modifiers and RVUs

[oreosandsake]

I track RVUs at my job

I am not sure how to track when i do a bilateral procedure. ex SIJ injection 27096, and when it is 17096-50

also, i have done bilateral genicular nerve blocks and it ends up billing as 64450 x6 + 77003 or 76942
it ends up looking like a lot of rVUs. anyone know how many peripheral nerve blocks get "paid" before they drop off? (like TFESI 64483, 64484, etc)

thanks

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[Ducttape]

Mod 50 is roughly 50%. The add on codes tend to be less.... Look at ASIPP fee schedules


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[ampaphb]

77002, not 77003. Your biller should use 77003, fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures when you are doing procedures in the spinal region.

 

[lobelsteve]

https://www.aapc.com/practice-management/rvu-calculator.aspx

 

[gasorrad]

The link does not show what happens when you add modifier 50 when we are doing bilateral procedures. It sounds like the reimbursement falls when we do bilateral procedures but is the wrvu less when we do bilateral procedures?

 

[SSdoc33]

yeah, hospitals generally try to f$ck you with the contralateral/bilateral side. you get 50% on that side. TFESIs, facets, SIJ, etc. if you do 2 levels on the same side, it "counts" more than a bilateral in terms of RVUs .

i dont have the numbers in front of me. i calculated it out one time..... makes you want to do a do a lot more unilateral procedures. but, if a patient has bilateral pain, i dont have the stones to make then come back for twice the number or injections. i just do it all at once.

 

[freddydpt]

Bilateral procedures double the wRVU of the code. Period. If anyone tells you otherwise they are trying to screw you or have been screwed in the past.

 

[Ducttape]

Bilateral procedures double the wRVU of the code. Period. If anyone tells you otherwise they are trying to screw you or have been screwed in the past.

really...

you must have a nice work situation.

insurances typically only pay for 150% of the fee allowance for mod 50... whoever is determining your wRVU is being especially nice if they are giving you 2x wRVU for something that pays 1.5x

http://www.beckersasc.com/asc-codin...-to-asc-and-physician-practice-modifiers.html
https://www.aapc.com/memberarea/forums/82131-rvu-report-physician-practice.html

(United Healthcare is not one of the nice ones): https://www.unitedhealthcareonline..../ReimbursementPolicies/MPR_MultProc_2011A.htm

 

[freddydpt]

really...

you must have a nice work situation.

insurances typically only pay for 150% of the fee allowance for mod 50... whoever is determining your wRVU is being especially nice if they are giving you 2x wRVU for something that pays 1.5x

http://www.beckersasc.com/asc-codin...-to-asc-and-physician-practice-modifiers.html
https://www.aapc.com/memberarea/forums/82131-rvu-report-physician-practice.html

(United Healthcare is not one of the nice ones): https://www.unitedhealthcareonline..../ReimbursementPolicies/MPR_MultProc_2011A.htm

Speaking strictly from an RVU perspective the 50 modifier doubles the RVU calculation. Some employers use the reimbursement at 50 percent to lower the docs RVU reimbursement if on an RVU model. It's a manipulation technique used by both sides. I've met docs who only do bilateral injections for that reason. Not cool on their part either.

 

[BobBarker]

Looking at my production sheet, it looks like they are doing both. They have a 20610-50 as .79x2 and SI joints -50 as 1.5x 1.48=2.22

Looks like overall they definitely do the latter much much more than the former. Maybe it depends on how they guess the billing will go?

@lobelsteve
Steve, what do they do for you?

 

[y2janitor]

For me, it is 50% of the original code

 

[gasorrad]

So it looks like there might be a difference between strictly wRVU vs reimbursement. wRVU may be doubled but reimbursement is not. I have a wRVU bonus model but not sure if they change it to reflect reimbursement.

 

[Ducttape]

Speaking strictly from an RVU perspective the 50 modifier doubles the RVU calculation. Some employers use the reimbursement at 50 percent to lower the docs RVU reimbursement if on an RVU model. It's a manipulation technique used by both sides. I've met docs who only do bilateral injections for that reason. Not cool on their part either.

um...

im saying that insurances pay 150% of unilateral procedure. 1.5x, not 2x.

if you are lucky, then your employer is doubling the wrvu, and they are getting paid less than they are paying out. this is a disconnect, not a manipulation, but mostly because your employer is too, er, stupid to know that they arent getting paid the full amount.

