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How to increase your RVUs?

Discussion in 'Emergency Medicine' started by GeneralVeers, 10.21.08.

  1. GeneralVeers

    GeneralVeers Globus Hystericus

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    SDN Members don't see this ad. (About Ads)
    Like most private groups, mine tracks RVUs per patient, and per physician.

    I'd like some advice from the old-timers on how to maximize this.

    For example: 85 year old with chest pain, on NTG drip, spoke with cardiologist and primary, and patient is admitted. It's obviously a level 5 visit, but how do you maximize your billing? Note: I only want to get paid for what I actually do, not bill for "grey areas" or outright fraud.

    Obviously you'd get the 3.80 RVUs for the admission.
    Last edited: 10.21.08
  2. kungfufishing

    kungfufishing Senior Member

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    I'm no old timer - I think we are contemporaries. However, I've been looking into the same subject. I think the most significant thing I've learned thus far is critical care time is more broadly applicable than I realized and can really help us get paid for the time we spend caring for sick people. Another one is the external jugular IV. At least here, it bills like a central line, yet takes all of 20 seconds to insert (obviously, given the right circumstance, that being nursing cant get a good peripheral).

    Very interested to read the more experienced responses here.
  3. spyderdoc

    spyderdoc SDN EM Moderator Moderator Lifetime Donor

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    Well, we don't work on RVUs sice we are full FFS, but make sure to do all the basics, like documenting your interpretations of ECGs, CXRs, and all procedures.

    Make sure to bill critical care time when applicable...

    If you do U/S, document and interpret all studies (no matter how minor), and make sure to place images on the chart. If you do a central line and use U/S, document it and it will increase your billing (although not by much).

    Do your own splinting and document that you did it (major missed $$ over time if you have tech do it).

    Manipulate your own fractures if trained and comfortable doing so. Billed as fracture care, so great reimbursement.

    Do all the annoying procedures, such as ingrown nails, fecal disimpaction, and therapeutic paracentesis (sure you get a lot of these in Vegas with all the alkies), etc...

    Make sure to include a good Ddx in your medical decision making section.

    Try to add "acute" to your diagnoses...

    I'm sure there wil lbe plenty others that haven't come to mind....
  4. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    I agree with the critical care billing not being done enough. As I was told by a colleague, basically anytime you're called to a room stat, chances are you can bill for critical care time.

    In addition to sepsis, MI, etc. other things that are considered eligible for critical care: anaphylaxis (even if you discharge the patient home), acute asthma exacerbation (more than just a couple nebs; mag, epi, etc.), atrial fib with RVR, acute CHF exacerbation, active seizure, stroke, active hemorrhage.

    Also, keep in mind that you need to write certain things to bill for them. Initiation of pressors, IV drips for BP or HR control, administration of thrombolytics (big time reimbursement from what I hear), etc.

    I usually don't splint my own fractures unless I'm manipulating them. My reimbursement isn't much for doing them, and I can make more money (and have better patient satisfaction overall) by seeing another patient instead of splinting the fracture.
  5. GeneralVeers

    GeneralVeers Globus Hystericus

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    1. When initiating IV drips, is it enough to document it in "medical decision making" and have the coders find it, or do you write it is a separate "clinical impression"?

    2. I've been told that if you write "splint evaluated by physician" it's equivalent billing.
  6. doctawife

    doctawife Rocephin is for wimps

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    From the pedi side...

    Anyone who gets three back to back albuterol treatments counts as status asthmaticus, and thus allows higher billing.

    Any neonate getting blood/urine/CSF studies for fever without localizing source is a five. FWLS work ups might be routine for the pedi ER, but they qualify for level five billing secondary to medical decision making. And document the LP while you're at it.
  7. TysonCook

    TysonCook Senior Member

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    I'm still in residency but you can bill time with critical care INCLUDING discussions with family re: the patient (not status updates). So all that time you spent on the phone or in the consult room speaking w/them about pmhx etc you can bill for.

