New to RVUs—Looking for Tips on Maximizing as a Psychologist Doing Lots of Testing

[borne_before]

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Hi all,

My company is about to start using RVUs, and I’m trying to get up to speed. I’ve never worked in a system that used them before, so I’m starting from square one.

I’m a pediatric psychologist and spend the majority of my time doing diagnostic evaluations, particularly for neurodevelopmental conditions (autism, ADHD, learning disorders, etc.). I also do some therapy, but testing is the bulk of my clinical time.


For those of you familiar with working under RVUs:

• What strategies have you used to maximize productivity and value under this system?
• Are there specific CPT codes that tend to have a better RVU “return”?
• How do you balance thorough, ethical assessments with the pressure to produce?

I’d love any advice, examples, or even things to watch out for. Thanks in advance!

 

[cara susanna]

I bill for the interview as a psychiatric eval, then the psych testing code for scoring, interpretation, and report writing. Usually it amounts to 3 units for the latter, totaling 4 hours (which is what we're allocated in our clinic for one assessment).

 

[oliversacks4thewin]

I know you are involved in very young pediatric testing, so I will recommend thoroughly reviewing the differences between neurodevelopmental testing vs neuropsychological testing through CMS' website, to ensure no accidental billing mistake occurs. The unfortunate truth is that neuropsychological codes just produce higher wRVU's than neurobehavioral assessments, but require very specific criteria to be eligible, as they should.

Article - Billing and Coding: Psychological and Neuropsychological Testing (A57481)

Use this page to view details for the Local Coverage Article for Billing and Coding: Psychological and Neuropsychological Testing.

www.cms.gov

I would also additionally factor in the difference between codes associated with provider vs. technician administered testing, which you can weigh the cost-benefit analysis of using technicians in testing. You can check this with the use of the wRVU calculator tools out there

RVU Calculator - AAPC Relative Value Units

CPT® RVU calculator provides a quick analysis of the work relative value units associated with a certain volume of CPT or HCPCS codes.

www.aapc.com

Finally, I strongly recommend you put together a spreadsheet of all of the work you do and track it with as much consistency as you can. wRVU systems are not built with psychologists in mind. Consequently they often forget that we do a thousand other things (consult with school/ other providers, research, staff committees, etc.) that do not show up "in the numbers" but are vital to your performance and produce a lot for the system you work for, just not to the bean-counters lol.

 

[docloufan]

Hi all,

My company is about to start using RVUs, and I’m trying to get up to speed. I’ve never worked in a system that used them before, so I’m starting from square one.

I’m a pediatric psychologist and spend the majority of my time doing diagnostic evaluations, particularly for neurodevelopmental conditions (autism, ADHD, learning disorders, etc.). I also do some therapy, but testing is the bulk of my clinical time.


For those of you familiar with working under RVUs:

• What strategies have you used to maximize productivity and value under this system?
• Are there specific CPT codes that tend to have a better RVU “return”?
• How do you balance thorough, ethical assessments with the pressure to produce?

I’d love any advice, examples, or even things to watch out for. Thanks in advance!

Some of my below advice assumes you take insurance and are not fee-for-service only. But I maintain most of it should apply either way.

I would say you can "maximize" by documenting your reasoning/reasons in a very, very detailed way (which is obviously not compensated) but be careful about "milking it." Ethics, back-end audits, etc. The reality is some work just doesn't fall into the listed codes and insurance companies obviously have to put some reasonable limits on some things.

There are obviously going to be some limits on time allowed for "record review," slowing typing and slow thinking isn't justifiable for more time, being a new person or in-training isn't justifiable for more time, and you need to make sure that everything you are doing is adding to the potential treatment/treatment plan of the patient (and justify that), rather than being more for your own (or the parents) curiosity...or some question that can better explored during therapy sessions with the child or parent. You shouldn't count "breaks" in the testing session(s) toward the billable units/time. Your interview with patient and parents should be billed as 90791 and ideally before requesting testing/testing codes. K-SADS, SCID-V, CAPS, DIAMOND, etc. are really supposed to be billed as a 90791 (or maybe something else?) rather than being bundled with 96130/96131/96136/96137. Some duplication of testing for certain areas/symptoms/diagnoses is important in some cases, but not all. And there certainly IS such a thing as too much duplication and/or too much psychometric data. 96146 is terrible (and will probable confuse or cause problems with insurance PA) and wouldn't recommend anyone mess with it at all.

Specific code definitions and the specific kind of work captured by each one is also is important but that's really not that complicated and you should be trained in that already.

 

[Sanman]

1. RVU systems, though usually similar as they are based on billables, vary from company to company. Some are fair and some are garbage designed to make you a productivity machine.

2. Familiarize yourself with phone and electronic communication (secure only, not email) codes and billing standards. It will help increase your productivity.

