how to generate rvu's per patient

[valianteffort]

Hello,
I am a new attending and have noticed some of my colleagues generate more RVUs per patient than I do in our monthly 'shame on you' meeting. I work on a nearly 100% RVU payscale. My understanding is a level 5 chart generates 4 RVUs and some of my colleagues average 5 RVUs or more per patient and we do not see that serious of acuity all the time. I do understand how to achieve a level 5 chart and requirements. I was wondering if anyone had some tricks or tips about how to generate more RVU's on top of the level 5 chart. I am also aware of when you can and can not bill for critical care time.

1) Does adding a differential to your note actually add RVUs? I had heard this in the past although for litigation I was told this is negative. For example, putting PE on a chest pain differential (in someone that PERC/WELLs out) and not acquiring a CTPE study.

2) Does writing that you reviewed 'old charts' increase RVUs?

3) Does a longer MDM create more RVU's? Mine are generally pretty short I am not sure if the private billing company will just see if I wrote 2 lines vs. 10 lines and determine complexity based of that

Appreciate the help!

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[southerndoc]

Listing PE in your differential isn't necessarily bad from a litigation standpoint. Listing it and not explaining how you ruled it out is. So if you list "differential includes AMI, PE, PTX" etc without anything further, then yeah, that can make you look bad during litigation. Simply writing "unlikely to be a PE given pain is not pleuritic, no shortness of breath, no tachypnea, no hypoxemia" is a way to rule it out.

In general, I tell residents you should never put down what you plan to rule out. Just document what you ruled out. Doesn't mean you have to test for it. Explain why you don't think something is there. If you list a long differential and forget to comment on half of it, then it could make you look bad in court because the plaintiff's counsel could say you're sloppy, lazy, or in a hurry since you didn't document why something was ruled out.

The new documentation requirements for CMS that will start soon will use more of your MDM to justify your level of service. Therefore, get in the habit of doing a great MDM now.

Writing that you reviewed old charts doesn't increase RVUs, but summarizing old records will substantiate your level of service. Doesn't need to be a very detailed summary.

I think you're concentrating on the wrong area here. MDM won't upcode a chart, but it can substantiate it. Concentrate on appropriate critical care billing, documenting reductions appropriately, documenting splinting (even if a tech applies it, if you supervised it put in a procedure note), etc. Document your pulse oximetry interpretations, x-ray interpretations (view the image yourself and note that in your chart), and EKGs. Some places bill for pulse ox and EKG interpretations.

 

[RustedFox]

Envision has webinars planned for the rest of the year regarding the new changes effective January 1st.

As usual, I expect better discussion here than they could ever assemble.

 

[Groove]

You get points in medical decision making complexity but the number of differentials doesn't necessarily equate to a higher code. Here's a link:

ED Charting and Coding: Medical Decision Making (MDM)

Bio Twitter Latest Posts Bjorn Watsjold, MDEmergency Medicine Chief Resident Division of Emergency Medicine University of Washington @akbjorn Latest posts by Bjorn Watsjold, MD (see all) ED Charting and Coding: Medical Decision Making (MDM) - November 16, 2016 ED Charting and Coding: Physical...

www.aliem.com

I used to list many differentials but then started listing the ones I ruled out such as PERC neg, therefore PE not suspected, etc... I have the same medicolegal concerns as @southerndoc in that you don't want to have a big list and not commenting on all of them. I do have a smart phrase that says something like "Differentials including but not limited to:" but I don't even really use that one very much either. After awhile, you learn which charts to spend time with more elaborate MDMs and which ones don't need it.

I don't know that I would waste an enormous amount of time now getting used to the old style of coding/billing with the upcoming new CMS changes for 2023 right around the corner.

