1.2 Establishment of Allowable Fees: Relative Values for Physicians (RVP)

The RVP is widely accepted as the basis of fee-for-service insurance reimbursement in the medical community. DVR uses the RVP to determine allowable fees for the purchase of most medical assessment and treatment services.

The RVP is divided into sections that address different aspects of the delivery of medical services, including the following:

• Anesthesia

• Evaluation and Management

• Medicine

• Pathology

• Radiology

• Surgery

The RVP utilizes Current Procedural Terminology (CPT) codes to identify medical services and treatment procedures. Each service or procedure is assigned a “relative value unit” (unit) which reflects its relative worth in terms of time, skill, severity of illness, risk to the patient, and risk to the physician. In addition, “conversion factors” represent an appropriate base rate that, along with the relative value unit, determines a unique dollar value for procedures.

The normal maximum allowable fee for a procedure is Units x Conversion Factor = Fee

• Anesthesia - $53.73 per unit plus per time unit

• Surgery - $99.83 per unit

• Radiology - $18.41 per unit

• Pathology - $13.72 per unit

• Medicine - $8.33 per unit

• Physical Medicine - $6.23 per unit

• Evaluation and Management - $10.16 per unit

While most CPT codes are assigned a relative value reflected by a particular number of units, there are exceptions. The following “values” may also apply:

• BR - By Report. A value is denoted in this way when the variance is too great to establish a relative value.

• RNE - Relativity Not Established. This is used to identify a procedure that is new or uncommon.

• xx.x(I) - Interim Value. This is used when the data received is below confidence levels.

In each of these situations, the maximum allowable rate is the usual and customary rate and must reflect the least possible cost.

A provider may also use a modifier to adjust the rate charged when certain circumstances apply. A complete list of modifiers is available in the Introduction of the RVP. When a modifier is used, the accompanying report must reflect the reason(s) and the authorization is amended to reflect the change in rate.

DVR only purchases medical services from a provider that is appropriately licensed and/or certified in accordance with the laws of the state in which they are providing service, is within their scope of practice, and is in good standing. Providers for which there are no state licensure laws must be certified or otherwise qualified in accordance with the standards provided in this chapter. Procedures performed by qualified non-physician providers must be rendered under the direct and personal supervision of a physician. Direct and personal supervision means that a physician is physically present on the premises at the time the procedure or examination is provided by the qualified non-physician provider.

Reimbursement for physician services shall be the lower of the allowable fee for corresponding Colorado providers or the out-of-state provider's actual charge.

Providers are reimbursed at different rates according to licensing and specialty. 

Physician providers are reimbursed at 100% of a procedure’s relative value, as follows:

• Doctor of Medicine, licensed under CRS 12-36 by the State Board of Medical Examiners

• Doctors of Osteopathy, licensed under CRS 12-36 by the State Board of Medical Examiners

• Chiropractors, licensed under CRS 12-33 by the State Board of Chiropractic Examiners

• Podiatrists, licensed under CRS 12-32 by the Colorado Podiatry Board

The following non-physician providers are reimbursed at 100% of the procedure’s relative value for a physician:

• Physical Therapists, licensed under CRS 12-41, and Occupational Therapists, certified by the American Occupational Therapy Certification Board, shall be reimbursed only for procedures in the “Medicine” section of the RVP (CPT codes 97001-97799)

• Speech Pathologists, certified by the American Speech and Hearing Association

• Optometrists, licensed under CRS 12-40 by the State Board of Optometric Examiners, may be reimbursed for only for the following ophthalmology procedures 92002, 92004, 92012, 92014, 92015, 92081, 92083, 99215, 99201, 99202, 99203, 99204, and 99205

• (DVR may also reimburse for dispensing of glasses under CPT 92340, 92341, 92342)

• Acupuncturists, registered under CRS 12-29.5 with the Colorado Office of Acupuncturists Registration; only for physical medicine procedures 97810, 97811, 97813, and 97814

The following providers are reimbursed at 90% of the procedure’s relative value for a physician:

• Psychologists, licensed under CRS 12-43 by the Colorado State Board of Psychologist Examiners

• Doctoral interns receiving one-on-one supervision by a licensed psychologist pursuant to the intern’s licensure under CRS 12-43

The following professional categories shall be paid at 75% of the relative value for a physician:

• Orthopedic Technologists, certified by the National Organization of Orthopedic Technologists

• Surgical Technologists, certified by the Association of Surgical Technologists

• Audiologists, practicing in Colorado prior to July 1, 1995, certified by the American Speech and Hearing Association, registered under CRS 12-5.5 with the Colorado Department of Regulatory Agencies, Division of Registrations. Audiologists beginning practice in Colorado on or after July 1, 1995 are registered under CRS 12-5.5 with the Colorado Department of Regulatory Agencies, Division of Registrations

• Respiratory Therapists, certified by the National Board of Respiratory Care

• Registered Nurses, licensed under CRS 12-38 by the State Board of Nursing, including family nurse practitioners certified by the American Nurses Association; pediatric nurse practitioners certified by the National Certification Board of Pediatric Nurse Practitioners and Nurses or the American Nurses Association; nurse anesthetists certified by the Council on Certification of Nurse Anesthetists or the Council on Recertification of Nurse Anesthetists; psychiatric and mental health nurses certified by the American Nurses Credentialing Center

• Optometrists licensed under CRS 12-40 by the State Board of Optometric Examiners; for procedures other than those identified under 1.c) above.

• Clinical Social Workers, licensed under CRS 12-43 by the State Board of Social Work Examiners, and interns receiving one-on-one supervision pursuant to the intern’s licensure under CRS 12-43

• Marriage and Family Therapists, licensed under CRS 12-43 by the State Board of Marriage and Family Therapists Examiners, and interns receiving one-on-one supervision pursuant to the intern’s licensure under CRS 12-43

• Licensed Professional Counselors, licensed under CRS 12-43 by the State Board of Professional Counselor Examiners, and interns receiving one-on-one supervision pursuant to the intern’s licensure under CRS 12-43-601

• School Psychologists, licensed under CRS 12-60-1044(1)(e)

• Learning Disability Specialists with an advanced degree in Learning Disabilities and/or Special Education, and a current Teacher’s Certification from the Colorado Department of Education

• Psychiatric and Mental Health Nurses, certified by the American Nurses Credentialing Center and licensed under CRS 12-38 by the State Board of Nursing

• Clinical Specialists in Psychiatric and Mental Health Nursing, certified by the American Nurses Credentialing Center and licensed under CRS 12-38 by the State Board of Nursing

• Registered Dieticians, certified as such by the National Commission on Dietetics Registration

• Physician Assistants, certified by the National Commission on Certification of Physician’s Assistants and under CRS 12-36-106(5)(a) by the State Board of Medical Examiners, including university trained Surgeon Assistants

The following are reimbursed at 50% of the procedure’s relative value for a physician:

• Massage Therapists, registered under 12-35.5 and certified by the National Certification Board for Therapeutic Massage and Bodywork; only for massage treatment (CPT code 97124)

• Registered Dietetic Technicians, certified through the Commission on Dietetics Registration

In all cases, payment for the procedures includes the preparation and provision of a written report. The report must reflect the complexity of the service, length of time involved, level of training and expertise required by the provider to perform the procedure, and the scope of medical services provided.