RVUs

[Iamnew2]

Can someone please elucidate me on how RVUs work? I'm going to be changing jobs soon and will be taking a base salary + RVU type gig with only RVU later. Can someone explain to me how this works (the RVU part)? I have never worked an RVU based gig - only employee with production which seemed kinda lame, and independent contractor type gig. Is there a certain amount of value per RVU that's assigned and how is that determined? And how do you see what your total RVUs are per month/year - do they give you a list typically? Thank you!

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[Ogliodendrocyte]

You

Can someone please elucidate me on how RVUs work? I'm going to be changing jobs soon and will be taking a base salary + RVU type gig with only RVU later. Can someone explain to me how this works (the RVU part)? I have never worked an RVU based gig - only employee with production which seemed kinda lame, and independent contractor type gig. Is there a certain amount of value per RVU that's assigned and how is that determined? And how do you see what your total RVUs are per month/year - do they give you a list typically? Thank you!

Ive never worked on RVU basis myself.l but here is a RVU calculator. Just plug in the cpt code plus however many you did then will calculate your RVUs

AAPC.com - Maintenance

 

[DOctorJay]

these videos should give you a good basis and answer most of your questions

the wRVU calculator posted above is very helpful as well

your new job will be tallying up all of these wRVUs for you based on how you bill (99214, 99244, 99204, 64483, etc). they should provide this to you at least on a monthly basis and I'd strongly recommend you monitor it yourself for at least the first few months to make sure they're capturing everything. some EMRs will make this easy if your job allows you access to the tools (EPIC does this but my network doesn't give us the option to see the wRVUs in there).

there are percentiles determined based off of your wRVU productivity. most jobs will want you producing around at least the 50th percentile and your bonuses will be determined based on your productivity above those thresholds.

if you share your contract details here many docs will chime in on how it looks and how to maximize your efforts. I'm a little nervous that if you don't know how these things work you may have been taken advantage of.

the most important piece of information in a contract like this is the $/wRVU you are receiving. you should calculate out what your total take home would be for varying levels (so check it at 5,000 wRVUS, 7,000 wRVUs, and 10,000 wRVUs)

 

[guytakingboards]

Can someone please elucidate me on how RVUs work? I'm going to be changing jobs soon and will be taking a base salary + RVU type gig with only RVU later. Can someone explain to me how this works (the RVU part)? I have never worked an RVU based gig - only employee with production which seemed kinda lame, and independent contractor type gig. Is there a certain amount of value per RVU that's assigned and how is that determined? And how do you see what your total RVUs are per month/year - do they give you a list typically? Thank you!

Relative Value Units are an attempt to quantify production in a standard way across all specialties. The monetary value of a single RVU is standardized. Medicare paid about $32.40 per RVU in 2021. Commercial payors pay a higher rates per RVU.

Each CPT code reimburses a certain amount of RVU's. As mentioned by ogliodendrocyte, you can calculate your monthly/yearly RVU production by totally all the CPT codes you billed times their RVU value.

If you're working a production/RVU based job, they *should* be giving you running updates on your productivity. They and you need to know how you're doing.

It'd probably be a smart thing to call the billing office of your current group and get your numbers for the past 1-2 years to get a baseline of how much work you've already been doing.

 

[DMBandFan86]

You should be given your wRVU pay chart before you sign a contract. Just ask the recruiter.

Takes a while to actually make production off base salary. Can be very hard the 1st year, especially if you got a sign on bonus. Easier if you are just inheriting patients from a highly established practice. But if starting a new practice then hopefully they give you 2-3 year guaranteed base. RVU payouts are also usually only paid out quarterly, bi-annually, or annually depending on your contract or adjustments to your salary every 6-12 months. Helps if the employer is willing to give you extra staff to increase your productivity, or scribe, or PA.

If you are getting admin pay as well (program/medical director), you would be wise to have your rvu productivity based on your clinical salary - admin pay. Then you don’t have to produce up to full salary before going on production.