As for your "shame meetings":

RVUs/hr vs LOS/TAT are two metric entities that are often at war with each other. Both are glamorized in most CMGs for different reasons. Obviously with RVU, you are viewed as "most productive" and generating/capturing the most work equalling the highest billing for the company so that's going to be glamorized. Yet, most hospital admin are really more focused on times...specfiically LOS/TATs/PFC. Reduction of LWOTs, AMA, etc..If you have the shortest times, chances are you are a minimalist and it's almost impossible to practice minimalism and still get maximum RVU/hr. For instance, I'm usually the fastest doc in my group each month yet I have the least captured RVU/hr. It's hard to capture RVUs if you aren't ordering lots of tests. RVU/hr is going to be a greater focus if you're in a CMG that is heavily RVU based such as ApolloMD, etc.. or an SDG that is based entirely on FFS. I work for a CMG with a more fixed/stable compensation formula and hence the focus tends to be on times, not RVU/hr. Either way, I wouldn't sweat it too much. Especially if you are a new attending. Better to just find your flow/comfort level and evolve from there.

 

[Janders]

The short answer is YES, even with current billing rules listing DDx and reviewing old charts does increase complexity and CAN increase a level 4 chart to a level 5. Frankly if your pay is entirely RVU based any you don’t know this, you’re in over your head and you need to study up quickly. No offense, its just your cash you are losing because you don’t understand the rules of the game.

Longer answer would include various points—
(1) You can’t upcode a simple ankle sprain to a level 5 just by reading 20 prior visit notes and listing ischemic limb and cellulitis on the differential. Well you could, but its fraud. You want low hanging fruit, not fraud.
(2) PROCEDURES (SPLINTING!) and CRITICAL CARE TIME (more than the first hour sometimes!) and even EKG INTERPRETATION AND POCUS can all also vastly improve your RVU / hr without changing your clinical care if you are not properly documenting them now.
(3) 1/1/23 the rules vastly change and your HPI, exam, ROS basically don’t matter, it’s ALL about MDM. So some of the rules you learn for the next 2.5 months won’t cary forward (though, honestly, the majority of the things they are going to look at for MDM in the near future also do give you complexity points now, it is just going to matter more and ROS won’t kneecap you anymore).

Remember:
You aren’t trying to game the system, you are trying to capture every penny you already earned by providing high quality emergency care through excellent application of the capricious and arbitrary rules of the coding and billing system :-D

 

[Groove]

Do you guys think being able to minimize HPI/ROS will hinder or help us medico legally? I can't figure out if that's a good thing or bad thing.

 

[EctopicFetus]

Do you guys think being able to minimize HPI/ROS will hinder or help us medico legally? I can't figure out if that's a good thing or bad thing.

In my group when I look at this it is typical that some people don’t do Ed obs or critical care. In additi9n fracture care, EKGs etc all matter as well.
if You have access to everyone’s data look at the e/m distribution are you on par? If so look at critical care Ed obs and other billable procedures.
i wouldn’t sweat it too much cause 2023 everything will change.

 

[EctopicFetus]

Do you guys think being able to minimize HPI/ROS will hinder or help us medico legally? I can't figure out if that's a good thing or bad thing.

The ROS is often nonsense. I think a good HPI will still be a good HPI but you don’t need a bunch of extra billing nonsense. Similarly you wont need a big exam for ankle pain. Overall I think it is good. What isn’t be8ngndiscussed by many is the likelihood of many level 5s becoming level 4s next year.
i think our RVU per patient will go down overall if you are currently at 15% or less level 3,2,1

 

[Janders]

The ROS is often nonsense. I think a good HPI will still be a good HPI but you don’t need a bunch of extra billing nonsense. Similarly you wont need a big exam for ankle pain. Overall I think it is good. What isn’t be8ngndiscussed by many is the likelihood of many level 5s becoming level 4s next year.
i think our RVU per patient will go down overall if you are currently at 15% or less level 3,2,1

Our Coding people were actually optimistic 4s could become 5s if you learn to do the MDM game properly.

 

[Janders]

The ROS is often nonsense. I think a good HPI will still be a good HPI but you don’t need a bunch of extra billing nonsense. Similarly you wont need a big exam for ankle pain. Overall I think it is good. What isn’t be8ngndiscussed by many is the likelihood of many level 5s becoming level 4s next year.
i think our RVU per patient will go down overall if you are currently at 15% or less level 3,2,1

Also I agree on this point—

HPI: Can remove the stilted descriptors (The patient has a sharp, constant, moderate pain improved by rest after being stabbed with a knife), but you still want a solid history. Streamlined but not a sea change, doubt it has medicolegal implications
ROS: Was trash. Remove trash. Better! I think a generic negative ROS can help and hurt you medicolegally, so push here.
Exam: Important improvement. Can now focus on the key elements. Might NOT having some normal findings (i.e. clear lungs in a ankle sprain that later is found to have surprise pneumothorax) hurt you in later medicolegal issues? I can see the possibility. But I think a generic “looks good from the door” template to which you add relevant findings offers the same protection.

