Acute Pain Service $/RVU?

[neutro]

Hi,

Does anyone know where can I find data on this?

My hospital approached me to start an acute pain service, as an independent contractor outside of the anesthesia practice. I will have to carry my own malpractice and do it through my own LLC and it would be productivity type of contract.

How do I find out what is an appropriate $/ rvu amount for acute pain service, and some nerve blocks if indicated - both US guided and if needed fluoro guided (im pain fellowship trained).

Thank you

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[NICMAN]

Good luck with that. This is not financially viable without a stipend. The revenues for any acute pain block has not increased in the last 5 years—actually most have decreased across the board.

That plus the fact that a lot of non-periop acute pain issues tend to be accompanied with poor payor mixes (trauma, rib fractures in little old ladies). That and the fact that you would be on call 24/7/365 for unresolved acute pain issues, motor deficits in thoracic epidurals, catheter not working, slipped out, was somehow cut accidentally…

No thanks.

 

[Hoya11]

Hi,

Does anyone know where can I find data on this?

My hospital approached me to start an acute pain service, as an independent contractor outside of the anesthesia practice. I will have to carry my own malpractice and do it through my own LLC and it would be productivity type of contract.

How do I find out what is an appropriate $/ rvu amount for acute pain service, and some nerve blocks if indicated - both US guided and if needed fluoro guided (im pain fellowship trained).

Thank you

Well I can tell you that we make about 500-800 per US block.

And usually office consults are 300-500 in reimbursement.

It sounds like they are doing the billing? And then they pay you based on generated RVUs?

It would just depend on volume of legit stuff vs opioid management if its worth it.

 

[Arantius]

You need a stipend. The revenue generated is basically zero. Ask for a stipend to cover a partial FTE salary for you to do this according to the time you think it will take. Hospital can bill fees for meds etc but your professional fee revenue will be basically zero

 

[nimbus]

What will prevent the existing anesthesiologists from doing the blocks? If there is money to be made, they will continue to do their own postop pain blocks and leave the complicated anticoagulated 400lb rib fractures to the OP.

 

[nimbus]

You need a stipend. The revenue generated is basically zero. Ask for a stipend to cover a partial FTE salary for you to do this according to the time you think it will take. Hospital can bill fees for meds etc but your professional fee revenue will be basically zero

The way the question is posed by OP makes it sound like the hospital will pay based on RVUs produced. But there are a lot of barriers to a financially viable, RVU based, acute pain service. For example, routine postop pain management is included in the surgical fee. That’s why inpatient acute pain services have largely been abandoned outside of academics. Agree that a fixed stipend not based on RVU production is the way to go.

 

[neutro]

This is inpatient only. No trauma. Community hospital. No discharge meds or prescribing… just inpatient consults. Blocks if appropriate… things like esi for acute hnp coming from er or epidural blood patch that we didn’t do a spinal on - can be done under fluoro etc
Things like assessing intrathecal lump function etc …no one knows how to deal with this at this time

But main demand is to be present and handle this. Hospital has an employed pain doc but he’s outpatient only. Of course I don’t plan to shoot myself in the foot that’s why it would need to be straight productivity based pay with a rate. Trying to figure out appropriate rate for each consult

Current anesthesia group that I’m employed by doesn’t have staff dedicated to pain consults. Nor they’re interested.

Yes the hospital will take care of payer mix and billing. Not my headache

I want to get paid for my work doesn’t matter if it’s Medicaid pr Cigna

 

[neutro]

How will we get an idea about fixed stipend from hospital if there’s no data available on how much revenue will be generated? They would want to pay atleast upto a threshold

 

[OptionOffense]

There is a reason why nobody wants to do this work. Ask for a lot of money

 

[nimbus]

This is inpatient only. No trauma. Community hospital. No discharge meds or prescribing… just inpatient consults. Blocks if appropriate… things like esi for acute hnp coming from er or epidural blood patch that we didn’t do a spinal on - can be done under fluoro etc
Things like assessing intrathecal lump function etc …no one knows how to deal with this at this time

But main demand is to be present and handle this. Hospital has an employed pain doc but he’s outpatient only. Of course I don’t plan to shoot myself in the foot that’s why it would need to be straight productivity based pay with a rate. Trying to figure out appropriate rate for each consult

Current anesthesia group that I’m employed by doesn’t have staff dedicated to pain consults. Nor they’re interested.