 

[pastafan]

um...

im saying that insurances pay 150% of unilateral procedure. 1.5x, not 2x.

if you are lucky, then your employer is doubling the wrvu, and they are getting paid less than they are paying out. this is a disconnect, not a manipulation, but mostly because your employer is too, er, stupid to know that they arent getting paid the full amount.

They could hypothetically be paying out more in pro fee than they are getting but they are cleaning up on the facility fee. Stupid or crazy as a fox.

 

[oreosandsake]

i had the patient come back in today to discuss the next step

i pulled out my US probe to see if I could see the sacral hiatus. those of you who have seen this under US know that it is a very simple landmark to find. what I found made me feel much better about what happened under fluoroscopy. interestingly, she did have a very arthritic coccyx. the closest thing that looked like a sacral hiatus had a tiny aperture. the right side cornu was much more elevated (superficial) than the left, not only rotated, but oddly arthritic. the patient did have history of coccyx fracture. she told me she had fallen really hard on her tailbone at one time in her life and had a big bruise on her bottom that took weeks to heal. the small ligament covering the only thing that appeared to be the entrance to the hiatus was very small. typically, when I do caudals I come in very flat. i think the only way to get into this one would have been to come in nearly perpendicular to the skin, and be satisfied.

anyhow... I am going to do bilateral TFESI probably at L5 (she has acute on chronic bilateral L4, L5, and S1 radiculopathies) and now am consenting people for "lumbar epidural steroid injection" - do you guys think that is reasonable? (I used to get very specific, Left L4 TFESI...)

separate Q, a friend suggested I do a interlaminar above the surgery, and go retrograde with a catheter... again, something I have never done. thoughts?

 

[lobelsteve]

i had the patient come back in today to discuss the next step

i pulled out my US probe to see if I could see the sacral hiatus. those of you who have seen this under US know that it is a very simple landmark to find. what I found made me feel much better about what happened under fluoroscopy. interestingly, she did have a very arthritic coccyx. the closest thing that looked like a sacral hiatus had a tiny aperture. the right side cornu was much more elevated (superficial) than the left, not only rotated, but oddly arthritic. the patient did have history of coccyx fracture. she told me she had fallen really hard on her tailbone at one time in her life and had a big bruise on her bottom that took weeks to heal. the small ligament covering the only thing that appeared to be the entrance to the hiatus was very small. typically, when I do caudals I come in very flat. i think the only way to get into this one would have been to come in nearly perpendicular to the skin, and be satisfied.

anyhow... I am going to do bilateral TFESI probably at L5 (she has acute on chronic bilateral L4, L5, and S1 radiculopathies) and now am consenting people for "lumbar epidural steroid injection" - do you guys think that is reasonable? (I used to get very specific, Left L4 TFESI...)

separate Q, a friend suggested I do a interlaminar above the surgery, and go retrograde with a catheter... again, something I have never done. thoughts?

Your friend should learn how to be better at tfesi.

 

[Ducttape]

I'm not sure that consent would be specific enough in certain states.

It's too specific for me at the current ASC I'm at. A "lumbar epidural" prompts the nurses to open that specific kit with the 20 ga Touhy....


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[lobelsteve]

My hospital has the same consent form for any procedure whether inpatient or outpatient. The procedure or surgery is left blank until pre-op or for procedure as part of the time out. It matters little what is on the consent as the consent states that procedure may be changed depending on what happens in OR or procedure suite.

