Are we being robbed as hospitalists?

[BicepsTriceps]

Probably not too hard. But easy to find in small towns.

Even at my residency hospital, which was at one of the most desirable cities in the country, hospitalists were allowed to leave at 3pm. Patient cap was 13 but the pay was ridiculous (210k/yr).

Where is that?

I don't care about the pay I need a low census, no day admissions and appropriate acuity job.

My current job, J1 waiver job, is making me lose my mind and I can't wait to jump ship as soon as I'm liberated.

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[CCM-MD]

Probably not too hard. But easy to find in small towns.

Even at my residency hospital, which was at one of the most desirable cities in the country, hospitalists were allowed to leave at 3pm. Patient cap was 13 but the pay was ridiculous (210k/yr).

That’s a great gig

 

[Splenda88]

Where is that?

I don't care about the pay I need a low census, no day admissions and appropriate acuity job.

My current job, J1 waiver job, is making me lose my mind and I can't wait to jump ship as soon as I'm liberated.

PM sent.

 

[Splenda88]

That’s a great gig

Really! 210k/yr... I would call it a good gig if it was 250k+.

 

[CCM-MD]

Really! 210k/yr... I would call it a good gig if it was 250k+.

That would be an even better gig

 

[collegestud2013]

So I’m curious: are you responsible for doing *everything* for admitted patients, including codes and such? I ask this because wards as a resident sucked hard - I was busting my ass for an entire shift, constantly drowning in crap to do. However, my understanding is that a lot of community hospitalists don’t have to do all the crap we did as residents - they don’t do codes, they don’t admit every time they’re on, some can “round and go”, and such. That makes things much easier.

Very hospital dependent.

Some hospitals designate ED physician , ICU attending, or anesthesiologist as formally responsible for running codes, while at other hospitals it will be the hospitalist. Probably should be present if it’s your patient regardless.

How much you do as hospitalist for each patient depends largely on how good the ancillary staffing is and how much subspecialty support there is. The better places will have full support and the other specialties will largely manage a lot of the patients including putting in orders, and procedures. But you will be expected to see higher volumes and your pay per wRVU tends to be lower. In places will poor support (especially critical access hospitals) a lot more will fall on the hospitalist. The census will be lower and pay tends to be higher per wRVU.

A dedicated admitting shift allows for round and go since it leaves rounder shifts for just rounding and no responsibility for admitting. Though if you are full time, you will probably be expected to rotate through the admitting shifts (unless they can “outsource” the shift to part time or locums).

Also unless you want to be a nocturnist, try to find a place that has full time nocturnists so you won’t have to rotate on nights.

 

[FutureInternist]

Where is that?

I don't care about the pay I need a low census, no day admissions and appropriate acuity job.

My current job, J1 waiver job, is making me lose my mind and I can't wait to jump ship as soon as I'm liberated.

Come to Lovelace in ABQ
325K
Census 15-17
Day Admitter - so very few days where rounders have any admits at all
Closed ICU
No procedures
No codes
“Round and go” - We “run errands” or “pop out to pick kids up from school”… 🤫. But admin knows we are going home 😏

 

[Splenda88]

Come to Lovelace in ABQ
325K
Census 15-17
Day Admitter - so very few days where rounders have any admits at all
Closed ICU
No procedures
No codes
“Round and go” - We “run errands” or “pop out to pick kids up from school”… 🤫. But admin knows we are going home 😏

How big is the hospital? How many day admitters?

We have one day admitter, but rounders still admit one on average.

 

[FutureInternist]

How big is the hospital? How many day admitters?

We have one day admitter, but rounders still admit one on average.

250-ish beds.

One day admitter, with rounders being back up (but as mentioned before, minimal admits - maybe 2 in a 7 day cycle)

2 night admitters.

Send message for any more Qs

 

[Suprep]

jokes on you if you think outpatient IM is lucrative. yes the work hours are 35-40 hours a week but the amount of time spent on non billable work, in basket messages, patient calls, the pay is nearly not worth it. the outpatient comp in employed positions sucks just as bad. at least in hospitalist work, there is not much in basket work and if giving up 26 weekends works for you and family, it is the wiser of the 2 options.