Yes the hospital will take care of payer mix and billing. Not my headache

I want to get paid for my work doesn’t matter if it’s Medicaid pr Cigna

How many acute pain consults do you think you would get per month? 1? 2? How many RVUs do you anticipate per month? Like you said, you’ll be fielding all the annoying calls that your current group doesn’t want. I doubt the volume/pay will be worth the interruption to your existing routine. Doing an addon lap chole that is served to you on a plate would be a much more efficient way to generate RVUs. Think about the wheels you would need to turn in order to get that ER HNP patient up to a procedural area to do the ESI under fluoro. Fluoro availability/conflicts has been an ongoing issue where I work. How much time would it take from the moment you lay eyes on the patient until you are done with the procedure, done your notes, orders, etc. How many RVUs would that generate? That’s why the hospital employed chronic pain guy doesn’t want it either. These consults/procedures are one-offs. The system is not set up around them so they will not be efficient.


You will also end up with consults for opioid tolerant patients (e.g. substance abuse, advanced cancer, sickle cell). Do you want to help manage those conditions?

 

[nimbus]

How will we get an idea about fixed stipend from hospital if there’s no data available on how much revenue will be generated? They would want to pay atleast upto a threshold

You need that data. Don’t go in blind. Since the hospital approached you, there must be some need. In addition to a $/RVU guarantee, try to get an RVU/month guarantee for your availability.

As for $/RVU, pain forum may be more helpful.

 

[neutro]

You need that data. Don’t go in blind. Since the hospital approached you, there must be some need. In addition to a $/RVU guarantee, try to get an RVU/month guarantee for your availability.

As for $/RVU, pain forum may be more helpful.

This makes sense. Thank you.

 

[neutro]

How many acute pain consults do you think you would get per month? 1? 2? How many RVUs do you anticipate per month? Like you said, you’ll be fielding all the annoying calls that your current group doesn’t want. I doubt the volume/pay will be worth the interruption to your existing routine. Doing an addon lap chole that is served to you on a plate would be a much more efficient way to generate RVUs. Think about the wheels you would need to turn in order to get that ER HNP patient up to a procedural area to do the ESI under fluoro. Fluoro availability/conflicts has been an ongoing issue where I work. How much time would it take from the moment you lay eyes on the patient until you are done with the procedure, done your notes, orders, etc. How many RVUs would that generate? That’s why the hospital employed chronic pain guy doesn’t want it either. These consults/procedures are one-offs. The system is not set up around them so they will not be efficient.


You will also end up with consults for opioid tolerant patients (e.g. substance abuse, advanced cancer, sickle cell). Do you want to help manage those conditions?

If I see the patient in er and then schedule for esi, the hospital would arrange for transport and arranging for me to do esi

Yes these specific scenarios would need to be looked at

As for consults, I only plan to do a detailed initial h/p, and follow ups only as needed. Yes I understand it can get crazy as where I did my fellowship we actually had 24/7 acute pain coverage that required 2 fellows, 4 nps and one attending - this was a major academic center with 25-30 patient census a day and 8-10 new consults/ day.

Clearly I do not wish for that as I’m busy with my anesthesia work also.