    Also, everyone that smokes gets a 3 min rundown on why/how to stop (total not all at once), and offered a patch/gum Rx, on DC is the phone # for smoking cessation. When you see 5+ patients a day that smoke, it adds up.
  8. Aloha Kid

    Aloha Kid Senior Member

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    This is a great topic. Has anyone attended any worthwhile courses on coding and billing for the average EP?
  9. BADMD

    BADMD

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    I've upped my RVUs by ensuring complete documentation of painful conditions (PQRST). Also by adding a multi-element differential diagnosis to the MDM you ensure highest complexity. Not to mention that the diagnosis can affect your final code. Giving a diagnosis of "Chest pain" will likely only give a level 4, while "Unstable Angina" can result in a 5.

    My chest pain documentation for possible MI/ACS usually includes a standard 7 life threatening causes of chest pain, plus MS pain. Between clinical impression, CXR, and ECG and trop, I can usually honestly dictate them as ruled out. Don't forget to document reasons for ordering things like lytes.

    Documenting you looked at the xray gives you one point in complexity. Documenting that you discussed it with radiology gives a second point. Reviewing old records is also another point. So that gives an easy 3 points to the complexity score. Tack on labs and ECG and you are golden.

    Don't forget the critical care codes. Anytime you use an antidote, you can bill for critical care (if you spent enough time). So naloxone and NAC can open billing doors.
  10. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Make sure you have enough elements covered in your ROS and PE to justify your level. Our most frequent downcodes are from missing these.

    A word of caution on critical care. You MUST have spent more than 30 minutes on the patient SEPERATE for your procedures to bill this. If you have a AMI who rolls in and out to cath in 29 minutes you can't bill the critical care time. If you have a patient who comes in and you tube them and do a central line and they go to the OR or ICU or whatever you need to document that you put in >30 min excluding the time spent on the procedures.
  11. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Remember, it's not time spent with the patient, but time spent involved in patient care, including documentation. If the patient goes to the cath lab in 20 minutes, but you spend another 10 minutes reviewing labs, documenting, discussing with the primary care physician (notifying him/her the patient went to the cath lab), notifying the family, etc., then you can bill for critical care time as this often exceeds 30 mins.

    Veers, it depends on your coders where you document. At one of my hospitals I have to write "dehydration requiring IV fluid rehydration" as a diagnosis to get reimbursed. At another hospital, it's ok to write IV fluid rehydration or drips in the medical treatment area. The coders will find it. (We get reimbursed for IV fluid rehydration if we give at least 2 liters. Not sure if Medicare reimburses for this anymore, but my group does on our productivity model.)

    Tyson makes a good point. Smoking cessation counseling is now a reimbursable diagnosis. You must document the time spent, and you must document "tobacco abuse" as a diagnosis as well as documenting your counseling. This reimbursement is provided by the tobacco industry and not the insurance industry (I think big tobacco reimburses the government and insurers).
  12. met19

    met19 Member

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    this is an interesting subject. i am training at big county institution where billing isnt a huge issue since alot of the pts are uninsured.
  13. beriberi

    beriberi Senior Member

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    Always document and interpret the O2 sat (i.e. 98% on Ra, NL) -- I am told under our model this works out to around $7.50/pt -- nice to think that I can lay claim to an extra $150/shift (more than I made on a shift in residency). The billers may only count it on the patients that it is relevent, but the thought makes me happy.
  14. kungfufishing

    kungfufishing Senior Member

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    our folks would not let me get paid for this (?) but it sounds like others do - I know I saw it in a USC lecture online, too.
  15. Jeff698

    Jeff698 Chief Resident

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    How broad can you go with your differential when the presentation is really obvious?

    Take care,
    Jeff
  16. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    If it's a slam dunk pneumonia, you could dictate things such as "Consideration was given for cardiac cause, PE, and pneumothorax. The patient is low risk for PE as the Wells score is 0. The pain is pleuritic which makes it less likely cardiac."

    That's how I do it. I don't really dictate "differential includes" but instead will mention why I think certain things are less likely. Even a slam dunk finger laceration can have a good MDM component by documenting why you think the finger isn't broken, how dirty the wound is, risk of infection, etc.
  17. jendc08

    jendc08 Member

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    I know this thread has been dead for awhile, but does anyone have any books or articles they can recommend for increasing billing/rvus?
  18. TrumpetDoc

    TrumpetDoc

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    I have tried a few things thy are VERY simple that a friend told me.
    And this is specific for dictating.