 

[VA Hopeful Dr]

jokes on you if you think outpatient IM is lucrative. yes the work hours are 35-40 hours a week but the amount of time spent on non billable work, in basket messages, patient calls, the pay is nearly not worth it. the outpatient comp in employed positions sucks just as bad. at least in hospitalist work, there is not much in basket work and if giving up 26 weekends works for you and family, it is the wiser of the 2 options.

You're wrong here.

My outpatient IM wife works 4 days per week, 20 patients per day max, 1 hour and 40 minute lunch break. Last year we took, including holidays, 36 days off. She came within a rounding error of hitting 300k.

 

[Suprep]

You're wrong here.

My outpatient IM wife works 4 days per week, 20 patients per day max, 1 hour and 40 minute lunch break. Last year we took, including holidays, 36 days off. She came within a rounding error of hitting 300k.

good for you both. My friend from residency made 441k as outpatient IM in 2021 W2, working 4.5 days, seeing what she describes 16 patients a day. not a metro. Location is key. no point making 300k in a non metro as a hospitalist. they should be hitting 375-400k in non metros.

 

[ADr.1Day]

You're wrong here.

My outpatient IM wife works 4 days per week, 20 patients per day max, 1 hour and 40 minute lunch break. Last year we took, including holidays, 36 days off. She came within a rounding error of hitting 300k.

@Suprep & @VA Hopeful Dr
It's all in the billing huh lol ? Looks like I better have me a couple of great billers in the future.

 

[VA Hopeful Dr]

@Suprep & @VA Hopeful Dr
It's all in the billing huh lol ? Looks like I better have me a couple of great billers in the future.

No, it's all in the setup/employer

 

[Suprep]

@Suprep & @VA Hopeful Dr
It's all in the billing huh lol ? Looks like I better have me a couple of great billers in the future.

Yes employer dependent. The said friend in the post is in RVU model. I asked her how she made over 400k and she said it is coz of high complexity patient panel and higher avg billing code coz of that.

There are private practice folks making over 500k, sometimes close to million. But they wont be doing the same hours as @VA Hopeful Dr spouse and my friend.

 

[VA Hopeful Dr]

Yes employer dependent. The said friend in the post is in RVU model. I asked her how she made over 400k and she said it is coz of high complexity patient panel and higher avg billing code coz of that.

There are private practice folks making over 500k, sometimes close to million. But they wont be doing the same hours as @VA Hopeful Dr spouse and my friend.

Or they do shady stuff.

There's a FP private practice where I am that requires all patients to get a yearly physical which includes ECG, chest x-ray, and a full lab panel (all done in house of course). Over 50 you get every other year treadmill stress (again in house).

A PP internist who recently retired did his own in house echos and carotid dopplers yearly on any patients with known CV disease.

Medicine can be very lucrative if you don't mind being unethical.

 

[Splenda88]

Or they do shady stuff.

There's a FP private practice where I am that requires all patients to get a yearly physical which includes ECG, chest x-ray, and a full lab panel (all done in house of course). Over 50 you get every other year treadmill stress (again in house).

A PP internist who recently retired did his own in house echos and carotid dopplers yearly on any patients with known CV disease.

Medicine can be very lucrative if you don't mind being unethical.

Interesting. I thought PP physicians would not get reimbursed for stuff like that.

 

[sloh]

Or they do shady stuff.

There's a FP private practice where I am that requires all patients to get a yearly physical which includes ECG, chest x-ray, and a full lab panel (all done in house of course). Over 50 you get every other year treadmill stress (again in house).

A PP internist who recently retired did his own in house echos and carotid dopplers yearly on any patients with known CV disease.

Medicine can be very lucrative if you don't mind being unethical.

Is this actually reportable?

 

[VA Hopeful Dr]

Is this actually reportable?

For what?

 

[VA Hopeful Dr]

Interesting. I thought PP physicians would not get reimbursed for stuff like that.