Hospital sees value in this…my chairman left it upto me as he sees some value

But let’s assume I end up doing 5-10 hours of acute pain work per week - I would like to get paid for this

 

[Ronin1]

Figure out how many consults/follow ups/ procedure you are looking at and what codes
Plug them into this Rvu calculator

RVU Calculator - AAPC Relative Value Units

CPT® RVU calculator provides a quick analysis of the work relative value units associated with a certain volume of CPT or HCPCS codes.

www.aapc.com

Most consults and visits will be 3 or less rvus. Many procedures have poor rvu value. For example 62321 cervical esi is 1.95 WRVU.

I get 72$ Per rvu and generate approximately 60 units in a day in a pain practice. I wouldn’t do what you are proposing for less than $200/unit especially given independent contractor status.

 

[Ronin1]

FWIW my community hospital has a mandatory Call rotation for any pain physician with privileges to handle this stuff. Everyone hates it and tries to get off that’s list as soon as eligible. Luckily I’m exempt

 

[neutro]

great, thank you for the information. very useful.

 

[nimbus]

FWIW my community hospital has a mandatory Call rotation for any pain physician with privileges to handle this stuff. Everyone hates it and tries to get off that’s list as soon as eligible. Luckily I’m exempt

We also have chronic pain doctors on the medical staff but it is like pulling teeth to get one to step foot in the hospital.

 

[nimbus]

Figure out how many consults/follow ups/ procedure you are looking at and what codes
Plug them into this Rvu calculator

RVU Calculator - AAPC Relative Value Units

CPT® RVU calculator provides a quick analysis of the work relative value units associated with a certain volume of CPT or HCPCS codes.

www.aapc.com

Most consults and visits will be 3 or less rvus. Many procedures have poor rvu value. For example 62321 cervical esi is 1.95 WRVU.

I get 72$ Per rvu and generate approximately 60 units in a day in a pain practice. I wouldn’t do what you are proposing for less than $200/unit especially given independent contractor status.

Wow. 2-3 units is shockingly low.

 

[neutro]

We also have chronic pain doctors on the medical staff but it is like pulling teeth to get one to step foot in the hospital.

Yes, and that is the main issue.

 

[neutro]

https://www.asra.com/docs/default-source/advocacy-documents/asra_2022-mpfs-code-comparison.pdf?sfvrsn=47cd1662_4

I found this.

Figure out how many consults/follow ups/ procedure you are looking at and what codes
Plug them into this Rvu calculator

RVU Calculator - AAPC Relative Value Units

CPT® RVU calculator provides a quick analysis of the work relative value units associated with a certain volume of CPT or HCPCS codes.

www.aapc.com

Most consults and visits will be 3 or less rvus. Many procedures have poor rvu value. For example 62321 cervical esi is 1.95 WRVU.

I get 72$ Per rvu and generate approximately 60 units in a day in a pain practice. I wouldn’t do what you are proposing for less than $200/unit especially given independent contractor status.

Are you hospital based pain physician? $ 72/ rvu is pretty good isnt it?

So for example, I am looking at 99223 - inpatient first visit, level 3 consult. That would be 3.78 RVUs. So close to $750 dollars for one consult if I charge $200/unit...Do you think that the hospital will agree with this?

 

[Ronin1]

I think you are looking at the admit codes. It should be 99253 or even 99203 if observation status.

I’m hospital based now but did plenty of inpatient work over the years as a pp guy. Always a loser financially.

I would expect them to want to pay median rates for anesthesia pain mgma. Probably 65-75 wrvu. But u can argue as independent contractor without benefits etc for at least 1.5x. But run the numbers to see what it might generate for the aggravation.

 

[deleted875186]

I think you are looking at the admit codes. It should be 99253 or even 99203 if observation status.

I’m hospital based now but did plenty of inpatient work over the years as a pp guy. Always a loser financially.

I would expect them to want to pay median rates for anesthesia pain mgma. Probably 65-75 wrvu. But u can argue as independent contractor without benefits etc for at least 1.5x. But run the numbers to see what it might generate for the aggravation.

