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I feel like I know more than most of my classmates, but still have lots of questions. First off, what's this deal with this procedural sedation? We aren't reimbursed if it's less than 16 min?
Can we talk about rvus?
- Thread starter winkleweizen
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Its always more than that. Its the total time the patient is monitored I believe. Most places have a policy where you monitor a patient at a minimum of 30 min.
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It's physician time at bedside. Most procedural sedation isn't billable by EPs.
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You are right, its physician direct contact, but its not 30 min minimum. The Cpt code is for the first 30 min, billable after 16 min minimum. After 30, its billed in 15 min intervals.
Quote Per ACEP:
Moderate Sedation codes include an initial code for the first 30 minutes of intra-service time, continuous time from meds given until your personal contact ends, (this code is fulfilled after 16 minutes is documented)
ACEP has a rather nice set of FAQs and articles on billing if you are interested.
Specific to sedation, the CPT codes-- similar to critical care-- are time based. Specifically the code you bill for is first 30 minutes of sedation (4 different codes, aged 0-5 and >5, solo provider and provider only doing section while someone else does procedure). So you need to hit 16 minutes, to go over HALF the 30 minute code, to be able to use it. The code is in increments of 15 minutes, so you'd need to go up to 37 minutes to get additional revenue.
In a similar way, critical care is billed by first HOUR, so you need to hit 30/31 minutes to claim it....
HOWEVER, you do NOT need to subtract time doing your shoulder reduction from your sedation time (the way you need to subtract time doing central line from your critical care time!)
RECOVERY TIME DOES NOT COUNT--
"these codes, as described by CPT Assistant (February 2006), “Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” - See more at: http://www.acep.org/Physician-Resou...Conscious)-Sedation-FAQ/#sthash.0WZTG3xe.dpuf"
Lastly the sedation is pre-bundled with a few procedures, most common for us being chest tubes...
Specific to sedation, the CPT codes-- similar to critical care-- are time based. Specifically the code you bill for is first 30 minutes of sedation (4 different codes, aged 0-5 and >5, solo provider and provider only doing section while someone else does procedure). So you need to hit 16 minutes, to go over HALF the 30 minute code, to be able to use it. The code is in increments of 15 minutes, so you'd need to go up to 37 minutes to get additional revenue.
In a similar way, critical care is billed by first HOUR, so you need to hit 30/31 minutes to claim it....
HOWEVER, you do NOT need to subtract time doing your shoulder reduction from your sedation time (the way you need to subtract time doing central line from your critical care time!)
RECOVERY TIME DOES NOT COUNT--
"these codes, as described by CPT Assistant (February 2006), “Intraservice time starts with the administration of the sedation agent(s), requires continuous face-to-face attendance, and ends at the conclusion of personal contact by the physician providing the sedation.” - See more at: http://www.acep.org/Physician-Resou...Conscious)-Sedation-FAQ/#sthash.0WZTG3xe.dpuf"
Lastly the sedation is pre-bundled with a few procedures, most common for us being chest tubes...
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Who cares? Just always bill > 16 minutes on procedural sedation. No one is going to audit you. I always instruct my scribe to bill > 30 minutes critical care time even if it's less than that. If they want to play games with us for our money, I'm happy to play games back.
critical care is easy to meet (it includes charting time, conversation time, consultant time, review old records time...) and hard to audit (they don't have a camera on you for these things....)
sedation time is harder to meet (you are supposed to be in the room...) and much easier to audit (most RNs have to stand there and document throughout the sedation, including start-stop times, when you leave the room, etc...). If your billing and the nursing charts frequently don't match up, it would be easy to "catch".
But i completely agree with the concept of games, and frankly I put a lot of work and potential medico-legal risk into a 12 minute sedation, is that supposed to be free??
sedation time is harder to meet (you are supposed to be in the room...) and much easier to audit (most RNs have to stand there and document throughout the sedation, including start-stop times, when you leave the room, etc...). If your billing and the nursing charts frequently don't match up, it would be easy to "catch".
But i completely agree with the concept of games, and frankly I put a lot of work and potential medico-legal risk into a 12 minute sedation, is that supposed to be free??
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Good topic.
I am paid hourly without RVU incentives at my full-time job but trained at an RVU center and occasionally work for RVUs.
All of my sedations are documented by RNs and usually RTs and honestly are rarely over 16 minutes. In residency I commonly sedated people ~30 min for ortho procedures (resident teams..) but are now much shorter. A distal radius that may have taken 20 minutes to sedate while ortho gets a "perfect" reduction now only takes ~5-10 minutes.
Because the start/stop times are documented by multiple people and clearly stated by myself (I actually do time outs and try to match times for consistent documentation) I don't feel comfortable saying that a 5 min shoulder dislocation took 16 minutes when it will be easy for an auditor to prove otherwise.
Now imo this is BS and my employer/myself should definitely be reimbursed for ED sedations, no matter how short, which with propofol combined with opioids are essential deep sedation and borderline-TIVA.. my record in residency was 75 minutes sedating a 350lb 5 ft woman post MVC with bilateral mid-shaft humerus fractures... probably should've gone to the OR.
I am paid hourly without RVU incentives at my full-time job but trained at an RVU center and occasionally work for RVUs.