    I add a lot of paragraph breaks where you want coders to know about. I.e. paragraph> monitor interpretation: ...
    Paragraph DDx: 1-3

    I also add DDx (3 needed for level 5 if I recall) even for little stuff. DDx: acute Fx, Sprain, contusion, etc.
    Simple lac, complex lac, tendon injury, etc..

    Monitor interp is an easy on to add complexity.
    Put pads on your Stemi's valid bc of VF/VT risk, and adds $

    I have seen my RVUs O
    Per PT go up significantly by using these and all others mentioned above.



    Sent from my iPhone using Tapatalk
  19. Groove

    Groove Member

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    hmm, thanks for those...
  20. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    How does putting pads on increase charges if you do nothing with them?
  21. EM_Rebuilder

    EM_Rebuilder Member

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    Got this in the mail today and thought of this thread: http://www.acep.org/MeetingHome.aspx?MeetingId=RC1

    Groove, I think something like that is an overkill for you (or me for that matter). Good billing and such is important, but focus on residency and then get BC out of the way.. then start thinking about this stuff. Unless you are at a shop that is 100% RVUs, the fact that you document the oxygen, etc does not mean a whole lot anyways....


    In the mean time, great suggestions on this thread and a few I will implement.... even though only about 15% of my pay is 'changed' by my RVUs...
  22. TrumpetDoc

    TrumpetDoc

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    Not sure exactly if it itself adds $$&
    Just going off lecture we had back in residency. Told van bill for pacing just "setting" up go it and documenting why.
    I plan on going to a course to learn more and confirm/ debunk.

    Seems to be working well for me though.



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  23. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    I have found that there are a lot of things that you can document that are presented by coders as "adding RVUs" when the truth is more murky. In many of these cases the additional documentation adds to the justifiable complexity of the case and helps prevent it from being downcoded. The billers/coders care a lot about downcodes because it's one of their metrics for quality. It won't actually directly add RVUs as with monitor or O2 sat interpretations.
  24. Arcan57

    Arcan57 Junior Member

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    It's plus/minus on whether you'll get reimbursed for the pulse ox or monitor interpretation depending on the payor.
  25. GeneralVeers

    GeneralVeers Globus Hystericus

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    My understanding so far is that it's relatively simple as far as standard medically-based charts.

    Charts are billed as a level 1 through 5, with a 99285 being the highest reimbursement. The levels are the "complexity" of the patient with most admissions being level 5.

    The more difficult part of charting comes with the specific diagnosis. For example documenting "uncontrolled diabetes" as a diagnosis pays more than "hyperglycemia". Likewise "rib fracture" pays more than a "chest wall contusion".

    Finally, procedures can buff up your RVUS more. Commonly missed procedures that we can bill for are: ultrasound-guided peripheral IV access, NG-tube placement, and personally supervising splint placement.
  26. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    That's true but it either pays or not. It doesn't play into the complexity to justify level stuff beyond being another data point.
  27. newschooldoc

    newschooldoc

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    I've heard the following, (with the disclaimer I haven't verified any of it);
    1. hip reductions are buku RVUs, (often cherry pickers grab this chart)
    2. anoscopy bills almost as many RVUs as direct laryngoscopy, (if you already have to do a rectal)
    3. acute bronchitis as a diagnosis rather than cough raises level three to four (everything else being equal)
    4. IM toradol increases back pain level three to four (not sure why)
    5. spontaneous vaginal delivery is so many RVUs it's almost worth doing
    6. placing foleys by MD is decent RVUs, (if the shift is slow, I've also found it wins you HUGE RN points)
    7. Any time you order an ABG consider billing it as critical care time.
    8. If you write "definitive fracture care provided" for fractures such as distal phalynx RVUs go way up just with these four words. (assuming closed/non-operative fracture)
    9. I was told three minutes of tobacco cessation was included automatically in any visit, if you want to bill more you need to specifically say 3-10 minutes of counseling was provided, (and include "tobacco use" as a diagnosis). I also hear this can get you/your group in trouble with your community PCPs
  28. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Good questions. One thing I have noticed over the years is that many of the things we hear stated as fact seem to change or turn out to be wrong. Every time I have a meeting with our billing company it seems that I don't know as much about how they code stuff as I thought I did. So take any answer I give with a grain of salt.

