How does the RVU model work?

[thegenius]

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This is a bad idea. It would disincentivize seeing sicker patients that require procedures. If you strictly do it by patients per hour, then I can go see 6 URIs while you’re working a code and I’ll make way more than you which everyone would agree is unfair.

Propensity for ordering tests (within reason) isn’t usually going to affect RVUs all that much. RVUs are assigned for each E/M code and whether you order 1 lab or 50 labs will usually not be the deciding factor in either your E/M code or correspondingly your RVUs on that at patient. Your patients are going to be predominantly 99283s, 99284s, and 99285s with some 99291s thrown in for critical care.

Yea I hear ya on that. However ordering tests probably has more of an impact than one might think. If you and I both see a headache, you order a head CT and I don't, that very well might bump you from a 99284 to a 99285, all with a simple click of a button. Giving IM shots of Toradol can increase your pay over just giving pills (from what I hear). Doing an hour long neb for asthma can permit you to bill 99291 even though in real life you could have gotten away with doing a single duoneb and d/c. I agree though that if you order a BMP, or a CMP+CBC+Trop+Coags that probably won't make much of a difference, if any.

The incentives in our system are all f-ed up. It's just terrible.

 

[deleted836128]

Side question, guys. We are supposed to select our own billing codes (just based off an instinct) so we can keep track of our RVUs ... and then the billing people will also check over it more thoroughly and make sure we billed properly and upcode or downcode as needed. I feel like I bill higher codes than everyone else but I don’t get any kick backs from billing stating that I billed too high. Therefore I am apparently selecting appropriate billing levels. But... I see a lot of my colleagues with a lot of 99282s...and a lot of belly pain 99283s. I hardly ever do a 99282. Here’s kinda my rough billing guestimates.

99282: super rare... maybe like a suture removal or simple med refill
99283: most fast track stuff that I order any work up or meds on... ankle sprain or fracture with x-rays, sore throat with negative Strep test, lower UTI
99284: belly pains with work up (labs, CT), stable patient with asthma or COPD exacerbation
99285: big chest pain work ups when I am ordering trops, EKGs, CTA chest, etc...most admissions, anyone unstable

What do you guys think? Like I said, Billing will downcode me and send me an email alerting me if I submit too high of a code but I NEVER get those emails.

Have also noticed a HUGE variation between what is considered critical care. I billed critical care twice today - a chest pain patient with tachycardia who had a PE and elevated troponins, and I started her on a heparin drip. A lot of docs or PAs wouldn’t bill for critical care for that in my ER. The other was an acute pancreatitis with dehydration and a heart rate in the 150s and elevated troponin. Does aggressive fluid resuscitation, cardiac monitoring and frequent reevaluations suggest this is a critical care patient since I spent more than 30 minute? There are some docs that would say no and others that would say yes. I don’t want to be over doing my billing !!!

 

[Hercules]

Side question, guys. We are supposed to select our own billing codes (just based off an instinct) so we can keep track of our RVUs ... and then the billing people will also check over it more thoroughly and make sure we billed properly and upcode or downcode as needed. I feel like I bill higher codes than everyone else but I don’t get any kick backs from billing stating that I billed too high. Therefore I am apparently selecting appropriate billing levels. But... I see a lot of my colleagues with a lot of 99282s...and a lot of belly pain 99283s. I hardly ever do a 99282. Here’s kinda my rough billing guestimates.

99282: super rare... maybe like a suture removal or simple med refill
99283: most fast track stuff that I order any work up or meds on... ankle sprain or fracture with x-rays, sore throat with negative Strep test, lower UTI
99284: belly pains with work up (labs, CT), stable patient with asthma or COPD exacerbation
99285: big chest pain work ups when I am ordering trops, EKGs, CTA chest, etc...most admissions, anyone unstable

What do you guys think? Like I said, Billing will downcode me and send me an email alerting me if I submit too high of a code but I NEVER get those emails.

Have also noticed a HUGE variation between what is considered critical care. I billed critical care twice today - a chest pain patient with tachycardia who had a PE and elevated troponins, and I started her on a heparin drip. A lot of docs or PAs wouldn’t bill for critical care for that in my ER. The other was an acute pancreatitis with dehydration and a heart rate in the 150s and elevated troponin. Does aggressive fluid resuscitation, cardiac monitoring and frequent reevaluations suggest this is a critical care patient since I spent more than 30 minute? There are some docs that would say no and others that would say yes. I don’t want to be over doing my billing !!!

In general we all tend to underbill. Everything you’ve said above sounds pretty reasonable in the ED setting.

 

[BoardingDoc]

Side question, guys. We are supposed to select our own billing codes (just based off an instinct) so we can keep track of our RVUs ... and then the billing people will also check over it more thoroughly and make sure we billed properly and upcode or downcode as needed. I feel like I bill higher codes than everyone else but I don’t get any kick backs from billing stating that I billed too high. Therefore I am apparently selecting appropriate billing levels. But... I see a lot of my colleagues with a lot of 99282s...and a lot of belly pain 99283s. I hardly ever do a 99282. Here’s kinda my rough billing guestimates.