Why wouldn't they?

 

[Suprep]

Or they do shady stuff.

There's a FP private practice where I am that requires all patients to get a yearly physical which includes ECG, chest x-ray, and a full lab panel (all done in house of course). Over 50 you get every other year treadmill stress (again in house).

A PP internist who recently retired did his own in house echos and carotid dopplers yearly on any patients with known CV disease.

Medicine can be very lucrative if you don't mind being unethical.

true. know of PP docs who do stress test, TTE and have local cardiologists read it for them for a discounted fee, the PP collects facility fee.

 

[sloh]

For what?

Against standard of care

 

[VA Hopeful Dr]

Against standard of care

Have to prove harm, and getting a yearly echo isn't hurting anyone.

I doubt there are many physicians who doing violate standard of care on occasion.

 

[sloh]

Have to prove harm, and getting a yearly echo isn't hurting anyone.

I doubt there are many physicians who doing violate standard of care on occasion.

Gotcha, was just curious bc I know pain docs can get penalized for excessive UDS (which by itself is harmless) but as you alluded to is usually tied to inapporpriate opioid prescriptions which does cause harm

 

[VA Hopeful Dr]

Gotcha, was just curious bc I know pain docs can get penalized for excessive UDS (which by itself is harmless) but as you alluded to is usually tied to inapporpriate opioid prescriptions which does cause harm

You're thinking of fraud since its a financial thing.

The PP group here gets around that by saying if your insurance doesn't cover it you're responsible for the cost.

 

[Osteoth]

Yes employer dependent. The said friend in the post is in RVU model. I asked her how she made over 400k and she said it is coz of high complexity patient panel and higher avg billing code coz of that.

There are private practice folks making over 500k, sometimes close to million. But they wont be doing the same hours as @VA Hopeful Dr spouse and my friend.

How do people get paid extra for complex patients? Just billing E/M level 5 vs level 4?

 

[Suprep]

How do people get paid extra for complex patients? Just billing E/M level 5 vs level 4?

yup higher level 5 codes based on time

 

[VA Hopeful Dr]

yup higher level 5 codes based on time

Billing level 5 as an outpatient PCP more than rarely is just begging for an audit.

 

[Osteoth]

Billing level 5 as an outpatient PCP more than rarely is just begging for an audit.

Yeah wouldn’t it be better to just bring them back every few weeks and keep billing 4s?

 

[bronx43]

Billing level 5 as an outpatient PCP more than rarely is just begging for an audit.

If you’re billing based on time and don’t see high volume then you’ll pass the audit with no issues. The problem arises when people see like 30 pts a day and bill a ton of level 5s based on time which add up to more than 24 hours in a day. If you see like 10 a day, then level 5 is certainly within reason. Whether you actually spend the whole 40-60 mins on patient care is a different story altogether.

But I agree it’s tough for a pcp to bill 5s based on MDM.

 

[VA Hopeful Dr]

If you’re billing based on time and don’t see high volume then you’ll pass the audit with no issues. The problem arises when people see like 30 pts a day and bill a ton of level 5s based on time which add up to more than 24 hours in a day. If you see like 10 a day, then level 5 is certainly within reason. Whether you actually spend the whole 40-60 mins on patient care is a different story altogether.

But I agree it’s tough for a pcp to bill 5s based on MDM.

Sure, but getting audited sucks even if you win.

 

[Suprep]

Sure, but getting audited sucks even if you win.

code appropriately and dont have to worry for fraud. IF you took 50 mins, document it. Most EMRs have traceable time one spent in the chart. will pass internal and external audit if being honest.

 

[VA Hopeful Dr]

code appropriately and dont have to worry for fraud. IF you took 50 mins, document it. Most EMRs have traceable time one spent in the chart. will pass internal and external audit if being honest.

Once again, getting audited sucks even if you win.

 

[bronx43]

Once again, getting audited sucks even if you win.

You know what also sucks? Doing the work but not being paid for it.
No one should overbill, but there’s no reason to underbill just to avoid a potential audit.

