Maximizing RVU

[GatorCHOMPions]

I'm about to take a job this summer where a portion of the salary is RVU. Anyone have online resources or books describing based ways to optimize billing. For example, I've heard a 15 mg continuous albuterol treatment can qualify as critical care, but how do you document it appropriately? What defines a complex laceration or I&D for reimbursement purposes?

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[RustedFox]

I'm always looking for ways to boost my RVUs, too. I asked this before, and I'll ask it again: if anyone knows of a good online coding/billing lesson or webinar (free or otherwise), please share it.

EDIT: Before anyone says "Google it, lolz" - I'm looking for recommendations for a course that is EM-centric that someone can say "Hey, I've seen/used this one. Its good." Otherwise, there's no way to know if its going to be worth the cost of admission.

 

[goodoldalky]

Brief answers, complex ID is packing placed, complex lac revision of margins or two+ layer closure. In the asthma example continuous albuterol qualifies for CC but I do not believe 15 minutes is continuous that is a standard timeframe. Continuous at my facility is 60 minutes+. Documentation for this is diagnosing status asthmaticus and billing CC statement.

The keys to this are ensuring every chart is documented to the maximum possible, and doing and documenting your own procedures. Don't forget to be fast.

 

[RustedFox]

I think one of the best tips involving critical care time that I've seen on here is the intoxicated or overdose patient that requires multiple repeat evaluation to ensure that there is no threat to their respiratory/neurologic condition. Document a re-eval every 15 minutes x3 and boom: there's your CC time.

Since my job started offering an RVU bonus, I've seen my hourly go up around 20 bucks/hour. No joke.

 

[MSmentor018]

were heavy rvu based. small stuff like ultrasound procedures, smoking counseling, splint re eval. diet counseling. back pain/exercises push it up easy by 1 or more rvu/pt. so if you're seeing 2/pph that's around 18-20 bucks/hr (depending on your rvu rate) like rustedfox said. you're probably doing this already in between telling them their lab results and giving them d/c instructions. "hey fatty stop smoking and eating mcdonalds, the lettuce on there doesnt count as veggies. when you're ready heres some d/c instructions on a better diet because you're a diabetic risk and call this number or your PCP for stop smoking advice. lie on your side and put a pillow between your legs for obvious back pain from lack of exercise. speaking of exercise go for a walk daily and start lifting with your legs instead of your back when you're picking up all your small childrens' " I think every state has a stop smoking line, we do in FL.

if you're a DO you can add small stuff like piriformis syndrome counterstrain treatment or lymphatic drainage for sinusitis. that's 60 seconds of pure $$$. I don't believe in all the OMT stuff but this actually works. so far the coders hasn't balked on my charting/billing and i just had my 1 yr audit

you're already taking every possible risk seeing these people hoping to hit the medical lottery, mind as well get paid for every single scrap of it

 

[hypnix]

Is there a certain amount of time you have to spend for diet cousneling or exercise counseling?

 

[bravotwozero]

Ortho procedures, particularly closed reduction on distal forearm fractures, pay mucho RVUS - seek them out if you can. Most places you can bill for floor codes/intubations - if you're near the end of your shift in a double coverage ed and not picking up new people, I'd jump all over it, that's also rvus in your pocket.


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[deleted77919]

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[Siggy]

I think one of the best tips involving critical care time that I've seen on here is the intoxicated or overdose patient that requires multiple repeat evaluation to ensure that there is no threat to their respiratory/neurologic condition. Document a re-eval every 15 minutes x3 and boom: there's your CC time.

Since my job started offering an RVU bonus, I've seen my hourly go up around 20 bucks/hour. No joke.

You mean your "toxic encephalopathy" patients?

 

[deleted109597]

Ortho procedures, particularly closed reduction on distal forearm fractures, pay mucho RVUS - seek them out if you can. Most places you can bill for floor codes/intubations - if you're near the end of your shift in a double coverage ed and not picking up new people, I'd jump all over it, that's also rvus in your pocket.

