ELI5: Radiation Oncology RVUs

[MansionMD]

Can someone please explain like I'm 5 years old:

How many RVU is each common Rad Onc physician task/encounter worth?

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[elementaryschooleconomics]

Our E/M wRVUs are the same as they are for all specialties.

The radiotherapy specific codes (77xxx) vary tremendously, from 0.45-11.87 (I think that's the range).

There's no easy/generic way to answer your question. I'm assuming you're asking because it appears like there's a mismatch between patient volume and wRVU amount compared to something like Pediatrics?

When a patient receives a course of radiation, there are a significant amount of "behind the scenes" steps in treatment planning and delivery which are billed with their own codes. Even then, you can't assume that a patient who comes for a 10-fraction course generates more wRVUs than a patient who comes for a single fraction (as in, a 10 fraction complex isodose case with 1 or 2 simple beams compared to radiosurgery).

I could SUPER ballpark you an answer and say, not counting E/M, that perhaps each course of radiation is 20-40 wRVUs. But...eh. Maybe not.

 

[Lamount]

There are very detailed lists of wRVU allotments for ~20 or so frequently billed RT codes (likely floating around business forum). There is a lot of nuance. What I have below is a broad generalization based on my practice… and I anticipate that some may disagree with my assertions.

Generally, there are two main sources of wRVU in rad onc: planning and delivery

1) planning: a 3D case will generate 10-15 RVU, IMRT will generate 15-20

2) delivery: a good chunk of RVUs for most patients will come from OTVs and CBCTs. Any given non stereotactic patient under treatment with daily CBCT will generate ~7-7.5 RVU between their weekly OTVs/CBCTs

For me, a typical IMRT stage III NSCLC getting 6 weeks CRT case will generate somewhere between 55-65 RVU

3) SBRT is different -you don’t bill for OTVs or CBCT, there is a flat rate for delivery. Between planning and delivery, SBRT will usually generate 25-30

4) E&M: consults and follow ups generate surprisingly few RVU compared to planning and delivery… and are an afterthought for me.

 

[elementaryschooleconomics]

There are very detailed lists of wRVU allotments for ~20 or so frequently billed RT codes (likely floating around business forum). There is a lot of nuance. What I have below is a broad generalization based on my practice… and I anticipate that some may disagree with my assertions.

Generally, there are two main sources of wRVU in rad onc: planning and delivery

1) planning: a 3D case will generate 10-15 RVU, IMRT will generate 15-20

2) delivery: a good chunk of RVUs for most patients will come from OTVs and CBCTs. Any given non stereotactic patient under treatment with daily CBCT will generate ~7-7.5 RVU between their weekly OTVs/CBCTs

For me, a typical IMRT stage III NSCLC getting 6 weeks CRT case will generate somewhere between 55-65 RVU

3) SBRT is different -you don’t bill for OTVs or CBCT, there is a flat rate for delivery. Between planning and delivery, SBRT will usually generate 25-30

4) E&M: consults and follow ups generate surprisingly few RVU compared to planning and delivery… and are an afterthought for me.

I think this is generally accurate, other than if we're talking pure wRVU, as long as it's being coded correctly, 3D is now roughly equivalent - or slightly more than - IMRT. Of course, since facility fees have a much higher conversion factor than professional fees, the hospital still makes more money on IMRT.

Why? Bundling! With IMRT you can't bill 77290 or 77280 (well, you should be able to snag 0.7 wRVU if you do VSIM on a different day for IMRT). Unless you're using physical compensator-based fields, you can only bill 77338 x1 for IMRT whereas you can bill 77334 * number of fields for 3D. You can also bill 77300 for at least the number of fields with 3D, and up to 10 if you want to get cute with FiF arrangements (10 is the MUE cap for 77300 regardless).

Yadda yadda, if you take a 30 fraction course comparing IMRT and 4-field box 3D, using a single vaclock, respiratory motion management, and only bill 77300 x4...my quick math shows 43.53 for IMRT and 43.64 for 3D. If you want to get cute and do 77300 x10, 3D then clocks in at 47.36 - almost 10% more than IMRT.

That's including a 99205 charge, but NOT any sort of IGRT (there's a lot of variation in IGRT practice).