3. Once you have read through what was posted above and what I suggested in detail, realize almost no one else will and ignorance is often rewarded by folks billing the wrong codes until someone does their homework.

 

[WisNeuro]

I bill for the interview as a psychiatric eval, then the psych testing code for scoring, interpretation, and report writing. Usually it amounts to 3 units for the latter, totaling 4 hours (which is what we're allocated in our clinic for one assessment).

Just one of the psych testing codes? If so, you may be undercoding.

 

[cara susanna]

Just one of the psych testing codes? If so, you may be undercoding.

I do the initial code and then the additional code (1+ units) for additional time. If there's more to that then yes, please tell me!

 

[Therapist4Chnge]

Why not 90791? Do that first, obv cover the necessary areas. Then appt 2 do the testing & report. It requires 2 appt, but depending on the testing, it could make more clinical sense to split up the time.

 

[ClinicalABA]

Why not 90791? Do that first, obv cover the necessary areas. Then appt 2 do the testing & report. It requires 2 appt, but depending on the testing, it could make more clinical sense to split up the time.

We do the initial intake billed as 90791, then bill testing codes on subsequent appointments.

 

[ClinicalABA]

Why not 90791? Do that first, obv cover the necessary areas. Then appt 2 do the testing & report. It requires 2 appt, but depending on the testing, it could make more clinical sense to split up the time.

We do the initial intake billed as 90791, then bill testing codes on subsequent appointments.

 

[docloufan]

I do the initial code and then the additional code (1+ units) for additional time. If there's more to that then yes, please tell me!

You charge/bill in 30 minute increments for the time it takes you to give and/or score more 2 or more tests (96136/96137). You should not count the time it takes for a patient to complete filling out the MMPI and/or any similar self-guided personality inventory or rating scale....only the labor of scoring it takes for those types of instruments.

Every hour you need for "interpretation" of those test results, integration of your interview data as it applies to those test results, the subsequent report writing, and the devising of treatment planning/recommendations within that report is billed with the "test evaluation services" codes, 96130 and 96131. APA has said the first unit/first hour (96130) can be automatically taken and used for "pre-service work"...but I have never really been sure what that means??? Maybe figuring out what the referral actually truly is about... and a preliminary record review?

 

[WisNeuro]

You charge/bill in 30 minute increments for the time it takes you to give and/or score more 2 or more tests (96136/96137). You should not count the time it takes for a patient to complete filling out the MMPI and/or any similar self-guided personality inventory or rating scale....only the labor of scoring it takes for those types of instruments.

Every hour you need for "interpretation" of those test results, integration of your interview data as it applies to those test results, the subsequent report writing, and the devising of treatment planning/recommendations within that report is billed with the "test evaluation services" codes, 96130 and 96131. APA has said the first unit/first hour (96130) can be automatically taken and used for "pre-service work"...but I have never really been sure what that means??? Maybe figuring out what the referral actually truly is about... and a preliminary record review?

This is what I have been told

 

[AcronymAllergy]

This is what I have been told

Same. And considerations about the test battery.

 

[PsyDr]

1) take a sheet of paper, put 1-16 down vertically, then fold in half vertically. Write down what you are doing every half hour. Now you know what you’re doing. Use this to start finding CPT codes for what you are doing.
2) start looking up cpt codes for EVERYTHING you do. Thinking about a case formulation? Billable. Phone call from a patient? Billable. Phone call to a referral source? Billable. Emr message? Billable. Record review? Billable. All of these activities have CPT codes. They may not pay anything, but you’re gaming the system your employer put you in.
3) if you are trying to be a “good guy”: don’t. Create policies and procedures. Patient wants to call you “for just 5 minutes”? Nope, make an appointment. Attorney is calling? Make an appointment. Your computers isn’t working, and maybe you could fix it yourself? Nope, that’s ITs problem and CC admin about it. Admin wants you to meet with them? Ask how they would consider this in terms of your rvus. 4) Stick with your contracted hours. Do not fall to pressure to work outside the initial agreement. If they move the goal post, ask how that will be compensated. Physicians and nurses are paid for being on call.
5) remember: you are NOT a billing specialist. They are shifting the responsibility for billing to you.

Finally: keep in mind that I am notoriously hard to work with.

 

[PsyDr]

You charge/bill in 30 minute increments for the time it takes you to give and/or score more 2 or more tests (96136/96137). You should not count the time it takes for a patient to complete filling out the MMPI and/or any similar self-guided personality inventory or rating scale....only the labor of scoring it takes for those types of instruments.

Reconcile your position with the cpt code description, specifically the part that says “administration” of the test. Then reconcile your position with the Federal law governing CMS that requires supervision of testing to be in person.