Hmm. My CMG, which colluded with my hospital to make it "our" responsibility (read, you guys working there, not us, and not the ICU docs, the hospitalists, or anybody else), flat out told us they didn't bill for floor codes. Of course, that was when we were trying to pin down our RVUs based on the charts of patients we actually took care of. I have no way of proving if they did or didn't bill for them. They certainly wanted us to take the T sheet up there, which seemed to be a different message.
I agree though, CPR is pretty high in RVUs. So is cardioversion.
Simple things, like documenting Xrays and interpreting labs, which is part of a T sheet, but often forgotten on an EMR, add up. Documenting repeat exams. Billing critical care like you should. You're already doing it, you might as well get paid for it.

 

[TooMuchResearch]

You mean your "toxic encephalopathy" patients?

They taught me to use that diagnosis in the medical ICU.

 

[MSmentor018]

Is there a certain amount of time you have to spend for diet cousneling or exercise counseling?

coders told me ">8 minutes"
it all must be on how savvy these guys are. with my last group, the coders didn't bill for all these little things.

 

[EctopicFetus]

coders told me ">8 minutes"
it all must be on how savvy these guys are. with my last group, the coders didn't bill for all these little things.

If you really spent 8 minutes doing this I would be shocked. On another note the RVUs associated with this are tiny and as such probably makes it worthwhile to just pick up another chart instead. All this cute stuff like this will open you for an audit and at that time you will regret trying to squeeze an extra $2 per patient.

I am 100% for getting paid for what we do but when you push the envelope you may get burned.

on another note, I second the ortho stuff and recommend you do Obs when possible. Those codes bill better than critical care.

 

[old_boy]

recommend you do Obs when possible. Those codes bill better than critical care.

Explain please - doesn't this require the patient be under "observation status" for at least 6 hours? How do you bill for this as the ED doc?

 

[EctopicFetus]

Observation - Physician Coding FAQ // ACEP

8 hours for medicare. For others it is at your discretion. Have you ever held on to that patient who accidentally OD'ed and poison control says to watch them? The drunk who hit his head? The kid who failed his PO challenge and gets IV fluid? yada yada yada...

Do these people have insurance? Who knows.. but you can find your niche and bill for it.

 

[Janders]

Bingo. 8 hours medicare. Other insurances are different. If you cross midnight, that counts as 8 hours...

You think someone is drunk / high and needs to sleep it off until they act sober / have a ride in the AM ? Thats observation my friend. You are ensuring they don't have a worsening toxidrome or a subtle medical / traumatic /psychiatric cause of their altered sensory. We all have those "drunks" who we tuck in at 2300 and then at 0100 realize they are getting worse. Thats why we don't just wheel them to the sidewalk and dump them...

Severe gastroenteritis or canibinoid hyperemesis or cyclical vomiting that fails your first round of therapy, but you really think you can keep them out of the hospital given a few more hours? Boom observation. Severe anaphylaxis you want to keep 4+ hours? Obs. Young woman with pyelonephritis who looks ok but is vomiting and can't keep pills down and its 10pm? Consider observation until AM for IVF, zofran, IV abx and reassessment.

Psych cases? All go in observation if they are staying in the ED. They aren't just waiting for placement. They are having multiple security measures for their safety, serial exams, serial interviews with their placement team, they get seen by the MD at least daily, they are being restarted on their home meds, they often get new/PRN meds from me, they might be under observation to ensure no withdrawal for their alcohol/heroin abuse, etc. Thats very much billable observation. That, and the fact many of them stabilize after 1-2 days in the ED, and actually go home / outpatient....

One that likely doesn't net a ton of money, but saves hospital beds and avoids admissions and gets people into the right level of service--
We do a lot of elderly falls obs-- fall go boom no reason, seem unsafe to go home at 11pm alone and don't quite pass the bedside get-up-and-go test? Obs, consider serial labs in AM, formal PT eval at 0800, case management at 0900, see if they need rehab or higher level of care placement or if they qualify for home services, etc etc.


Now if your ED has 40 in the WR all night, you can't spare a bed for this type of obs.

Anyway, do NOT start putting people into observation to make money. However, if you are already holding people in your ED for >4hr, and NOT at least CONSIDERING observation billing/status, you are likely doing yourself and your facility a disservice.