This is what I assumed, hosptial probably has in mind to pay you typical RVU threshold they pay the chronic pain outpatient guy. 60-70 $/unit is not enough to make doing a consult and ESI (2-3 units for consult and 2 units for a LESI) worth it, since that whole process will probably take several hours. Plus you’ll be on call. Plus you’ll get garbage consults. Plus all these procedures can honestly just wait until they can see an outpatient pain doc and get a medrol dose pack to go from the ED.

Can you negotiate a flat rate per week for coverage, then an RVU model for each consult or procedure?

 

[Maz777]

The procedures themselves aren't going to make it financially viable. It's the notes.

Level 4 initial consult note is ~3.3 wRVUs (99254). A level 3 progress note is ~2 wRVUs (99233).

Let's say you round on 20 patients a day, which is a lot. 5 initials, 15 follow-ups is 46.5 wRVUs. Let's say you do 1-2 blocks per day, add on 2-3 wRVUs. Total is 50 wRVUs. What is your daily rate you are aiming for? $3000? Then you would need $60/wRVU to make it financially viable for you. Given the fact that they aren't covering your malpractice or benefits, you're going to need to bump that up dramatically.

20 notes per day is a lot though but can be easily accomplished in 3-4 hours if you are efficient with a good EMR.

Starting an acute pain service from scratch is very painful. It takes a long while to build up the inpatient volume/list. Meetings, getting in with the surgical/medicine services, etc. Can't say that it is fun. That being said, if you can make $3000+/day and be done by noon, that isn't bad at all. To make it work and get people on board, it would have to be a full-time gig.

 

[deleted875186]

The procedures themselves aren't going to make it financially viable. It's the notes.

Level 4 initial consult note is ~3.3 wRVUs (99254). A level 3 progress note is ~2 wRVUs (99233).

Let's say you round on 20 patients a day, which is a lot. 5 initials, 15 follow-ups is 46.5 wRVUs. Let's say you do 1-2 blocks per day, add on 2-3 wRVUs. Total is 50 wRVUs. What is your daily rate you are aiming for? $3000? Then you would need $60/wRVU to make it financially viable for you. Given the fact that they aren't covering your malpractice or benefits, you're going to need to bump that up dramatically.

20 notes per day is a lot though but can be easily accomplished in 3-4 hours if you are efficient with a good EMR.

Starting an acute pain service from scratch is very painful. It takes a long while to build up the inpatient volume/list. Meetings, getting in with the surgical/medicine services, etc. Can't say that it is fun. That being said, if you can make $3000+/day and be done by noon, that isn't bad at all. To make it work and get people on board, it would have to be a full-time gig.

I don’t believe what your describing is what the OP is talking about. He described more of a chronic pain population, lumbar radic, pumps, etc, sounds like a much smaller volume.

Also, rounding on 20 patients sounds terrible, 5 new and 15 follow ups, no way all those encounters and notes are done in 4 hours.

 

[chessknt]

The procedures themselves aren't going to make it financially viable. It's the notes.

Level 4 initial consult note is ~3.3 wRVUs (99254). A level 3 progress note is ~2 wRVUs (99233).

Let's say you round on 20 patients a day, which is a lot. 5 initials, 15 follow-ups is 46.5 wRVUs. Let's say you do 1-2 blocks per day, add on 2-3 wRVUs. Total is 50 wRVUs. What is your daily rate you are aiming for? $3000? Then you would need $60/wRVU to make it financially viable for you. Given the fact that they aren't covering your malpractice or benefits, you're going to need to bump that up dramatically.

20 notes per day is a lot though but can be easily accomplished in 3-4 hours if you are efficient with a good EMR.

Starting an acute pain service from scratch is very painful. It takes a long while to build up the inpatient volume/list. Meetings, getting in with the surgical/medicine services, etc. Can't say that it is fun. That being said, if you can make $3000+/day and be done by noon, that isn't bad at all. To make it work and get people on board, it would have to be a full-time gig.