 

[WisNeuro]

Ah the joys of non-clinical work, not having to pay attention to a gajillion codes. Just X amount of time doing X at YYY/hr. Invoice. Send. Check.

As for my actual clinical work, pretty easy in PP, and my dementia evals are pretty streamlined and follow very similar times at this point.

 

[docloufan]

Reconcile your position with the cpt code description, specifically the part that says “administration” of the test. Then reconcile your position with the Federal law governing CMS that requires supervision of testing to be in person.

I dont know what this means. If you wanna say something, just say it.

 

[PsyDr]

I dont know what this means. If you wanna say something, just say it.

You are wrong about not being able to bill for the administration of the MMPI.

1) The CPT code relevant to the MMPI includes "test administration" (i.e., the time spent watching the patient fill out the form). This definition means you can and should bill for the time it takes the patient to complete the form.

2) CMS Fact Sheet states that underbilling is the same as overbilling (i.e., fraud). This means you should bill for the time spent administering the MMPI.

3) Before you say "But I am not there": The manual states that you are required to "supervise" the administration of the MMPI. Federal law defines supervision as you being "on premise".

TL; DR: You can and should bill for the administration of the MMPI. Not just the time you spent scoring and interpreting it.

 

[cara susanna]

I bill for chart review too.

 

[docloufan]

You are wrong about not being able to bill for the administration of the MMPI.

1) The CPT code relevant to the MMPI includes "test administration" (i.e., the time spent watching the patient fill out the form). This definition means you can and should bill for the time it takes the patient to complete the form.

2) CMS Fact Sheet states that underbilling is the same as overbilling (i.e., fraud). This means you should bill for the time spent administering the MMPI.

3) Before you say "But I am not there": The manual states that you are required to "supervise" the administration of the MMPI. Federal law defines supervision as you being "on premise".

TL; DR: You can and should bill for the administration of the MMPI. Not just the time you spent scoring and interpreting it.

I dont think this is correct, sorry.

 

[WisNeuro]

I dont think this is correct, sorry.

From a technical/legal standpoint, it just may be. The only formal guidelines I have seen from APA only stipulate that you do not count the time it takes to administer a computerized test that does not require supervision.

 

[borne_before]

So I just spent 15 minutes reviewing a chart and reading up on a autosomal dominant gene variant with an associated neurodevelopmental syndrome. I can bill for that?

Or do I want to spend at least 31 minutes doing that?

 

[Therapist4Chnge]

TL; DR: You can and should bill for the administration of the MMPI. Not just the time you spent scoring and interpreting it.

I charge for it bc I am present and need to monitor to answer questions. I’d guess <5 patients a year make it through the -2RF and don’t ask me a question. My average patient is probably 10-14yr of education, often English as a second language, etc. Otherwise I’m organizing paperwork, getting some scoring done, etc.

 

[Therapist4Chnge]

So I just spent 15 minutes reviewing a chart and reading up on a autosomal dominant gene variant with an associated neurodevelopmental syndrome. I can bill for that?

Or do I want to spend at least 31 minutes doing that?

You bet! I always do it for forensic cases, but ALSO for clinical work. If I am reviewing a chart to inform on the case and data I’m collecting, that all applies. Take that 15min and I’m sure at some point you’ll spend 16-30+ min on a related task for that case too.

Lawyers bill in 6min increment, and we should too…or at least track like them. Being a neuropsychologist taught me to track my time and be more efficient while doing it. Codes were made to include report writing, which is central to our work.

 

[AcronymAllergy]

So I just spent 15 minutes reviewing a chart and reading up on a autosomal dominant gene variant with an associated neurodevelopmental syndrome. I can bill for that?

Or do I want to spend at least 31 minutes doing that?

There is a chart review code, although I don't remember what it is. From what I remember, the wRVUs are pretty bad and I don't know that it actually pays anything. Or if this is a patient you'll be seeing for an evaluation, you just roll that time into the evaluation code(s).

 

[PsyDr]

I dont think this is correct, sorry.

Cool.

"I don't believe in 42 CFR 410.32, or Association, A. M. (2024). CPT Professional 2025, American Medical Association."- doclofan

 

[borne_before]

Well crap, theyre closing our clinic in two months. thisll be at least useful if I go to place the does RVU billing.

 

[Sanman]

Well crap, theyre closing our clinic in two months. thisll be at least useful if I go to place the does RVU billing.

Sorry to hear that. Are you definitely out of the job or could you be located to a different clinic?

 

[borne_before]

Sorry to hear that. Are you definitely out of the job or could you be located to a different clinic?

I'm out of a job at the end of June. Not sure what my plans will be. There's a couple of potential positions at hospitals nearby. I've always kicked around the idea of private practice.

 

[WisNeuro]

I'm out of a job at the end of June. Not sure what my plans will be. There's a couple of potential positions at hospitals nearby. I've always kicked around the idea of private practice.

