To Fix Software and AI Reimbursement - Do We Need to Understand the RUC?
Maybe.
For at least five years, CMS has had difficulty pricing software-intensive services like AI. In 2025, CMS included an RFI for "public comment" on these problems in both the July 2025 Physician (Part B) rulemaking and the Hospital Outpatient rulemaking.
One Damn Thing After Another
One case study was the great difficulty CMS had when in pricing "Heartflow" software in both the OPPS and Part B settings.
Another case study was the difficulty in pricing a photographic device that gives retinal diagnostics. Processed through the RUC, the AMA valuation committee gave 92229 a few dollars for technician time ($9), seventy cents for capital equipment ($14,000 device x 13 minutes), and a software fee.
CMS declined the software fee as a payable item, leaving the $40 service valued at about $10. CMS arbitrarily assigned an RVU value paying $46. This dates back to 2019/2020.
On the Clin Lab Fee Schedule side, things used to work, then broke. AMA issued and CMS accepted around 10 codes for complex whole slide imaging (WSI) tests, and generally priced at $700. Then, AMA stopped issued WSI PLA codes, so nothing happened for a couple years.
Amidst many AMA initiatives around AI policy, AMA is now revising its Appendix S, and has begun putting new WSI tests into "Category III." But we don't know if CMS will include these Category III lab test codes in its summer lab crosswalk/gapfill process. I think they can and should, since CMS has classed WSI tests as CLFS tests, even when they are closely reviewed as ADLTs. And FDA and CLIA and, say, New York State, classifies computatioinal pathology tests as CLIA tests. So they should go into the summer CLFS crosswalk/gapfill process. File that under "track this."
All About the RUC
In 2016, Miriam Laugesen of Columbia published a wonderful book about the AMA RUC process, "Fixing Medical Prices," (Harvard University Press.)
It turns out there are a lot of RUC documents, some intricately detailed, on the AMA website.
For example, there is an encyclopedic 27 page article about practice expense components - which will be relevant, if only for contrast, to future software valuation. Find it here:
https://www.ama-assn.org/system/files/practice-expense-component.pdf
Find it all on a sidebar blog - I've listed about 20 AMA RUC resources there.
https://bqwebpage.blogspot.com/2026/05/ruc-resources-are-numerous-at-ama.html
At the bottom of the long sidebar, you can get files for RUC decisions and meeting minutes going back to 1993 (!!!). The AMA RBRVS subscription database (about $300) lists the last RUC review by date for every CPT code, and with that date, you can get the original files at AMA. And you can also track the most recent debates for how the RUC is handling new Category I codes with software. Currently as recent as...May 2026!