A level 3 progress note is high complexity, there is no way you are legally billing high level MDM (or taking a complex interval history) every day on every one of the follow ups. Complex MDM is a combination of high risk, 4 + data points or 4+problem points. If you are only managing the pain issue I can't envision how you would ever get there on a routine basis. You definitely arent billing by time with 15 follow ups you are finishing in under 3 hours.

 

[neutro]

Thanks guys, yes this fell through. Appreciate all the responses.

not a lot of weekend support which hospital wants

will try again if i get more pain guys in the practice who want to rotate with me, and then i can negotiate a subsidy as well

anyone interested in doing this work - please PM me. we are hiring for anesthesia also

 

[aneftp]

The chronic pain docs won’t do it (the Acute pain inpatient care). That tells you something. You will get consulted from the ER all the time in addition to the floor. I’d demand 450k-500k guarantee plus rvu

It’s a money losing service and that’s why the hospital can’t get anyone to cover it. And they won’t even attempt to pay someone to cover it.

 

[neutro]

The chronic pain docs won’t do it (the Acute pain inpatient care). That tells you something. You will get consulted from the ER all the time in addition to the floor. I’d demand 450k-500k guarantee plus rvu

It’s a money losing service and that’s why the hospital can’t get anyone to cover it. And they won’t even attempt to pay someone to cover it.

Yeah it’s money losing but it’s a service for the patients also as well as hospitalists. At least that’s the premise where they have acute pain services

Sometimes it can prevent delays in hospital discharge. Note sure if that saves money. I’m sure it does to some degree but no one from the administration will tell us how much indirect or downstream revenue is generated due to having an appropriate pain management plan in place for inpatients

 

[anaesthetic]

Yeah it’s money losing but it’s a service for the patients also as well as hospitalists. At least that’s the premise where they have acute pain services

Sometimes it can prevent delays in hospital discharge. Note sure if that saves money. I’m sure it does to some degree but no one from the administration will tell us how much indirect or downstream revenue is generated due to having an appropriate pain management plan in place for inpatients

I have no opinion on this except that this appeal to “better patient care” is how hospitals have been taking advantage of doctors and nurses for so long without shame.

F U, pay me. IMHO.

 

[aneftp]

I have no opinion on this except that this appeal to “better patient care” is how hospitals have been taking advantage of doctors and nurses for so long without shame.

F U, pay me. IMHO.

If you look at the hospital collections.
A routine hip pinning (not replacement). A surgeon gets $1500-2000 With commercial insurance. It’s a 30-45 min procedure. The hospital COLLECTS anywhere between 20-30k for a 3 stay stay. It’s an insane amount of money. And they don’t want to subsidize the cost of acute pain service.

 

[nexus73]

If you look at the hospital collections.
A routine hip pinning (not replacement). A surgeon gets $1500-2000 With commercial insurance. It’s a 30-45 min procedure. The hospital COLLECTS anywhere between 20-30k for a 3 stay stay. It’s an insane amount of money. And they don’t want to subsidize the cost of acute pain service.

of course not, that's admin's money

 

[neutro]

If you look at the hospital collections.
A routine hip pinning (not replacement). A surgeon gets $1500-2000 With commercial insurance. It’s a 30-45 min procedure. The hospital COLLECTS anywhere between 20-30k for a 3 stay stay. It’s an insane amount of money. And they don’t want to subsidize the cost of acute pain service.

I was talking to a pain physician who has a mini empire in outskirts of Dallas market with many practices and ASCs, and he routinely mentions that whatever laws hospitals operate on are outside his understanding and not sure how they were even passed. It does not happen anywhere else in any industry. The laws are non-sensical, absolutely corrupt and provide no direct benefit to the patient or physicians providing care.

 

[nimbus]

We had hospice/palliative care doing some acute pain management (even for non terminal patients) at our place a while back. But that seems to have trailed off. I don’t know who, if anyone, is doing it now.