 

[DMBandFan86]

Another thing I’d note that someone else also mentioned is to watch your coders. Do your own audits. Some places are 100% inpatient coding, which gives docs little say in the code being placed from your service. I had been in a situation where they were completely missing patients (for entire IPR stays), billing incorrectly based on my documentation, etc. Nothing worse than spending an hour on a patient, documenting time based coding and your employer only gave you credit for a level 1. And that was with turning in a billing sheet that they later told me they were just shredding and not looking at. Or spending 4 weeks on a patient that they either forgot to bill or give you credit for. If you are going on EPIC that should make things easier.

 

[j4pac]

If your plan on reviewing your own imaging…that can be billed but you’ll need a 25 modifying. I’d definitely get a list of every conceivable cpt code for procedures, encounters, imaging review, etc. you’ll need to know -50 modifier indications for all of the procedures, including Botox and other injections.

I didn’t hate RVU production…I honestly would have disliked collections more. Worrying about who to provide care would have sucked. But Im now free of production models and work on salary, which is definitely my favorite route…military and academics just works better for me because I really just want to see patients and have minimal thought toward who I’m seeing and the procedures I’m choosing to do on patients.

 

[Iamnew2]

If your plan on reviewing your own imaging…that can be billed but you’ll need a 25 modifying. I’d definitely get a list of every conceivable cpt code for procedures, encounters, imaging review, etc. you’ll need to know -50 modifier indications for all of the procedures, including Botox and other injections.

I didn’t hate RVU production…I honestly would have disliked collections more. Worrying about who to provide care would have sucked. But Im now free of production models and work on salary, which is definitely my favorite route…military and academics just works better for me because I really just want to see patients and have minimal thought toward who I’m seeing and the procedures I’m choosing to do on patients.

I'm going to ask another question on this thread and would love it if you guys would chime in. At My current hospital the staff for example when a patient goes out for a LOA/ACT and say they are nearing the end of their stay (for example literally leaving the day before they would discharge as an LOA) they want to bring them back for a whole new admission under debility. Say they admitted for a CVA, completed all their medicare days, then go out for something completely unrelated, and then they want to bring them back under debility. I find this to be utterly shady. Thoughts?

 

[RangerBob]

I'm going to ask another question on this thread and would love it if you guys would chime in. At My current hospital the staff for example when a patient goes out for a LOA/ACT and say they are nearing the end of their stay (for example literally leaving the day before they would discharge as an LOA) they want to bring them back for a whole new admission under debility. Say they admitted for a CVA, completed all their medicare days, then go out for something completely unrelated, and then they want to bring them back under debility. I find this to be utterly shady. Thoughts?

Sorry--I'm confused. Is LOA/ACT the same as a home visit? Or just an early discharge? LOA to me means "leave of absence" and I'm not sure how that applies to rehab.

I also don't understand what "then go out for something completely unrelated means."

Still, it sounds sort of fishy from what I can gather. While you can certainly bring someone back to rehab shortly after they're discharged, you would need a rationale and they'd need to meet criteria just as they did before. The few quick re-admits we've had in that situation are ones who say had a stroke, went home, then fell and had a non-operative pelvic fracture.

It's hard to justify a debility diagnosis if the person was literally just discharged. And the debility needs to be caused by something--UTI, PNA, etc. I've never had a patient get debility in just a day or two--even if their acute care stay is only a day or two, the issue was brewing long before that.

Plus, without a new event, it would be hard to meet/justify medical necessity if you literally just discharged the patient and said they're medically stable enough to go home.

If the unit is really being that sketchy, AND you're already set for your new job, AND you don't mind burning down the house, my understanding is you can report that sort of fishy stuff to Medicare and you actually get half of whatever Medicare recoups back after they do an investigation/audit. However, if you're the one signing the PAS/certifying that patient as appropriate for IPR when they're actually not, then you're putting yourself at risk. You could always argue the hospital is pressuring you, but you can be sure if there was ever an audit/lawsuit, the hospital is probably going to say they deferred entirely to your professional expertise.

If your hospital is pressuring you to admit patients you know aren't appropriate for rehab, it's as simple as telling them it's your license on the line, and you won't do it. I know that's easier said than done when it's your job on the line, but if the place really is that shady then you either need to fix that or get out.