 

[SSdoc33]

i had the patient come back in today to discuss the next step

i pulled out my US probe to see if I could see the sacral hiatus. those of you who have seen this under US know that it is a very simple landmark to find. what I found made me feel much better about what happened under fluoroscopy. interestingly, she did have a very arthritic coccyx. the closest thing that looked like a sacral hiatus had a tiny aperture. the right side cornu was much more elevated (superficial) than the left, not only rotated, but oddly arthritic. the patient did have history of coccyx fracture. she told me she had fallen really hard on her tailbone at one time in her life and had a big bruise on her bottom that took weeks to heal. the small ligament covering the only thing that appeared to be the entrance to the hiatus was very small. typically, when I do caudals I come in very flat. i think the only way to get into this one would have been to come in nearly perpendicular to the skin, and be satisfied.

anyhow... I am going to do bilateral TFESI probably at L5 (she has acute on chronic bilateral L4, L5, and S1 radiculopathies) and now am consenting people for "lumbar epidural steroid injection" - do you guys think that is reasonable? (I used to get very specific, Left L4 TFESI...)

separate Q, a friend suggested I do a interlaminar above the surgery, and go retrograde with a catheter... again, something I have never done. thoughts?

? acute on chronic bilateral L4, L5, and S1 radiculopathies? 6 radiculopathies? ummm....no

electromyographer got a little trigger happy with his needle and diagnosis.

this is a LOL with stenosis. most likely central stenosis at L4-5. bilateral L5 TFESI and be done with it. not sure why interlaminar or caudal ever enters the equation. intelaminar after surgery is not a good idea, and a caudal so far away from the level of stenosis is not smart, either

 

[Ducttape]

My hospital has the same consent form for any procedure whether inpatient or outpatient. The procedure or surgery is left blank until pre-op or for procedure as part of the time out. It matters little what is on the consent as the consent states that procedure may be changed depending on what happens in OR or procedure suite.

NY state "rules" fwiw"

NEW YORK STATE SURGICAL AND INVASIVE PROCEDURE PROTOCOL

A. SCHEDULING
Scheduling must include:
1. Entire procedure, exact site, level, digit, and side/laterality (including spelling out "Left", "Right" and "Bilateral" – no abbreviations other than C-Cervical, T-Thoracic, L-Lumbar, S-Sacral when identifying spinal levels – e.g. L4-5).
2. Specific information on implant/implant system and/or equipment.
3. Specific information on removal of device.
4. Information on harvest and donor sites.
5. The Operating Room (OR), or the person responsible for accepting requests to schedule procedures, must verify the information provided by the surgeon/physician. The information should be verified in a manner agreed to by both the institution and physicians (read-back, fax, e-mail, etc).

B. CONSENT DOCUMENT
Consent documentation must include:
1. First and last name, date of birth of patient and medical record number of the patient.
2. Name and description of surgery or procedure in terms that are understandable to the patient (correct site/side, level and digit with the side spelled out as "Left", "Right" or "Bilateral").
3. No acronyms or abbreviations (except spinal levels noted in section A above).
4. Specific implant/implant system to be placed or device to be removed.
5. Patient/family/guardian/health care agent signature and date.
6. Witness signature and date.
7. Physician signature and date.
8. If the consent is altered or illegible it must be re-done and re-signed by all parties.

 

[lobelsteve]

NY state "rules" fwiw"

Vote for more of the same right?

 

[Ducttape]

if you are talking politics... Pataki (Republican) I believe was the governor when these regulations were passed.

The State Senate that year was predominantly Republican, as it usually is, and the Assembly is historically Democratic.

 

[gasorrad]

Wanted to bring up this again. For bilateral procedures they had been only crediting me for unilateral wrvu. When I brought this up, they are talking about giving 1.3X wrvu for bilateral procedures. Is this fair? Is this what most people are getting?

 

[lobelsteve]

I think you're getting hosed. They're getting 1.5 times for you, plus all other fees.

 

[Ligament]

Bilateral procedures double the wRVU of the code. Period. If anyone tells you otherwise they are trying to screw you or have been screwed in the past.

No way. We get paid 50% less for the other side. Its a rip off.

 

[DOctorJay]

does anyone have an excel spreadsheet to tabulate wRVUs? I want to keep closer tabs on my numbers and although the AAPC site Steve posted above is very helpful it still is clumsy to use (have to multiply by 1.5 for bilateral procedures, only has 10 input slots).

 

[kstarm]

Yes I am interested as well