99282: super rare... maybe like a suture removal or simple med refill
99283: most fast track stuff that I order any work up or meds on... ankle sprain or fracture with x-rays, sore throat with negative Strep test, lower UTI
99284: belly pains with work up (labs, CT), stable patient with asthma or COPD exacerbation
99285: big chest pain work ups when I am ordering trops, EKGs, CTA chest, etc...most admissions, anyone unstable

What do you guys think? Like I said, Billing will downcode me and send me an email alerting me if I submit too high of a code but I NEVER get those emails.

Have also noticed a HUGE variation between what is considered critical care. I billed critical care twice today - a chest pain patient with tachycardia who had a PE and elevated troponins, and I started her on a heparin drip. A lot of docs or PAs wouldn’t bill for critical care for that in my ER. The other was an acute pancreatitis with dehydration and a heart rate in the 150s and elevated troponin. Does aggressive fluid resuscitation, cardiac monitoring and frequent reevaluations suggest this is a critical care patient since I spent more than 30 minute? There are some docs that would say no and others that would say yes. I don’t want to be over doing my billing !!!

Your guesstimates sound accurate to me. As for your 2 cases of CC time: 100% yes both of those are critical care worthy. HR 150 and +troponin in a patient? Done. That qualifies as CC time. I don't know how anyone could possibly argue otherwise. "You mean to say that the patient who came to the ED with a heart rate so high that it was measurably damaging their heart was NOT critically ill? That they'd probably do just fine if left to their own devices?"

Just because you're used to seeing dying people all the time doesn't mean that they aren't dying. Your charting should accurately reflect that.

 

[Groove]

Side question, guys. We are supposed to select our own billing codes (just based off an instinct) so we can keep track of our RVUs ... and then the billing people will also check over it more thoroughly and make sure we billed properly and upcode or downcode as needed. I feel like I bill higher codes than everyone else but I don’t get any kick backs from billing stating that I billed too high. Therefore I am apparently selecting appropriate billing levels. But... I see a lot of my colleagues with a lot of 99282s...and a lot of belly pain 99283s. I hardly ever do a 99282. Here’s kinda my rough billing guestimates.

99282: super rare... maybe like a suture removal or simple med refill
99283: most fast track stuff that I order any work up or meds on... ankle sprain or fracture with x-rays, sore throat with negative Strep test, lower UTI
99284: belly pains with work up (labs, CT), stable patient with asthma or COPD exacerbation
99285: big chest pain work ups when I am ordering trops, EKGs, CTA chest, etc...most admissions, anyone unstable

What do you guys think? Like I said, Billing will downcode me and send me an email alerting me if I submit too high of a code but I NEVER get those emails.

Have also noticed a HUGE variation between what is considered critical care. I billed critical care twice today - a chest pain patient with tachycardia who had a PE and elevated troponins, and I started her on a heparin drip. A lot of docs or PAs wouldn’t bill for critical care for that in my ER. The other was an acute pancreatitis with dehydration and a heart rate in the 150s and elevated troponin. Does aggressive fluid resuscitation, cardiac monitoring and frequent reevaluations suggest this is a critical care patient since I spent more than 30 minute? There are some docs that would say no and others that would say yes. I don’t want to be over doing my billing !!!

Refer to some of our other threads on CC time. There are a lot of good tips. Agree with above, in general....we all underbill for CC IMO. The first example you provided with heparin gtt is a no brainer. Just about any drip will qualify for CC as long as you document appropriately. I'd have to know more about the second case and it would also depend on your diagnosis. Were they septic? I bill CC for almost all of my sepsis patients.

We have a new coding company for my CMG and I've noticed I'm getting a few more kick backs for cases where I used CC billing and their opinion was that it did not qualify. The problem is that they are not providing many specifics on why the case didn't qualify and are in the process of providing better quality feedback.

 

[TooMuchResearch]

Those are both critical care.

We don't do any coding/billing other than a CC addendum. We pay someone else to do that stuff.

Side question, guys. We are supposed to select our own billing codes (just based off an instinct) so we can keep track of our RVUs ... and then the billing people will also check over it more thoroughly and make sure we billed properly and upcode or downcode as needed. I feel like I bill higher codes than everyone else but I don’t get any kick backs from billing stating that I billed too high. Therefore I am apparently selecting appropriate billing levels. But... I see a lot of my colleagues with a lot of 99282s...and a lot of belly pain 99283s. I hardly ever do a 99282. Here’s kinda my rough billing guestimates.

99282: super rare... maybe like a suture removal or simple med refill
99283: most fast track stuff that I order any work up or meds on... ankle sprain or fracture with x-rays, sore throat with negative Strep test, lower UTI
99284: belly pains with work up (labs, CT), stable patient with asthma or COPD exacerbation
99285: big chest pain work ups when I am ordering trops, EKGs, CTA chest, etc...most admissions, anyone unstable

What do you guys think? Like I said, Billing will downcode me and send me an email alerting me if I submit too high of a code but I NEVER get those emails.

Have also noticed a HUGE variation between what is considered critical care. I billed critical care twice today - a chest pain patient with tachycardia who had a PE and elevated troponins, and I started her on a heparin drip. A lot of docs or PAs wouldn’t bill for critical care for that in my ER. The other was an acute pancreatitis with dehydration and a heart rate in the 150s and elevated troponin. Does aggressive fluid resuscitation, cardiac monitoring and frequent reevaluations suggest this is a critical care patient since I spent more than 30 minute? There are some docs that would say no and others that would say yes. I don’t want to be over doing my billing !!!