State the amount reported as direct compensation on a W2, 1099, or K1 (for partnerships)
plus all voluntary salary reductions such as 401(k), 403(b), Section 125 Tax Savings
Plan, or Medical Savings Plan. The amount reported should include salary, bonus
and/or incentive payments, research stipends, honoraria and distribution of profits.
Do not include:
1. The dollar value of expense reimbursements, fringe benefits paid by the medical
practice such as retirement plan contributions, life and health insurance, or automobile
allowances, or any employer contributions to a 401(k), 403(b) or Keogh Plan.
Report amount of collections attributed to a physician for all professional services.
Include:
1. Fee-for-service collections;
2. Allocated capitation payments;
3. Administration of chemotherapy drugs; and
4. Administration of immunizations.
Do not include:
1. Collections on drug charges, including vaccinations, allergy injections, and
immunizations, as well as chemotherapy and antinauseant drugs;
2. The technical component (TC) associated with any laboratory, radiology, medical
diagnostic or surgical procedure collections;
3. Collections attributed to nonphysician providers;
4. Infusion-related collections;
5. Facility fees;
6. Supplies; or
7. Revenue associated with the sale
Report the total gross patient charges attributed to a physician for all professional
services. Gross patient charges are the full dollar value, at the practice’s established
undiscounted rates, of services provided to all patients, before reduction by charitable
adjustments, professional courtesy adjustments, contractual adjustments, employee
discounts, bad debts, etc. For both Medicare participating and nonparticipating
providers, gross charges should include the practice’s full, undiscounted charge
and not the Medicare limiting charge.
Include:
1. Fee-for-service charges;
2. In-house equivalent gross fee-for-service charges for capitated patients;
3. Administration of chemotherapy drugs; and
4. Administration of immunizations.
Do not include:
1. Charges for drugs, including vaccinations, allergy, injections, and immunizations
as well as chemotherapy and antinauseant drugs;
2. The technical component associated with any laboratory, radiology, medical diagnostic
or surgical procedure;
3. Charges attributed to nonphysician providers;
4. Infusion-related charges;
5. Facility fees;
6. Supplies; or
7. Charges associated with the sale of hearing aids, eyeglasses, contact lenses,
etc.
A documented, face-to-face contact between a patient and a provider who exercises
independent judgment in the provision of services to the individual. If a patient
sees multiple providers on the same day for the same set of problems/diagnoses,
it is considered one encounter. If a patient with multiple problems/diagnoses sees
multiple providers on the same day and each provider manages a different set of
problems/diagnoses, then it can be considered as multiple encounters.
Include:
1. Pre- and post-operative visits and other visits associated with a global charge;
2. For diagnostic radiologists, report the total number of procedures or reads,
regardless of place of service; and
3. For obstetrics care, where a single CPT-4 code is used for a global service,
count each ambulatory contact as a separate ambulatory encounter (e.g., each prenatal
visit and postnatal visit is an ambulatory encounter). Count the delivery as a single
surgical case.
Do not include:
1. Ambulatory encounters attributed to nonphysician providers;
2. Encounters for the physician specialties of pathology or diagnostic radiology.
(see #2 under “Include” above);
3. Encounters that include procedures from the surgery chapter (CPT codes 10021-69979)
or anesthesia chapter (CPT codes 00100-01999);
4. Number of procedures, since a single encounter can generate multiple procedures;
5. Visits where there is not an identifiable contact between a patient and a physician
or nonphysician provider such as when the patient comes into the practice solely
for an injection, vein puncture, EKG, or EEG administered by an RN or technician;
6. Administration of chemotherapy drugs; or
7. Administration of immunizations.
Ambulatory encounters
Report total number of encounters, using the previous definition, with the following
Centers for Medicare and Medicaid Services (CMS) place of service codes:
11 Office
12 Home
20 Urgent Care Facility
22 Outpatient Hospital
23 Emergency Room
24 Ambulatory Surgical Center
31 Skilled Nursing Facility
32 Nursing Facility
33 Custodial Care Facility
34 Hospice
50 Federally Qualified Health Center
52 Psychiatric Facility Partial Hospitalization
53 Community Mental Health Facility
54 Intermediate Care Facility for Mentally Retarded
55 Residential Substance Abuse Treatment Facility
56 Psychiatric Residential Treatment Center
62 Comprehensive Outpatient Rehabilitation Facility
65 End Stage Renal Disease Treatment Facility
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
Report the total surgery/anesthesia cases performed annually by each provider. A
surgery/anesthesia case is a case between a provider and a patient where at least
one procedure performed is a procedure from the surgery chapter (CPT codes 10021-69979)
or anesthesia chapter (CPT codes 00100-01999) of the Current Procedural Terminology,
Fourth Edition, copyrighted by the American Medical Association (AMA). Note that
the number of cases, not procedures, should be counted since a case may consist
of multiple procedures. Surgery/anesthesia cases include cases performed on an inpatient
or outpatient basis, regardless of facility or site. For anesthesia care teams,
an anesthesiologist who supervises one or more CRNAs, include total care team cases.
Report the RVUs, as measured by the 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, nonphysician
providers, and other health care professionals. The RVU system is explained in detail
in the December 1, 2006 Federal Register, pages 69624 to 70251. Addendum B: 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 December 1, 2006, Federal Register, effective for calendar
year 2007, should be used; and
• The total RVUs for a given procedure consist of three components:
1. Physician work RVUs;
2. Practice expense (PE) RVUs; and
3. Malpractice RVUs.
Thus, total RVUs = physician work RVUs + practice expense RVUs + malpractice RVUs.
For 2006, there were two different types of practice expense RVUs:
1. Fully implemented nonfacility practice expense RVUs; and
2. Fully implemented facility practice expense RVUs.
Any adjustments to RVU values through periodic adjustments and updates made by CMS
should be included.
Physician work RVUs
1. RVUs for the “physician work RVUs” only including any adjustments made as a result
of modifier usage;
2. Physician work RVUs for all professional medical and surgical services performed
by providers;
3. Physician work RVUs for the professional component of laboratory, radiology,
medical diagnostic and surgical procedures;
4. Physician 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;
5. Physician work RVUs for procedures for both feefor-service and capitation patients;
6. Physician work RVUs for all payers, not just Medicare;
7. Physician work RVUs for purchased procedures from external providers on behalf
of the practice’s fee-for-service patients; and
8. 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.
Do not include:
1. RVUs for “malpractice RVUs”;
2. RVUs for other scales such as McGraw-Hill or California;
3. RVUs for purchased procedures from external providers on behalf of the practice’s
capitation patients;
4. RVUs that have been weighted by a conversion factor. Do not weigh the RVUs by
a conversion factor; or
5. RVUs where the Geographic Practice Cost Index (GPCI) equals any value other than
one. The GPCI must be set to 1.000 (neutral).