    Don't know about this. Is it because it's a hip as opposed to a shoulder?

    I could see that being true.

    That is likely true. I diagnose complicated bronchitis if I'm giving antibiotics. If not then I diagnose viral URI. It's been a chore to get the MLPs in sync with this but it's important to make the chart and diagnosis match the plan. They frequently diagnose viral syndrome and want to give a Zpack. I have to get them to go back and change it. If it's viral then no abx. Even if it's complicated bronchitis abx are barely indicated but sometimes you gotta feed the beast.

    I hate Toradol. Too expensive and nephrotoxic for what it is. That's a step I probably wouldn't take especially if it's just to upcode.

    Unless it reimburses a billion dollars it's not worth doing for me. I'll keep holding the elevator door so they can roll up to L&D.

    Anyone know how much it reimburses?

    Consider it but be careful. I know people who have been audited for critical care billing and it's not pretty. If you're really changing therapy or managing NIPPV then go for it (if they're tubed or likely to be tubed then CC is indicated). If you're just checking on an asthmatic who then tunes up and goes home then I'd be reluctant to bill CC (or get the ABG in the first place).

    I have heard this as well. I have also heard there is a time component where if you recommend follow up in less than 48 hours the ortho gets to bill for the fracture care and if it's over 3 days we get it.

    This may become a bigger issue and the OIG continues to crack down on everyone. You know how orthos love to say how they don't need to see it for a week or two? I bet most of them still bill for the fracture care. I think this hasn't been a problem because we tell everyone to follow up in 2 days no matter what they say. But now that we're all trying to capture this stuff CMS would see 2 bills for the acute fracture care. This may get interesting.

    I have heard the part about the time frames as well. I can see how it might cause an issue with the PMDs.
  29. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

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    Document what you do, and learn what pays more. This thread has a good list. It does help to document the stuff you're already doing, like calling consultants, PCPs, family members, nursing homes etc. Also checking old records and the controlled substance database. It all adds to the complexity of the case.

    Missed critical care is huge. They don't have to go to the ICU (or even be admitted) for it to be critical care.

    Splints are also huge. I am curious as to whether checking them pays the same as actually doing them.

    We do the 3+ minutes of tobacco cessation counseling. I wish I could get that for alcohol, prescription meds, and drugs of abuse too. I spend far more time counseling about narcotics, and I'd like to be able to bill for it.

    Obviously documenting the procedures you'd need to do anyway- reductions, intubations, chest tubes, central lines, probably peripheral lines if you have to do them. Remember that ultrasound guided anything pays more (I've heard up to 3 times as much.) Why not use it while doing central lines, LPs, peripheral lines etc?

    It's all a balancing act, because time spent billing and extraneous things is time not spent seeing another patient. But if you're in a shop like mine where we're currently only seeing 1.4 an hour, you really want to take the time to maximize the billing on each patient. Or, if you prefer, you can just make less money for the same amount of work. You pick.
  30. The White Coat Investor

    The White Coat Investor AKA ActiveDutyMD Partner Organization

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    Better yet, figure out a way to spend another minute on the patient. Remember phone calls, thinking, charting, taking history, looking at the x-ray, examining, walking down to the cath lab to see how it went etc all count. (The 3 seconds you spent reading the EKG don't, of course, but you get $12 for that anyway.)
  31. Apollyon

    Apollyon Screw the GST Lifetime Donor

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    5 years ago, I was told NOT to put that, because ortho on followup can't bill for it then. Specifically, we were warned against it.
  32. StevieStud

    StevieStud

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    Unless it reimburses a billion dollars it's not worth doing for me. I'll keep holding the elevator door so they can roll up to L&D.

    Hold the door?

    Hells Bells said my mentor, I will carry her 300 lb arse up 2 flights of stairs if I have to.
  33. Arcan57

    Arcan57 Junior Member

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    The OP is quite old, but the patient he's describing would be critical care because of the nitro gtt (vasoactive gtt requiring titration).
  34. Zanegray

    Zanegray

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    Bump!

