Kyle Richards: Yeah, thanks, Sam, for the intro. It's great to be here on UroToday and to give this presentation. As Sam was alluding to, I've been involved in this committee called the RUC, which stands for RVU Update Committee, since I was a fellow with my mentor, Dr. Norm Smith. And since 2022, I've been the AUA RUC member, which is, as Sam mentioned, another hat that I wear in addition to being an academic urologist and a bladder cancer surgeon and researcher at the University of Wisconsin. So, for the brief time that we have, I wanted to hone the presentation to define what the RUC actually is, and then I'm going to go into how the RUC actually functions. I'm going to use an example of robotic prostatectomy as a case study to highlight some of the things that we think about when we're thinking about RVUs and how physicians and qualified healthcare professionals are reimbursed for the work that they do. So what is the RUC? The RUC stands for Relative Value Unit Update Committee. A relative value unit is really the currency of medicine. A lot of us get paid based on the amount of RVUs that we generate from seeing patients and doing procedures. And every RVU gets converted to a subsequent dollar amount by private insurers, CMS, Medicare. The U for update means that this committee updates these codes, really they're CPT codes. Every procedure and every office visit has a CPT code associated with that. And these codes are updated by the RUC on an annual basis.
The RUC actually meets three times a year in person to hash this out. To give you some perspective, there are 11,000 CPT codes in the fee schedule. So the RUC can't update all 11,000 codes every year. So, just for 2026, there were 288 new codes, 84 deletions, and 46 revisions. So the RUC works very hard to keep the CPT codes up-to-date to make sure the RVUs are accurate. And it's a committee. I'm the only urologist on the committee. I have an alternate, his name is Dr. Tom Turk, who's at Loyola, and urology has a seat on the committee. It's a committee of independent experts that was actually formed in 1991. It's run and staffed by the American Medical Association as their First Amendment right to petition the federal government. It's a committee of independent experts that provides recommendations to CMS on RVUs, and CMS can then take it or leave it. In general, they accept about 90% of the RUC recommended RVU values, and there are 29 voting members with urology being one of those members. Since its inception in 1991, urology has always had a seat at that table. So, flipping gears to how the RUC functions. It largely functions based on collecting data from specialty societies. The AUA, the American Urological Association, will send out surveys that will ask its members to provide time, complexity, and values relative to other services. The more respondents, the better, because if you have 30 respondents versus 130, you're going to have a better range of data. And in general, it takes about 15 to 30 minutes to complete the survey. Let's dive into robotic prostatectomy as a case study to get a sense for how the RUC functions. So robotic prostatectomy, many urologists are quite familiar with. Actually, the code for that was created in 2015, so not that long ago, really 11 years ago. And at that time, the survey went out as I showed, that was completed by 32 urologists. The median skin-to-skin time that came from that survey was 180 minutes, and it went through the RUC process, and the RUC voted, and ultimately, recommended an RVU of 26.8 based on a myriad of factors. However, CMS disagreed for several reasons, and actually set the RVU at 21.36.
Well, there is a mechanism if specialty societies or providers disagree with the CMS value, that you can appeal that. But in general, to get that changed, you have to have new compelling data. And fortunately, right around that time, there was this paper that was published in European Urology that we're forever grateful for because it basically showed in this very large cohort of a hospital data set that the operating room time for robotic prostatectomy was actually much higher. It was 309 minutes, much higher than the survey of 32 urologists. So this was a strong argument then to take to CMS to say, "Hey, the times on the survey maybe weren't that accurate." And actually CMS agreed, and increased the RVU back to the 26.1 level. Now, there also are times where technology and diffusion of technology can sometimes hurt the specialty. In fact, that happened in 2021 because there was this new CPT code that was created for robotic simple prostatectomy. Robotic prostatectomy was considered part of that family, which subsequently meant that it needed to be resurveyed. In this survey, there were 190 respondents that had 180 minutes of skin-to-skin time. So the survey, actually, time from 2021 was identical to the time from 2015. However, what did change is now it was typically robotic prostatectomy, the surveyee said was typically a 23-hour observation or an outpatient surgery. And some of this, I think, was reflected on what was going on in 2020 with COVID where a lot of surgery was getting pushed towards the outpatient setting. So RUC and CMS, because of those changes, agreed to an RVU of 22.46 at this time. So this is just an example of how diffusion of technology can sometimes pull other codes into that family that have to be resurveyed. And the reason why that happens is because you're trying to build relativity within families of codes, so that there's not what we call a rank-order anomaly where you've got a family of codes where one is an outlier, there's more RVUs, or more time. So it has to fit a certain pattern.
What subsequently happened then with robotic prostatectomy more recently, is that the pelvic lymph node dissection met the bundling threshold. If there are two CPT codes that are billed together 75% or more of the time, that automatically triggers a bundling threshold within Medicare. So we had to create some new codes and robotic prostatectomy was re-surveyed in 2024 as part of a family of new codes. These are the codes, 55866 with the old code and then X1 and X2 for the no-dissection bundling. The RUC actually recommended a value of 29.58 for the robotic prostatectomy and pelvic lymph node dissection, which actually would've been a slight increase compared to the old codes. However, CMS disagreed and set RVU at 27.41 based on some methodology that the AUA certainly didn't agree with. And subsequently, letters were written to Dr. Oz, who's the current administrator for the Center for Medicare and Medicaid Services. And we actually just had a meeting with CMS this week to try to argue our case. So, in summary, the AUA does have a work group that develops and presents a strategic plan. The RUC does still have influence within CMS. There has been lots of news and political things that have been ongoing about the potential role of the RUC and CMS potentially no longer needing our services. But I think that there's still relevance to the RUC and it does still have influence. The process itself does try to be fair, equitable, and consistent. And having gone to many, many RUC meetings, the people that sit around that table are really trying to get it right for all of organized medicine.