@Lamount, if you're getting 55-60 per Stage III lung, I assume you're also billing special treatment procedure, doing both a vaclock and a wingboard, and daily CBCT? By my math, that would put you at 56.21 wRVU for IMRT.

 

[Neuronix]

For professional wRVUs for simple clinic visits and encounters like 77427 and 9920X 9921X, go here: RVU Calculator - AAPC Relative Value Units

Where it gets impossible to ELI5 is for treatment courses. There are many codes billed depending on the exact treatment situation, each with their own numbers of wRVUs.

If someone has an easy to digest summary of common treatment scenarios and wRVUs generated, please send to me. I do not have such a summary in the billing forum, but would be happy to share it.

 

[Lamount]

I think this is generally accurate, other than if we're talking pure wRVU, as long as it's being coded correctly, 3D is now roughly equivalent - or slightly more than - IMRT. Of course, since facility fees have a much higher conversion factor than professional fees, the hospital still makes more money on IMRT.

Why? Bundling! With IMRT you can't bill 77290 or 77280 (well, you should be able to snag 0.7 wRVU if you do VSIM on a different day for IMRT). Unless you're using physical compensator-based fields, you can only bill 77338 x1 for IMRT whereas you can bill 77334 * number of fields for 3D. You can also bill 77300 for at least the number of fields with 3D, and up to 10 if you want to get cute with FiF arrangements (10 is the MUE cap for 77300 regardless).

Yadda yadda, if you take a 30 fraction course comparing IMRT and 4-field box 3D, using a single vaclock, respiratory motion management, and only bill 77300 x4...my quick math shows 43.53 for IMRT and 43.64 for 3D. If you want to get cute and do 77300 x10, 3D then clocks in at 47.36 - almost 10% more than IMRT.

That's including a 99205 charge, but NOT any sort of IGRT (there's a lot of variation in IGRT practice).

@Lamount, if you're getting 55-60 per Stage III lung, I assume you're also billing special treatment procedure, doing both a vaclock and a wingboard, and daily CBCT? By my math, that would put you at 56.21 wRVU for IMRT.

We get 7.6 RVU a week for OTV (77427: 3.37) + 5 CBCT (77014 =0.85 x 5), so about 45 RVUs for a 6 week course, not even counting planning.

We probably underbill 3D planning… but oh well. That stuff is a little above my head

 

[elementaryschooleconomics]

We get 7.6 RVU a week for OTV (77427: 3.37) + 5 CBCT (77014 =0.85 x 5), so about 45 RVUs for a 6 week course, not even counting planning.

We probably underbill 3D planning… but oh well. That stuff is a little above my head

You're in a bigger academic setting right?

You could have the best and most nuanced understanding of billing ever, and even then...you would never "pierce the armor" of an academic billing department.

They don't understand anything other than "are we in the black or the red". Even once they get in the red, things are unlikely to change.

It's crazy.

 

[seper]

What's also important to figure out, is how are wRVU are distributed amongst docs. There are no set rules.
For example, does MD who prescribes SBRT but never shows up for delivery get the whole pie? How about Syed template, does the brachytherapist who inserted device and signed the plan gets everything?

 

[elementaryschooleconomics]

What's also important to figure out, is how are wRVU are distributed amongst docs. There are no set rules.
For example, does MD who prescribes SBRT but never shows up for delivery get the whole pie? How about Syed template, does the brachytherapist who inserted device and signed the plan gets everything?

Yup.

In my network, most of the wRVUs are credited to the doc who signed off on something. So if an SBRT case is started by Physician X, but Dr X goes on vacation and is covered by Physician Y, then Dr Y would get the 77435 wRVUs if they did the "official" OTV.

But one of the sites assigns the wRVUs to the doc who is listed as the "attending physician" for that patient, even if someone else signs off on something.

Super confusing, yay!

 

[medgator]

Yup.

In my network, most of the wRVUs are credited to the doc who signed off on something. So if an SBRT case is started by Physician X, but Dr X goes on vacation and is covered by Physician Y, then Dr Y would get the 77435 wRVUs if they did the "official" OTV.

But one of the sites assigns the wRVUs to the doc who is listed as the "attending physician" for that patient, even if someone else signs off on something.