 

[southerndoc]

Our Coding people were actually optimistic 4s could become 5s if you learn to do the MDM game properly.

I've heard the opposite. Hope you're correct.

 

[RustedFox]

Too complicated.

You just diamond hands RVUs to the moon.

Simple as that.

 

[thegenius]

Hello,
I am a new attending and have noticed some of my colleagues generate more RVUs per patient than I do in our monthly 'shame on you' meeting. I work on a nearly 100% RVU payscale. My understanding is a level 5 chart generates 4 RVUs and some of my colleagues average 5 RVUs or more per patient and we do not see that serious of acuity all the time. I do understand how to achieve a level 5 chart and requirements. I was wondering if anyone had some tricks or tips about how to generate more RVU's on top of the level 5 chart. I am also aware of when you can and can not bill for critical care time.

Unless there are exceptional circumstances, I suspect anyone averaging > 5 RVU/pt is committing fraud. This is under the rubric of what a typical community ER sees on a typical day.

I work in a typical community ER and our average RVU/pt is between 3.9 - 4.2. 66% of the pts we see have nonsense complaints that shouldn't ever even come to an ER, and I suspect that 66% is more or less in-line with the majority of community ERs around the nation.

 

[thegenius]

As for your "shame meetings":

RVUs/hr vs LOS/TAT are two metric entities that are often at war with each other. Both are glamorized in most CMGs for different reasons. Obviously with RVU, you are viewed as "most productive" and generating/capturing the most work equalling the highest billing for the company so that's going to be glamorized. Yet, most hospital admin are really more focused on times...specfiically LOS/TATs/PFC. Reduction of LWOTs, AMA, etc..If you have the shortest times, chances are you are a minimalist and it's almost impossible to practice minimalism and still get maximum RVU/hr. For instance, I'm usually the fastest doc in my group each month yet I have the least captured RVU/hr. It's hard to capture RVUs if you aren't ordering lots of tests. RVU/hr is going to be a greater focus if you're in a CMG that is heavily RVU based such as ApolloMD, etc.. or an SDG that is based entirely on FFS. I work for a CMG with a more fixed/stable compensation formula and hence the focus tends to be on times, not RVU/hr. Either way, I wouldn't sweat it too much. Especially if you are a new attending. Better to just find your flow/comfort level and evolve from there.

This is a very important point everyone I agree 100%. OP, ultimately you need to practice medicine the way you feel is appropriate and sound, and you get RVUs as such. I wouldn't markedly change your style of practice to increase RVUs. Instead focus on giving patients the kind of emergency care you think is fit for their complaint and you will go home feeling good about the work you do.

All groups have "top producers", "most efficient", "mininimalists", etc. Just be somewhere within the averages and you'll be fine. For instance if your group admits between 13-18% of pts, and you are admitting either 4% or 30% of your patients (obvious outliers), then you are doing something wrong.

 

[Arcan57]

Just tell your scribe to bill between 32-37 minutes of critical care on every patient you see. Easy boost to >5 RVUs/pt.

One of the most important lessons to learn as an early attending is that there are a lot of ways to play the game. Groups have outliers in both the pts/hr and the RVU/pt metrics. In residency, benchmarking yourself against the top doc(s) is a good way to learn the volume and coding games. In attendinghood, the outliers may just be better doctors but are far more likely to be using hacks that are dangerous/stupid.

That CC time example is something I've seen out of a director level doc. At my first job the highest RVU/hr doc would pick up a ton of patients, order every test the hospital had on every one of them and then admit them all to the hospitalist. Working with the doc was a nightmare because they'd completely saturate the hospital's imaging capacity and all the techs were busy redrawing clotted uric acid levels on podagra pts with long hx of gout. I've seen docs that take over every patient that they get signout on (even the admitted boarders), docs that sign up for 12 patients at once at the beginning of their shift (even if it takes them 4 hours to get around to the 12th one), and even docs that would pick up patients in the waiting room 30 minutes before their shift ends and try and manage the rest of the encounter from home.