 

[Suprep]

You know what also sucks? Doing the work but not being paid for it.
No one should overbill, but there’s no reason to underbill just to avoid a potential audit.

exactly. too many ppl keep worrying too much about overcoding and end up under coding, just to be safe. Be honest, don't worry.win-win.

 

[VA Hopeful Dr]

You know what also sucks? Doing the work but not being paid for it.
No one should overbill, but there’s no reason to underbill just to avoid a potential audit.

All true, but if as a PCP you're billing level 5 on a regular basis you're almost certainly overbilling.

Or you're seeing 12 patients/day and spending 50 minutes with each one.

 

[Suprep]

All true, but if as a PCP you're billing level 5 on a regular basis you're almost certainly overbilling.

Or you're seeing 12 patients/day and spending 50 minutes with each one.

let em audit

 

[bronx43]

All true, but if as a PCP you're billing level 5 on a regular basis you're almost certainly overbilling.

Or you're seeing 12 patients/day and spending 50 minutes with each one.

I guess it depends on how “regular” it is. If you’re seeing 25 a day and 1/3rd are level 5, then it’s going to raise eyebrows, as it should.

But if you’re seeing 15-20, and 10-15% are level 5 based on time, then it’s not unreasonable.

 

[VA Hopeful Dr]

I guess it depends on how “regular” it is. If you’re seeing 25 a day and 1/3rd are level 5, then it’s going to raise eyebrows, as it should.

But if you’re seeing 15-20, and 10-15% are level 5 based on time, then it’s not unreasonable.

From a PCP perspective, that would absolutely be if not unreasonable than at minimum unusual.

 

[bronx43]

From a PCP perspective, that would absolutely be if not unreasonable than at minimum unusual.

For level 5 returns? That’s 40 mins of total time spent including reviewing records and documentation.
I’m not a pcp, but as a resident, spending 40 mins with a complex patient in GIM clinic wasn’t unusual.

 

[VA Hopeful Dr]

For level 5 returns? That’s 40 mins of total time spent including reviewing records and documentation.
I’m not a pcp, but as a resident, spending 40 mins with a complex patient in GIM clinic wasn’t unusual.

Bolded for emphasis. You've been out of training for awhile, you know how much more efficient you get - doubly so when you see the same patients over time.

I can't remember the last time I spent 40 minutes total on a patient. My outpatient internist wife occasionally will, but that's usually just the patients she can't shut up - they are rarely actually sick. She does bill those as level 5s but usually a literal handful a week at most.

The only level 5s I code are people I send to the ER, like the guy Tuesday with a hemoglobin of 3.6. Or pretty much anyone who can't keep their oxygen above 90.

 

[Splenda88]

I did not know there was level 5. We only have level 3 inpatient. I bill every admission and first progress note at level 3. After that is level 2 and rarely 1.

 

[NotAProgDirector]

I did not know there was level 5. We only have level 3 inpatient. I bill every admission and first progress note at level 3. After that is level 2 and rarely 1.

There are 5 billing levels for outpatient, and 3 for inpatient.

You need to be very careful billing a level 3 for all admissions / day 1 progress notes. If you get audited, they may find that fraudulent if it's out of alignment with the national distribution. Even if you have your notes "supporting" the code, they may assume that you have inflated your notes.

 

[chessknt]

There are 5 billing levels for outpatient, and 3 for inpatient.

You need to be very careful billing a level 3 for all admissions / day 1 progress notes. If you get audited, they may find that fraudulent if it's out of alignment with the national distribution. Even if you have your notes "supporting" the code, they may assume that you have inflated your notes.

I don't think an auditor is allowed to assume anything, the entire point of an audit is to be factual. They would have to somehow prove that your documentation was false.

And basing it off the national distribution seems pointless too--people underbill all the time out of a fear of an audit and drive billing codes down but that doesn't somehow mean that billing correctly per the level of documentation is some how inappropriate. It is like salary data where hospitals and PE firms report their low salaries to deflate the average salary then use the 'average' they have created to drag high earners down because they aren't in line with this number.

