained
in detail in the November 15, 2019 Federal Register, pages 62568-63563. Addendum D: Relative Value Units (RVUs) and Related Information presents a table of RVUs by CPT code. Your billing system vendor should be able to load these RVUs into your system if you are not yet using RVUs for management analysis. When answering this question, note the following:

  • The RVUs published in the November 15, 2019 Federal Register, effective for calendar year 2020, should be used; and

  • The total RVUs for a given procedure consist of three components:

    • Physician work RVUs;

    • Practice expense (PE) RVUs; and

    • Malpractice RVUs.

Thus, total RVUs = physician work RVUs + practice expense RVUs + malpractice RVUs.

  • For 2020, there were two different types of practice expense RVUs:

    • Fully implemented nonfacility practice expense RVUs; and

    • Fully implemented facility practice expense RVUs.

  • “Nonfacility” refers to RVUs associated with a medical practice that is not affiliated with a hospital and does not utilize a split billing system that itemizes facility (hospital) charges and professional charges. “Nonfacility” also applies to services performed in settings other than a hospital, skilled nursing facility, or ambulatory surgery center. You should report total RVUs that are a function of “nonfacility” practice expense RVUs.

  • “Facility” refers to RVUs associated with a hospital affiliated medical practice that utilizes a split billing fee schedule where facility (hospital) charges and professional charges are billed separately. “Facility” also refers to services performed in a hospital, skilled nursing facility, or ambulatory surgery center. If you are a hospital affiliated medical practice that utilizes a split billing fee schedule, you should report your total RVUs as if you were a medical practice not affiliated with a hospital.

  • To summarize, there are two different types of total RVUs:

    • Fully implemented nonfacility total RVUs; and

    • Fully implemented facility total RVUs.

  • The Federal Register Addendum D presents six columns of RVU data. The column labeled “Physician work RVUs” is what you should report as work RVUs. Any adjustments to RVU values through periodic adjustments and updates made by CMS should be included.
     

*Work RVUs

Include:

  • RVUs for the “physician work RVUs” only; including any adjustments made as a result of modifier usage;

  • Work RVUs for all professional medical and surgical services performed by providers;

  • Work RVUs for the professional component of laboratory, radiology, medical diagnostic, and surgical procedures;

  • Work RVUs for all procedures performed by the medical practice. For procedures with either no listed CPT code or with an RVU value of zero, RVUs can be estimated by dividing the total gross charges for the unlisted or unvalued procedures by the practice’s known average charge per RVU for all procedures that are listed and valued;

  • Work RVUs for procedures for both fee-for-service and capitation patients;

  • Work RVUs for all payers, not just Medicare;

  • Work RVUs for purchased procedures from external providers on behalf of the practice’s fee-for- service patients;

  • Anesthesia practices should provide the physician work component of the RVU for flat fee procedures only such as lines, blocks, critical care visits, intubations, and post-operative management care; and

  • All RVUs associated with professional charges, including both medically necessary and cosmetic RVUs.

Do not Include:

  • RVUs for “malpractice RVUs”;

  • RVUs for other scales, such as McGraw-Hill, California;

  • RVUs for purchased procedures from external providers on behalf of the practice’s capitation patients;

  • RVUs that have been weighted by a conversion factor. Do not weigh the RVUs by a conversion factor; or

  • RVUs where the Geographic Practice Cost Index (GPCI) equals any value other than one. The GPCI must be set to 1.000 (neutral).
     

*Total RVUs

Include:

  • RVUs for the “physician work RVUs,” “practice expense,” and “malpractice RVUs,” including any adjustments made as a result of modifier usage;

  • RVUs for all professional medical and surgical services performed by physicians, advanced practice providers, and other physician extenders such as nurses and medical assistants;

  • RVUs for the professional component of laboratory, radiology, medical diagnostic, and surgical procedures;

  • For procedures with either no listed CPT code or with an RVU value of zero, RVUs can be estimated by dividing the total gross charges for the unlisted or unvalued procedures by the practice’s known average charge per RVU for all procedures that are listed and valued;

  • RVUs for procedures for both fee-for-service and capitation patients; and

  • RVUs for all payers, not just Medicare.