Get the basics down: what's the difference between a level 3,4, and 5 chart looks like, making sure there's a billable procedure note on all the MSK immobilizations we do, use of the critical care modifiers when you're doing critical care, etc.

In terms of patients/hr, get comfortable in deciding who doesn't need testing but needs an extra 5 minutes of face time to feel comfortable going home. Pts who don't need any workup but get anything ordered that requires lab/radiology resources are the biggest drag on the system. Invest in your relationship with your hospitalists. Being able to admit patients who have low yield cross-sectional imaging pending vs. having to wait for final reads can save hours (if your hospital actually has beds available). Prioritize disposition. Get the not sick out before whatever you gave them starts to wear off or they decide that since they're here there's this other thing they wanted to get checked out also.

 

[turkeyjerky]

Unless there are exceptional circumstances, I suspect anyone averaging > 5 RVU/pt is committing fraud. This is under the rubric of what a typical community ER sees on a typical day.

I work in a typical community ER and our average RVU/pt is between 3.9 - 4.2. 66% of the pts we see have nonsense complaints that shouldn't ever even come to an ER, and I suspect that 66% is more or less in-line with the majority of community ERs around the nation.

So true. I started my first job shortly after the contract changed from a private group, 100% rvu based to hospital employed. Seeing some of the previous charts from the old group was shocking. People billing CC time on simple chest pain rule outs, etc.

 

[Groove]

So true. I started my first job shortly after the contract changed from a private group, 100% rvu based to hospital employed. Seeing some of the previous charts from the old group was shocking. People billing CC time on simple chest pain rule outs, etc.

Yeah, it's nice to not have to worry about that. There were some good things about my last CMG gig but the whole RVU centric billing drove me crazy. We would be billing stuff like....drug cessation/smoking cessation/alcohol cessation counseling. Plop an US on a belly and print an image, then throw in bedside US exam. CC time for just ridiculous stuff....I can even remember defending it on here. It's so nice to not have to worry about that stuff these days along with getting audited. 95% of my pay is fixed with a very small portion that's productivity based. You'd think that would make the docs lazy but we've got a really motivated group. We've got a handful of slow pokes but that's typical for any group. Personally, I hated having to walk in a room and spend so many neurons figuring out how to maximize the RVU for that visit. It really contributed to burnout for me. It was a constant source of stress and tension during every shift.

 

[EctopicFetus]

So true. I started my first job shortly after the contract changed from a private group, 100% rvu based to hospital employed. Seeing some of the previous charts from the old group was shocking. People billing CC time on simple chest pain rule outs, etc.

fwiw I dont do this but Kevin klauer (CMG ho) and now do overlord said we should be doing this multiple times. If you read the criteria for critical care he isn’t wrong hard to justify the 30 mins and I think doesn’t equal the spirit of the rule.

 

[EctopicFetus]

One other thing just cause you document CC in an ideal world your coders decide if it meets criteria or not. No doubt tons of nonsense out there.

 

[Mount Asclepius]

So true. I started my first job shortly after the contract changed from a private group, 100% rvu based to hospital employed. Seeing some of the previous charts from the old group was shocking. People billing CC time on simple chest pain rule outs, etc.

One other thing just cause you document CC in an ideal world your coders decide if it meets criteria or not. No doubt tons of nonsense out there.

Like billing critical care for patient with mild alcohol withdrawal without AMS or DTs resolved with one dose of Ativan and discharged home. I saw one doc try to bill critical care on that. Our coders shot that down. They might even save some docs from audits who bill ridiculous critical care.

Also had a transfer once from a smaller OSH staffed by a CMG for an older patient with questionable pneumonia with an oxygen saturation of 88-89% on RA resolved with 2L O2. Now would have been a direct admit transfer, but was ED to ED at the time. Maybe billable, but far from the spirit of cc billing. Not something I would do.

 

[southerndoc]

I know of a doc who was terminated because he was billing CC on TIAs, appendicitis, etc.