 

[lejeunesage]

I'm going to ask another question on this thread and would love it if you guys would chime in. At My current hospital the staff for example when a patient goes out for a LOA/ACT and say they are nearing the end of their stay (for example literally leaving the day before they would discharge as an LOA) they want to bring them back for a whole new admission under debility. Say they admitted for a CVA, completed all their medicare days, then go out for something completely unrelated, and then they want to bring them back under debility. I find this to be utterly shady. Thoughts?

Yo, this sounds shady af.
As a sporadic thing if/when something new/unexpected happened to the patient after discharge?
Sure.

Say a stroke patient goes home, falls, breaks their hip, requires a hemiarthroplasty, and now needs rehab s/p joint replacement? Sure.
But a stroke patient goes home, then is just readmitted for debility because... something something I want to get paid more? GTFOOT ASAP.

Like I said, shady af.

 

[DMBandFan86]

If they are LOA still then no they would be the same diagnosis.

If they were gone more than 3 midnights then you can bring them back as a re-admission or new diagnosis that justifies why they need IPR. Eventually they will run out of hospital days. Maybe they got sick enough to need more rehab.


Historically, a lot of shady stuff has gone on in many IPRs. That’s why Medicare made the 60/40 rule as a way of cutting it down. Where I had been working used to just admit anyone who came into the hospital before the 60/40 (way before I started). Then you end up with a census of people near death trying to do rehab. Next Medicare will cut down on the encephalopathy diagnosis for all the dementia patients who developed an infection.

 

[Iamnew2]

Sorry--I'm confused. Is LOA/ACT the same as a home visit? Or just an early discharge? LOA to me means "leave of absence" and I'm not sure how that applies to rehab.

I also don't understand what "then go out for something completely unrelated means."

Still, it sounds sort of fishy from what I can gather. While you can certainly bring someone back to rehab shortly after they're discharged, you would need a rationale and they'd need to meet criteria just as they did before. The few quick re-admits we've had in that situation are ones who say had a stroke, went home, then fell and had a non-operative pelvic fracture.

It's hard to justify a debility diagnosis if the person was literally just discharged. And the debility needs to be caused by something--UTI, PNA, etc. I've never had a patient get debility in just a day or two--even if their acute care stay is only a day or two, the issue was brewing long before that.

Plus, without a new event, it would be hard to meet/justify medical necessity if you literally just discharged the patient and said they're medically stable enough to go home.

If the unit is really being that sketchy, AND you're already set for your new job, AND you don't mind burning down the house, my understanding is you can report that sort of fishy stuff to Medicare and you actually get half of whatever Medicare recoups back after they do an investigation/audit. However, if you're the one signing the PAS/certifying that patient as appropriate for IPR when they're actually not, then you're putting yourself at risk. You could always argue the hospital is pressuring you, but you can be sure if there was ever an audit/lawsuit, the hospital is probably going to say they deferred entirely to your professional expertise.

If your hospital is pressuring you to admit patients you know aren't appropriate for rehab, it's as simple as telling them it's your license on the line, and you won't do it. I know that's easier said than done when it's your job on the line, but if the place really is that shady then you either need to fix that or get out.

I love you Ranger Bob! (In an academic sort of way!) Yes this is exactly what I tell the team. So we had a patient that would be going home in two days, and that was simply because of the logistics otherwise she would have gone home early. She came in with a CVA. Then had a mild GI bleed so she went out to the hospital, I suggested since the patient was going to be discharging anyways in a couple of days, to have her go home. Team almost chewed me out as to how we should admit her under "debility" and have her come back. I said that's not appropriate. She had a stroke, was doing well and we were going to dc her anyways. We had another patient literally that was going to dc today to SNF, she went out because of AMS bu they want to bring her back as a debility. I said no we were going to dc to SNFtoday I can't make up this stuff guys I can't and won't make up diagnosis and like you said I keep on explaining to them that debility is due to something! I keep telling them this is medicare fraud and it's not appropriate, and they rag on me non stop. I find this delusional. And no the home visit is something different - this patient they were going to do a home evaluation as they do for all strokes but because she went out as an acute transfer to the hospital they said well we have to do the home eval - maybe she needs SNF!

