Put forth by Hsiao et al5in the late 1980s as an alternative to the system of payments based on historical charges, and in an effort to more rationally assign monetary values to the broad range of services delivered by physicians, the Resource Based Relative Value Scale (RBRVS) was adopted by Congress in 1989 and implemented in the Medicare Fee Schedule in 1992. RBRVS establishes a value for every current procedural technology (CPT) code based on the following: (1) total work input performed by the physician for each service; (2) practice costs, including malpractice premiums; and (3) the cost of specialty training. This value is then converted to a monetary value by applying a standardized conversion factor. The CCI was established by Medicare in 1996 to promote national correct coding methodologies and to control improper coding leading to inappropriate payments.6 The CCI is based on coding conventions defined in the American Medical Association CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. The payment for a given service is determined by the total RBRVS value of the component procedures and the application of CCI to determine which procedures are payable. The introduction of new procedures, advances in technology making some procedures simpler and some more difficult to perform, the unique circumstances of individual patients, and other factors conspire to make physician and facility compensation less rational in certain situations. While the entities that maintain these standards should continuously update them to make the resulting payments as rational as possible for all situations, it is with great peril that one tampers with the value assigned to a single procedure, for there are likely dozens or hundreds of procedures and services that other specialists would consider undervalued and equally worthy of revision. Far rarer is advocacy for reducing the relative value of a procedure or service for which technological advances have reduced the work required, despite the fact that, for Medicare, physician payment is a zero-sum game due to the application of the Sustainable Growth Rate provisions of the Social Security Act as amended in 1997 by the Balanced Budget Act, which is intended to control the growth in aggregate Medicare expenditures for physicians’ services. Increasing the payment for one service requires an offsetting decrease in payments for other services.