    Any recent info on RVUs? Where should I go or who should I talk to to find out what is important at our joint? There is a lot of "I've heard that...". But I'm not sure what is really real...
  35. shopsteward

    shopsteward

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    Try talking to the coders? Perhaps set up a formal session through whoever manages them where you can learn what their issues are, what works for them and what doesn't?
  36. Arcan57

    Arcan57 Junior Member

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    ACEP has tons of RVU talks. If you work for a CMG, they have people whose sole job is ensuring maximized appropriate billing. If you're out on your own, talk to the coders although they may or may not be up on things depending on their experience and level of investment.

    I don't have any super secret tips for increasing RVUs, but common areas that are missed are:

    1) Not documenting all 3 of the PMHx, SH,FamHx triad (lose level 5 billing).
    2) Not having a ten-point ROS or an attestation that all other systems were reviewed and were negative.
    3) Not billing for splinting - splinting pays ridiculously well for time invested, as the payment is the same regardless of the material used in the splint. A leather and plastic pre-fab thumb spica bills the same as a lovingly hand-crafted plaster splint. However, you have to document a post-application exam to get credit.
    4) Critical care - we do tons of critical care that we don't consider as such because it's routine for us. Bolus vaso-active meds for unstable vitals or titratable drips are almost always appropriate for critical care. Asthma w/ initial respiratory distress and 3 back-to-back nebs with reassessments is widely accepted as crit care, even if they go home. Billing <30 min of crit care can be useful since it bypasses the documentation requirements needed for a Level 5 chart. So on the CPR came in dead, stayed dead billing crit care avoids the necessity of documenting SocHx, ROS, etc.
    5) If you are unable to complete the history or physical due to anything other than the patient speaking a different language, if you document as such you are excused from being held responsible for them.
  37. FSU2013

    FSU2013

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    First, let me apologize if this question is dumb or has been answered elsewhere (hey, at least I didn't start a new thread, right?), but what exactly is required to bill for U/S? One of my attendings said he can't because the U/S machines in the ED can't print. Is there any specific certification an EM physician needs to get reimbursed for this, or are all EM MDs eligible to bill for this? My understanding is that you don't need to have an U/S fellowship, right? Basically, is there anything I need to know concerning U/S training in residency that I should be asking about during interview season.....I don't want to come out of training and hear "well, you can't bill for that because you only did X weeks of U/S not Y, or you didn't sit through whatever random joke course so that you are technically certified to do it.

    Thanks!
  38. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Good question. I'm not an expert on this so you'll probably get better responses from others but I don't think printing is a requirement. I suspect he just means that you need to archive the images. We do this by storing them on the hard drive and then dumping them periodically into the rads storage. Some of our US machines WiFi the studies into storage automatically.

    You don't have to be fellowship trained. You do have to be credentialed in your hospital based on whatever criteria they use for credentialing.
  39. FSU2013

    FSU2013

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    But that is something you do at the hospital you work at as an attending, not a resident, right?

    Thanks!
  40. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Yes, we bill for US.
  41. tkim

    tkim D-d-d-dilaudid

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    Physician SDN 10+ Year Member
    You need to attach hard copy or electronic image of US study to be able to bill for it.
  42. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

    Joined:
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    Just to clarify for my own knowledge when you say "attach" you mean that it has to be available right? You can reference it in the documentation and that's enough?
  43. jendc08

    jendc08 Member

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    How do you attach it to an emr chart?
  44. Hercules

    Hercules Son of Zeus

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    Mobile, AL
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    Yes, just make sure it's there in case of an audit.
  45. EvoDevo

    EvoDevo Sm00th... Moderator Emeritus

    Joined:
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    Land of Female Abdominal Pain...
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    Even with emr's, there is still going to be some sort of paper face sheet, ecg's, etc. You can print the image and put it in there....
    Last edited: 09.09.12
  46. EctopicFetus

    EctopicFetus Keeping it funky enough

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    Maybe where I worked the practice was different. You just have to have a QI process.. you dont need to print it for proof. You can simply save it on the machine as long as at some point it gets pulled.
  47. Khaos

    Khaos I beat the game, now what

    Joined:
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    Rylos
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    SDN 7+ Year Member
    Since I have been an attending for a year, RVU's is something that I have focused on. I started the first three months with an average RVU/patient at 3.5 and gradually increased to 4.45 - 4.5/patient. In all honesty the same type of patients, just better documentation. In my 3rd year of residency I went to the ACEP RVU stuff and this year I went to a couple of RVU things...