Super confusing, yay!

You bill, you kill

 

[seper]

You bill, you kill

University bills. You sign where you are told

 

[evilbooyaa]

Yup.

In my network, most of the wRVUs are credited to the doc who signed off on something. So if an SBRT case is started by Physician X, but Dr X goes on vacation and is covered by Physician Y, then Dr Y would get the 77435 wRVUs if they did the "official" OTV.

But one of the sites assigns the wRVUs to the doc who is listed as the "attending physician" for that patient, even if someone else signs off on something.

Super confusing, yay!

The second option seems very risky in the setting of a bill being dropped for a 77435 when a physician is noted to be on say vacation or otherwise not in the office.

Do the work (OTV, CBCT review, etc.), get the RVU. This is why people finalize and sign off on their own plans the vast majority of the time, and I have no problem signing off on plans or covering films for my colleagues on vacation.

Only downside is the SBRTs where the treating doc is never present - that ends up being done for free....

 

[evilbooyaa]

What's also important to figure out, is how are wRVU are distributed amongst docs. There are no set rules.
For example, does MD who prescribes SBRT but never shows up for delivery get the whole pie? How about Syed template, does the brachytherapist who inserted device and signed the plan gets everything?

Whoever supervises the treatment for each fraction should get the billing for each of the fractions.

 

[sirspamalot]

If you're in academics, I'm not even sure why you are concerned with RVU unless of course, you are simply the bottom of the pyramid and starving while feeding the apex predators. You will never, I repeat never, ever understand the billing, and even if you do.. you won't understand what nonsense is going on at your institution. This is the way.

Out here in community practice, there is no quarter given.

 

[elementaryschooleconomics]

The second option seems very risky in the setting of a bill being dropped for a 77435 when a physician is noted to be on say vacation or otherwise not in the office.

Do the work (OTV, CBCT review, etc.), get the RVU. This is why people finalize and sign off on their own plans the vast majority of the time, and I have no problem signing off on plans or covering films for my colleagues on vacation.

Only downside is the SBRTs where the treating doc is never present - that ends up being done for free....

So I think the billing is done "correctly", in that the charge is submitted under the signing physician, but the university "counts" it for the attending physician.

I dunno, I'm clearly utterly obsessed with this stuff and even I can barely figure out what's happening.

 

[udrag14]

The second option seems very risky in the setting of a bill being dropped for a 77435 when a physician is noted to be on say vacation or otherwise not in the office.

Do the work (OTV, CBCT review, etc.), get the RVU. This is why people finalize and sign off on their own plans the vast majority of the time, and I have no problem signing off on plans or covering films for my colleagues on vacation.

Only downside is the SBRTs where the treating doc is never present - that ends up being done for free....

Yea. Usually the attending on site is billing. agree the second option is terrible and could lead to cms pain

 

[Neuronix]

If you're in academics, I'm not even sure why you are concerned with RVU unless of course, you are simply the bottom of the pyramid and starving while feeding the apex predators. You will never, I repeat never, ever understand the billing, and even if you do.. you won't understand what nonsense is going on at your institution. This is the way.

Out here in community practice, there is no quarter given.

I'm in academics, and I am paid in $ per RVU. You better believe I'm concerned.

 

[A_DeMichele]

Some large employed practices divvy up wRVU however management feels and manipulate the totals. Hell, I even worked at a place that would “award” wRVU for things like travel

 

[dieABRdie]

Since I decided to pursue rad onc mid-medical school.... I've watched as academic department after academic department institutes RVU bonuses or targets. Meanwhile maintaining their promotion structure as based on grants, research and publication. The Universities have really lost their way.

 

[Fpg1245]

Since I decided to pursue rad onc mid-medical school.... I've watched as academic department after academic department institutes RVU bonuses or targets. Meanwhile maintaining their promotion structure as based on grants, research and publication. The Universities have really lost their way.

It’s just a total breakdown in the traditional mission and structure of the Dept. The HC reform ruined academia it literally turned them into the monsters they became today.

 

[medgator]

It’s just a total breakdown in the traditional mission and structure of the Dept. The HC reform ruined academia it literally turned them into the monsters they became today.

It isn't nearly like this in other specialties though when it comes to academic vs non academic practices