All of my sedations are documented by RNs and usually RTs and honestly are rarely over 16 minutes. In residency I commonly sedated people ~30 min for ortho procedures (resident teams..) but are now much shorter. A distal radius that may have taken 20 minutes to sedate while ortho gets a "perfect" reduction now only takes ~5-10 minutes.
Because the start/stop times are documented by multiple people and clearly stated by myself (I actually do time outs and try to match times for consistent documentation) I don't feel comfortable saying that a 5 min shoulder dislocation took 16 minutes when it will be easy for an auditor to prove otherwise.
Now imo this is BS and my employer/myself should definitely be reimbursed for ED sedations, no matter how short, which with propofol combined with opioids are essential deep sedation and borderline-TIVA.. my record in residency was 75 minutes sedating a 350lb 5 ft woman post MVC with bilateral mid-shaft humerus fractures... probably should've gone to the OR.
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Another anesthesia questions. Anyone know the rvus for a hematoma block vs bier block? I usually get adequate anesthesia with either and both are quick to perform.
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Time your next sedation. The chances of you being in the room less than 16 minutes are extremely low.
First there's the 30 seconds waiting for the nurse.
Then two minutes waiting for the RT.
Then the nurse goes back out to get a second bottle of propofol, just in case.
Now you're ready to begin. You chat with the patient for another minute, then start pushing meds.
It takes 3 minutes to get the patient where you want sedation wise.
You yank on the shoulder for a couple of minutes.
Then you send the tech out for the sling he forgot. He brings it back and you get it on over a minute or two.
You stand there for another 2 or 3 minutes until the patient is following commands and talking to you.
You sign the nurses paperwork and walk out.
Total time? 16 minutes. That's pretty darn typical for me and that's assuming a quick, easy procedure. Check your watch next time. I doubt you ever have less than 10 minutes of time in the patient's room for a sedation. And if you're super fast and efficient and get done in 11 minutes, well, you're being paid very, very well to stand there for 5 more minutes picking your nose.
As far as critical care time, that counts all the time you spent on the patient except procedures. History, exam, calling a consultant. Waiting for the consultant to call back. Talking to the consultant. Putting in your orders. Doing your chart. Going back in the room and checking on the patient. Talking to the family. Talking to the nurse etc. The likelihood you spent fewer than 30 minutes on that patient is extremely low unless it was a STEMI. For those patients I go down to the cath lab halfway through the case and talk to the cardiologist for a few minutes about what he found. Boom. A legit 30 minutes.
First there's the 30 seconds waiting for the nurse.
Then two minutes waiting for the RT.
Then the nurse goes back out to get a second bottle of propofol, just in case.
Now you're ready to begin. You chat with the patient for another minute, then start pushing meds.
It takes 3 minutes to get the patient where you want sedation wise.
You yank on the shoulder for a couple of minutes.
Then you send the tech out for the sling he forgot. He brings it back and you get it on over a minute or two.
You stand there for another 2 or 3 minutes until the patient is following commands and talking to you.
You sign the nurses paperwork and walk out.
Total time? 16 minutes. That's pretty darn typical for me and that's assuming a quick, easy procedure. Check your watch next time. I doubt you ever have less than 10 minutes of time in the patient's room for a sedation. And if you're super fast and efficient and get done in 11 minutes, well, you're being paid very, very well to stand there for 5 more minutes picking your nose.
As far as critical care time, that counts all the time you spent on the patient except procedures. History, exam, calling a consultant. Waiting for the consultant to call back. Talking to the consultant. Putting in your orders. Doing your chart. Going back in the room and checking on the patient. Talking to the family. Talking to the nurse etc. The likelihood you spent fewer than 30 minutes on that patient is extremely low unless it was a STEMI. For those patients I go down to the cath lab halfway through the case and talk to the cardiologist for a few minutes about what he found. Boom. A legit 30 minutes.
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If you work or are going to work for a CMG then the RVU thing gets much muddier. My feeling is that they decide beforehand how much to pay you, and make the RVUs match this number.
A few months ago we got the yearly RVU summary, the two fastest docs, who saw the most PPH, were consistently paid the lowest RVU on a monthly basis. Very suspicious. I brought it up with my director and was told that "their practice pattern was different hence lower RVU". Bull****.
It is not a documentation issue because we have scribes and capture 99% of revenue according to what we are told by our billing folks. I have completely stopped worrying about RVUs. It's all a way to mind-screw you into thinking you re actually making money based on what you work. No way to check its accuracy since CMGs have closed books.
Your mileage may vary with an honest democratic group. Good luck finding one of those.
A few months ago we got the yearly RVU summary, the two fastest docs, who saw the most PPH, were consistently paid the lowest RVU on a monthly basis. Very suspicious. I brought it up with my director and was told that "their practice pattern was different hence lower RVU". Bull****.
It is not a documentation issue because we have scribes and capture 99% of revenue according to what we are told by our billing folks. I have completely stopped worrying about RVUs. It's all a way to mind-screw you into thinking you re actually making money based on what you work. No way to check its accuracy since CMGs have closed books.
Your mileage may vary with an honest democratic group. Good luck finding one of those.