Come on over here, I get calls all the time for peds assessment. Most places are sitting at 9+ month wait lists for peds neuro.

 

[AcronymAllergy]

Come on over here, I get calls all the time for peds assessment. Most places are sitting at 9+ month wait lists for peds neuro.

Ditto. So, so, so ditto RE: peds neurodevelopmental d/o evals (not even specifically neuropsych).

Or if you feel comfortable doing adult autism and ADHD evaluations, I could probably fill your calendar until retirement just with that.

It's stressful for sure, which sucks. But folks with solid peds assessment skills are in high demand pretty much everywhere.

 

[WisNeuro]

Ditto. So, so, so ditto RE: peds neurodevelopmental d/o evals (not even specifically neuropsych).

Or if you feel comfortable doing adult autism and ADHD evaluations, I could probably fill your calendar until retirement just with that.

It's stressful for sure, which sucks. But folks with solid peds assessment skills are in high demand pretty much everywhere.

Definitely, I get more than a handful of these calls a month despite never advertising and my referral sources knowing that I do not see these.

 

[PsyDr]

I'm out of a job at the end of June. Not sure what my plans will be. There's a couple of potential positions at hospitals nearby. I've always kicked around the idea of private practice.

May I suggest that you use this time to collect forms and referral source names?

 

[AcronymAllergy]

Definitely, I get more than a handful of these calls a month despite never advertising and my referral sources knowing that I do not see these.

Same. My referral sources know I don't do them, but they still keep sending them, probably in the hopes that one day I might relent and take at least a couple.

 

[cara susanna]

Based on what I've seen from other psychologists, doing adult ADHD or autism evals is bound to get you complaints.

 

[Sanman]

Based on what I've seen from other psychologists, doing adult ADHD or autism evals is bound to get you complaints.

Are we talking board complaints or just the rantings of people who spend too much time on the internet and believe their complex ptsd caused from being spanked once at age 2 has clearly given them adhd per reddit?

 

[WisNeuro]

Are we talking board complaints or just the rantings of people who spend too much time on the internet and believe their complex ptsd caused from being spanked once at age 2 has clearly given them adhd per reddit?

Both. In my experience, people willing to pay cash for these evals are invested in having the diagnosis, and feel entitled to it no matter what after paying cash for the eval. I have far better ways to make money with far less headache, than doing these evals.

 

[borne_before]

Come on over here, I get calls all the time for peds assessment. Most places are sitting at 9+ month wait lists for peds neuro.

This is good news. I am a bit of unicorn, too. I'm a male child psychologist who does testing and intervention (evidenced based parent management training). However, I am not a neuropsychologist.

Ditto. So, so, so ditto RE: peds neurodevelopmental d/o evals (not even specifically neuropsych).

Or if you feel comfortable doing adult autism and ADHD evaluations, I could probably fill your calendar until retirement just with that.

It's stressful for sure, which sucks. But folks with solid peds assessment skills are in high demand pretty much everywhere.

I'd probably go to age 21 for autism/adhd/IDD evaluations. There's like four jobs I've identified thus far. But, I am waiting to see the vibe of those positions before I make any decisions.

Thank's y'all. I'm definitely feeling the love. At least I get some runway to figure things out.

I know this is kind of dumb, but this place saw the poorest and most medically complex kids in my state. About 5000 kids are now going to be pushed into other systems of care that are already at capacity. This is gonna be a public health crisis. No one has the capacity to continue seeing these kiddos for med management alone (both neurological meds and behavioral meds).

 

[borne_before]

If I do start a private practice, I might "blog" about it here or make a post for each "hurdle" with a prefix: "Startin' a practice: Finding an office" or "Startin' a practice: billing"

 

[Sanman]

If I do start a private practice, I might "blog" about it here or make a post for each "hurdle" with a prefix: "Startin' a practice: Finding an office" or "Startin' a practice: billing"

Keep it in a single thread. Easier to follow.

 

[Sanman]

I know this is kind of dumb, but this place saw the poorest and most medically complex kids in my state. About 5000 kids are now going to be pushed into other systems of care that are already at capacity. This is gonna be a public health crisis. No one has the capacity to continue seeing these kiddos for med management alone (both neurological meds and behavioral meds).

As someone that has worked with some of the very poorest individuals for over a decade, the next few years are not going to be good for the poor people business. I would limit medicaid exposure until the dust settles.

 

[borne_before]

What even do I name my practice?

 

[PsyDr]

What even do I name my practice?

The name isn't that important. Your state will have a website where you can see if an LLC name is available. Once you find a generic name for your LLC, you can also file a DBA business title (doing business as). So "BorneBefore LLC" can also legally present itself as "Super Awesome A 1 Psychology Practice LLC".