 

[bronx43]

There are 5 billing levels for outpatient, and 3 for inpatient.

You need to be very careful billing a level 3 for all admissions / day 1 progress notes. If you get audited, they may find that fraudulent if it's out of alignment with the national distribution. Even if you have your notes "supporting" the code, they may assume that you have inflated your notes.

That doesn’t make sense. If they assume you’re committing billing fraud purely based on distribution (regardless of actual documentation) then there’s no reason to even do an audit. Then, anyone who is a certain SD outside of norms will just get hit with a citation.

 

[VA Hopeful Dr]

That doesn’t make sense. If they assume you’re committing billing fraud purely based on distribution (regardless of actual documentation) then there’s no reason to even do an audit. Then, anyone who is a certain SD outside of norms will just get hit with a citation.

My understanding is that they audit if you're outside geographic norms, but they still have to find evidence of improper billing to fine.

But knowing CMS/insurance companies I wouldn't be surprised if the post you responded to is accurate as well.

 

[Splenda88]

My understanding is that they audit if you're outside geographic norms, but they still have to find evidence of improper billing to fine.

But knowing CMS/insurance companies I wouldn't be surprised if the post you responded to is accurate as well.

Well, I will be more careful in my billing now. No more all 3 for new admits.

 

[collegestud2013]

I did not know there was level 5. We only have level 3 inpatient. I bill every admission and first progress note at level 3. After that is level 2 and rarely 1.

Probably okay to bill just about all admissions as Level 3 as long as your H&P documentation has all the info that's needed for a level 3 H&P. Level 3 is the most commonly billed for inpatient H&Ps, and new admissions usually do take some effort.

Would be more careful about billing all your follow-up progress notes as level 3 since a good amount of them are level 2 (when compared to other hospitalists' billing). Especially for patients who have been there for a week and are completely stable and you're barely changing your note from the previous day. However, even for a completely stable patient that you're not changing much medically, you can still bill on time. For example you spent more than 35 minutes talking with the patient/family or talking with case manager about their discharge planning, you can still bill a level 3 even if you don't end up doing any high complexity medical decision making on that patient that day.

However, audits get are not usually triggered by just looking at any single note, but usually when your distribution of billing is much higher than the average for your practice or location.

 

[chessknt]

Probably okay to bill just about all admissions as Level 3 as long as your H&P documentation has all the info that's needed for a level 3 H&P. Level 3 is the most commonly billed for inpatient H&Ps, and new admissions usually do take some effort.

Would be more careful about billing all your follow-up progress notes as level 3 since a good amount of them are level 2 (when compared to other hospitalists' billing). Especially for patients who have been there for a week and are completely stable and you're barely changing your note from the previous day. However, even for a completely stable patient that you're not changing much medically, you can still bill on time. For example you spent more than 35 minutes talking with the patient/family or talking with case manager about their discharge planning, you can still bill a level 3 even if you don't end up doing any high complexity medical decision making on that patient that day.

However, audits get are not usually triggered by just looking at any single note, but usually when your distribution of billing is much higher than the average for your practice or location.

Billing by time got 'updated' recently--level 3 inpt f/u is like 50+ minutes now or something ****ed. All the inpatient E/M rules changed this year so you need to re learn how to play their stupid game.

 

[gutonc]

Billing by time got 'updated' recently--level 3 inpt f/u is like 50+ minutes now or something ****ed. All the inpatient E/M rules changed this year so you need to re learn how to play their stupid game.

Came here to say the same thing. You no longer have to do as much BS, but you have to take longer to do it if you're billing on time. The upside is that documentation and chart time counts now and you can ditch the statement about ">50% face-to-face", so I suspect that a lot if it is a wash.

For 2023, if billing on time, it looks like this:

99221	40 min
99222	55 min
99223	75 min
99231	25 min
99232	35 min
99233	50 min

The MDM rules loosened up a bit and are better spelled out too, so you might be doing better on MDM under the new system than the old. But you probably should have looked at the PPT or whatever training email I know your hospital sent you and made you swear under oath that you looked at before you could work a shift in January.