    First, remember the basics. It's been said here, but let me reiterate. Always have PMH, surgical, and social. When a patient has pain, do your PQRST crap...we learned it in medical school...now we can bill for it. Always remember all of the HPI and review of systems. I have a set, memorized review of systems that I ask everyone so I don't have to worry about not hitting the 10 systems on one that ended up admitted or something. Unless it is a toothache that is obvious, I ask my memorized crap. For physical exam, document everything you do and make sure you do eight systems. Remember, just looking at them when you talk you can tell there's no d/c or erythema from the eyes, CN II - XII are grossly intact, if they are in distress or not (that's 3 systems right there).

    Crit Care makes a huge difference. Using the mantra of "if I left the patient alone, they could die" is a great way to determine if crit care can be billed. We all understand the obvious intubated, hypotensive patient. Don't forget you can't bill crit care and for a procedure so you have to time it differently. If you spent 10 minutes intubating someone, it's not crit care...but the 10 minutes in the room listening to the patient, watching the vitals, having the resp therapist come down, the nurses getting the crash cart and meds do...We usually get those but the problem is the ones that aren't too sick but aren't great either. A pyelo in a young girl that has a HR of 120 on arrival with temp of 101 but after a bolus or two, tylenol, abx her HR is now 80, BP is normal, temp is normal and she is healthy and you d/c home she is still crit care. If you left her alone she could've crumped (wouldn't have been right away because young and healthy but definitely would've). An asthma patient that has O2 sat 93%, RR 24 and wheezing like crazy but after 3 nebs, steroids and such...and now they are at their baseline and everything normalized, it is still crit care even if you d/c home. If I left that person alone for another hour or two they wouldn't have made it. We do a horrible job billing for crit care and miss so many opportunities.

    Procedures are easy ways to get RVU's but we all knew that already and it usually isn't a problem when it comes to billing since we usually remember to document those.
  48. diphenyl

    diphenyl Dancing doctor

    Joined:
    07.31.08
    Messages:
    280
    Location:
    Ca
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    Attending Physician
    SDN 5+ Year Member
    Most often missed billable procedures:

    -Ultrasounds including fast scans.

    -Mentioning ultrasound when using it as part of a procedure such as a central line

    -injections. This included pushing certain meds during procedural sedation. (in my shop only the doc's themselves can push diprivan)

    -under billing of critical care time. This is one of the most common things missed. Anyone with serial breathing treatments, needs CC documented. Same goes for any drip, anybody whom is cardioverted (chemically or electrically.)

    -serial cardiac monitoring and pulse oximetry monitoring. (need at least 2 documented readings to bill)
  49. tkim

    tkim D-d-d-dilaudid

    Joined:
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    What I meant to say but haven't succeeded in doing is that the image must be retrievable in some way - either a hard copy in the chart or an archived image in PACS.

    It isn't enough to say "imaged GB blah blah".
  50. tkim

    tkim D-d-d-dilaudid

    Joined:
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    We place US guided central lines, but cannot bill for them as such because we have no way of archiving the image.

    http://www.acep.org/Content.aspx?id=30502

    FAQ 4. What documentation is necessary for the coding of emergency department ultrasound examinations?

    For each ultrasound service performed/coded, the following is necessary:


    Interpretation &#8211; a written interpretation and report must be completed and be maintained in the patient's medical record. The report must describe the structures or organs studied and supply an interpretation of the findings.

    Medical necessity &#8211; the medical record documentation must indicate why the test was medically necessary.

    Image Retention &#8211; appropriate image(s) with measurements when clinically indicated of the relevant anatomy / pathology must be permanently stored and available for future review. Please note that an image is now required for all procedures performed with an ultrasound.

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