Do not Include:

  • RVUs for other scales such as McGraw-Hill, California;

  • The technical component (TC) associated with any medical diagnostic, laboratory, radiology, or surgical procedure. If your practice cannot break this out, report RVUs and select the appropriate response to the question regarding technical component. If you can report total RVUs without technical component, answer 0% for the technical component question; or

  • RVUs where the Geographic Practice Cost Index (GPCI) equals any value other than one. The GPCI must be set to 1.000 (neutral).

 

Total ASA units

ANESTHESIOLOGY SPECIALTIES ONLY

For anesthesiology practices, provide the American Society of Anesthesiologists (ASA) units. The ASA units for a given procedure consist of three components:

  • Base unit;

  • Time in 15-minute increments; and

  • Risk factors.

Please note:

  • Adjustments should be made if the provider supervises a CRNA that is not employed by the reporting practice; and

  • Do not duplicate units for split bills. Instead, report units on a per case basis.
     

*Number of individual patients

The total number of individual patients who received services from the practice during the 12-month reporting period.

Include:

  • Fee-for-service and capitation patients. A patient is simply a person who received at least one service from the practice during the 12-month reporting period, regardless of the number of encounters or procedures received by that person. If a person was a patient during 2019, but did not receive any services at all during 2020, that person would not be counted as a patient for 2020. A patient is not the same as a covered life. The number of capitated patients, for example, could be less than the number of capitated covered lives if a subset of the covered lives did not utilize any services during the 12-month reporting period.
     

Number of patient encounters

A documented interaction, regardless of setting (including tele-visits and e-visits), between a patient and healthcare provider(s) for the purpose of providing medical services, assessing illness or injury, and determining the patient's health status. If a patient sees two different providers on the same day for one diagnosis, it is one encounter. If a patient sees two different providers on the same day for two unrelated issues, then it is considered two encounters. Encounters are procedures from the evaluation and management chapter (CPT codes 99201-99499) or the medicine chapter (CPT codes 90281-99607) of the Physicians’ Current Procedural Terminology, Fourth Edition, copyrighted by the American Medical Association (AMA).
Include:

  • Pre- and post-operative visits and other visits associated with a global charge;

  • Visits that resulted in a coded procedure;

  • The total number of procedures or reads for diagnostic radiologists and pathologists, regardless of place of service;

  • For obstetrics care, where a single CPT-4 code is used for a global service, count each as a separate ambulatory encounter (e.g., each prenatal visit and postnatal visit is one encounter). Count the delivery as a single encounter; and

  • Encounters that include procedures from the surgery chapter (CPT codes 10021-69990) or anesthesia chapter (CPT codes 00100-01999).

Do not Include:

  • Encounters with direct provider to patient interaction for the specialties of pathology or diagnostic radiology (see #3 above under "Include”);

  • Visits where there is not an identifiable contact between a patient and a physician or advanced practice provider (i.e., patient comes into the practice solely for an injection, vein puncture, EKGs, EEGs, etc. administered by an RN or technician);

  • Administration of chemotherapy drugs; or

  • Administration of immunizations.
     

Practice panel size for the past 18 months

CARDIOLOGY AND PRIMARY CARE PRACTICES ONLY

Answer the panel size or ‘set of patients cared for by a physician’ as the number of individual unique patients that have been seen by any provider within the practice over the past 18 months. To determine the panel size per physician, use the following methodologies:

  • If a patient has only seen one physician in the practice, assign the patient to that physician.

  • If a patient has seen more than one physician in the practice, assign the patient to the physician seen most frequently.

  • If a patient has seen more than one physician in the practice the same number of times, assign the patient to the physician who did the patient's last physical.

  • If a patient has not had a physical, assign him/her to the physician seen most recently.
     

*Surgical anesthesia

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • Any case with base and time units where anesthesia services such as general, regional or MAC are provided, regardless of whether or not there were multiple providers on the case. Generally these are the “0” anesthesia codes or services which cross over to these codes. Obstetrical cases, critical care, chronic and acute pain services, as well as flat fee procedures are each listed as a separate category for which you will give separate counts.

  • List base units and minutes for surgical anesthesia cases only.