And what really the RUC does as the take-homes is it gives doctors a seat at the table. And this is something that's really critical, I think, that more doctors, more providers need to get engaged and involved in their state medical societies, the AUA summits, in talking to our politicians as well that make some of these decisions, so we need to make sure we continue to have a seat at the table. And understanding how the process works can really help demystify the enigma when it comes to things like budget neutrality, new technology, and bundling of codes. And if you ever get a RUC survey, and it's a procedure that you're familiar with, I encourage everybody to fill out that survey because the more data we have, the better results, better arguments, we'll be able to argue for when it comes to presenting at the table. Thank you for listening. And that ends my slide portion of the presentation.
Sam Chang: Wow, that was a fantastic overview. I just want to start off with some general questions for you. My understanding is that there is, within urology, a total number of RVUs for urology. Is that correct or totally incorrect? So, in other words, if an RVU total for, say, a retroperitoneal lymph node dissection goes up, does that mean something needs to be pulled away from another CPT code? Can you give me an idea of... Am I totally off base-
Kyle Richards: No.
Sam Chang: ... or does that have some semblance of truth?
Kyle Richards: No, it does, and the reason why that is, Sam, is because... I slid it in there at the end, the word budget neutrality. So the federal government and CMS in how they reimburse, they function within a budget-neutral system. So when we were presenting the prostatectomy codes, and we went from one prostatectomy code to three, now that just went live in 2026, we had to explain how within that family of three codes, the RVUs had to be neutral within that family based on our prediction. So we try, as a society, the AUA tries to predict and project what the utilization is going to be for those three codes so that it's budget neutral. If the society has a code or a family of codes, and they can argue that... There's a way that you can actually ask for more RVUs. It's called compelling evidence, but there are very strict criteria that you have to meet to be able to satisfy that qualification. And so it's very difficult for societies to have new CPT codes, or even old CPT codes to justify higher RVUs because of this issue with budget neutrality.
Sam Chang: I think along those lines, as you fill out these RUC surveys, this is not a time to show off. This is not a time to say, I can do a robotic prostatectomy in 60 minutes, and et cetera, et cetera. I want to really emphasize the importance of honesty, don't you think-
Kyle Richards: Yeah.
Sam Chang: ... when it comes to these surveys? Tell us a little bit about how we should consider these surveys. Do we include procedures we don't do so often, et cetera? Give us an idea about that.
Kyle Richards: Yeah, I think you bring up really good points, Sam, in that the RUC survey, the AUA comes up with a specific vignette, basically. It describes the patient that we're trying to perform the service on. And what we call that is we call that the typical patient. We've all had cases that go really fast and cases that take way longer because some are easy, some are hard, but we want what's typical. And there are certainly some procedures, and there are certainly some providers that may say, "Well, there really isn't a typical patient," or, "I just operate on all the difficult patients because I'm at Vanderbilt, and I'm Sam Chang," but hopefully, we all have some. So you want to think typical patient, you don't want to... And that's the, I would say, the rub against the RUC process is CMS and other sort of critics will say, "Well, surgeons are really bad at estimating their times anyways. Isn't there a better way of doing this?" But I think we all know, if you've done enough surgery, you know how long it takes you to do a typical case. You don't want to say what your outliers are, you want to say what it typically takes you and be honest. And it's really skin-to-skin. So it's when you make that first incision till when you put in that last stitch, that's the time we're looking for.
Sam Chang: Yeah, I think that makes a big difference because you really want to get an accurate estimate of truly the effort of physicians. And obviously, just as you say, there's a range. And so we want to be fair to all practicing urologic surgeons, taking into account the difficulty of certain cases, how often or how common procedures are, versus those that are outlying. It's a really important and difficult role that you've taken leadership in for years and years, Kyle. So we want to appreciate thanks for everything that you've done, and all the efforts that you've made on behalf of all, actually, practicing urologists. And if you could leave us with one kind of either piece of advice or hope, give us that tidbit.
Kyle Richards: Yeah, thanks for your kind words, Sam, and it's been great talking to you. I always enjoy it. I think sometimes people don't realize how hard there are people working behind the scenes to try to ensure that urologists are valued fairly. And the AUA has a team, I lead the team, but it's not just me, it's Tom Turk. Before me, it was Bill Gee, who was the former president of the AUA, and then the Southeast Section in Lexington, Kentucky, and Norm Smith, who paved the way for me. And we've got Jonathan Kiechle and Seth Cohen who are AUA advisors, the AUA staff, and there's a lot... So a lot of us are working really hard behind the scenes, but we need more people. We need more, I would say, more young activists to help us out on the ground level in their local institutions, at their state level, and at the national level to ensure that we, as providers, we as the folks that are seeing patients aren't getting pushed aside by administrators. And so I think that would be my main take-home message or something to leave people with, is to get involved and don't just complain about it, but we're always looking for people to help and everyone can make a difference at various levels.
Sam Chang: Well, that's a perfect note to end on, Kyle. Again, thank you for spending some time on this and enlightening urologists as they, hopefully, will get a better idea of what's going on, just as you say, behind the scenes as we try to make efforts to increase the equity for all of those practicing urologic surgery. So I'll look forward to spending some time with you again in the near future, and thanks again.
Kyle Richards: Yeah, thank you, Sam. And if anybody wants to get involved or wants to learn more about this, just don't hesitate to reach out.
Sam Chang: Perfect.