    • For base units and time minutes, list one set of base units and time minutes per case only. Do not double-count medically directed cases. The best way for most practices to do this is to list physician base units and physician minutes only.

    • Academic practices should beware not to double count resident units and should only count units for the supervising attending.

    • If you have a significant number of cases which involve unsupervised CRNAs (QZ modifier), the base units and minutes for these cases should be added.

For the “Charge per ASA unit,” indicate the monetary fee that is applied to an American Society of Anesthesiologists (ASA) unit. The ASA units for a given procedure consist of three components:

  • Base unit;

  • Time in 15-minute increments; including time converted from 10-minute or 12-minute time units to 15-minute increments. The divisor to convert a pool of 10-minute time units to 15-minute units is 0.6667, and the divisor to convert a pool of 12-minute time units to 15-minute units is 0.80. For example, a 4-hour case will generate 24 10-minute time units, which is the equivalent of 16 15-minute time units (24 / 0.6667 = 16) or 20 12-minute time units, which is still the equivalent of 16 15-minute time units (20 / 0.80 = 60); and

  • Risk factors, which include the full value, at the practice’s undiscounted rates, of all services provided to fee-for-service, discounted fee-for-service, and non-capitated patients for all payers. If you charge time units based upon something other than 15 minute units, use your best efforts to convert your charge per unit to an equivalent amount that you would charge if you were billing based upon 15 minute time units.
     

Labor epidurals (CPT codes 59409, 01960, 01967)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • Labor epidurals (59409, 01960 or 01967). If a labor epidural is started and then a C-section is performed, count as one of each.
     

C-Sections (CPT codes 59514, 01961, 01968)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • C-sections (59514, 01961 or 01968). If a labor epidural is started and then a C-section is performed, count as one of each.
     

Epidurals (CPT codes 62324, 62326)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • The epidural (62324, 62326) for the day that the procedure was performed and count each day of subsequent follow-up as one follow-up visit (01996). For example, if patient A has an epidural placed for post-op pain on Monday and you visit him/her on Tuesday, Wednesday, and Thursday, you would list one epidural and three days of follow-up visits.
     

Follow-up visits (CPT codes 01996, 99231-99233)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • The epidural (62318, 62319) for the day that the procedure was performed and count each day of subsequent follow-up as one follow-up visit (01996). For example, if patient A has an epidural placed for post-op pain on Monday and you visit him/her on Tuesday, Wednesday, and Thursday, you would list one epidural and three days of follow-up visits.
     

Nerve blocks for post op pain (CPT codes 64400-64530)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • Nerve blocks for post op pain (CPT codes 64400-64530).
     

Critical care services (CPT codes 99291, 99292)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • Critical care services (CPT codes 99291, 99292).
     

Other (lines, intubations, etc.) (CPT codes, 36555-36558, 36568-36569, 36620, 93503, 93312-93318, 31500)

ANESTHESIOLOGY PRACTICES ONLY

Include:

  • Central venous lines (36555-36558, 36568-36569), arterial lines (36620), and Swan Ganz catheters (93503) placed by members of your group;

  • TEEs (93312-93318) that are performed and/or monitored by your group. Each separate CPT code billed is counted as one service;

  • Intubations (31500) that are not associated with anesthetic cases; and

  • Other flat fee procedures that are not applicable to any other category. For example, if an E/M visit has been included under critical care, acute or chronic pain, do not double count here.
     

*Total for anesthesiology procedures

ANESTHESIOLOGY PRACTICES ONLY

Add “Surgical anesthesia,” “Labor epidurals,” “C-Sections,” “Epidurals,” “Follow-up visits,” “Nerve blocks for post op pain,” “Other acute pain services,” “Critical care services,” and “Other flat fees” for total number of cases, total gross charges and total revenue.
 

Claims processed per biller

ANESTHESIOLOGY PRACTICES ONLY

To calculate, take the total number of claims processed by your group, divide by the total number of FTE who processed anesthesiology billing. For example, if your group processed 30,000 anesthesiology claims in 2020 and had 5.5 FTE working on anesthesia billing, you would enter 5454.54 (30,000/5.5) for “Number of claims processed per biller for anesthesia claims.”

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