Yes they don't care about medical necessity -I keep telling them Medicare requires medical necessity. They don't care. I even tried to explain to them - how can we readmit a patient that we were going to discharge today and fabricate a debility? The liaisons even lie to me and fabricate FIM scores (which I didn't know that they came up with the FIM scores until recently!!!) to make them seem lower functionally than they are, and once they are at the hospital they want to keep patients for 4, 5 plus days after they are mod I- despite me explaining to them once they are mod I patients have reached their goals and outside of medical issues they go home!!!!

I deny inappropriate patients, but now they are ignoring my recommendations and having the Medicine team admit them - despite them not being pm&r physicians. They say they are "double credentialed" as rehab/medicine doctors - despite the fact that they have no PM&R training, and they write PM&R notes despite the fact that they are not PM&R doctors. I have told them all of this is not legal.

I feel like I'm in the twighglitht zone - then I had the director of patient outcomes literally insult me in the hallway - I reported him to HR.

" go out for something completely unrelated means." -what I mean by this is this patient for example had a CVA as initial diagnosis for rehab, then they had a mild GI issue and had to go out to the acute care transfer. So the reason for why they went out had nothing to do with the initial diagnosis. They want me to do a whole new readmission under "debility" - patient was min A and walking with a RW!!!

They want to at times admit patients that are supervision!! Yeah I'm out of there shortly. I won't do shady stuff. They have had like 8 or 9 medical directors in like 10 years - it's not shocking why!

 

[Iamnew2]

Yo, this sounds shady af.
As a sporadic thing if/when something new/unexpected happened to the patient after discharge?
Sure.

Say a stroke patient goes home, falls, breaks their hip, requires a hemiarthroplasty, and now needs rehab s/p joint replacement? Sure.
But a stroke patient goes home, then is just readmitted for debility because... something something I want to get paid more? GTFOOT ASAP.

Like I said, shady af.

Yes exactly if there is a new diagnosis of course I would admit. I've had patients exactly as you mention - CVA, go home fall, have hip fracture. No problem to re admit.

But as mentioned, for example, we had a CVA who was going to dc in a day or two, went out for GI issues, was doing well mostly min A, ambulating close to 200ft, then had a mild bleed, GI wasn't impressed but she's elderly so they are monitoring her, now the staff want me to re-admit her (she was out 3 midnights so she would have to be a new referral), and they were like can we admit under debility? I said no, she would have just discharged in a couple of days of course I can't readmit under debility!

I tell them - this is MY license, I will NOT commit fraud no matter how much pressure you guys put on me. Then they insult me or tell me how I'm unreasonable. It is super shady.

 

[Iamnew2]

If they are LOA still then no they would be the same diagnosis.

If they were gone more than 3 midnights then you can bring them back as a re-admission or new diagnosis that justifies why they need IPR. Eventually they will run out of hospital days. Maybe they got sick enough to need more rehab.


Historically, a lot of shady stuff has gone on in many IPRs. That’s why Medicare made the 60/40 rule as a way of cutting it down. Where I had been working used to just admit anyone who came into the hospital before the 60/40 (way before I started). Then you end up with a census of people near death trying to do rehab. Next Medicare will cut down on the encephalopathy diagnosis for all the dementia patients who developed an infection.

Agreed. This is exactly what they try to do here - patient admitted for appropriate diagnosis (in this case, CVA) doing well, about to go home, goes out on a LOA, 3 midnights pass, something minor happens in this case some gastritis or something, then they want to do another whole admission as a debility. I agree, medicare will absolutely cut down on the encephalopathy type diagnosis and other things like that.

They get angry when I don't admit supervision or min A patients. Instead of allowing the physician to manage the team, they want to tell the physician what to do.

 

[lejeunesage]

I love you Ranger Bob! (In an academic sort of way!) Yes this is exactly what I tell the team. So we had a patient that would be going home in two days, and that was simply because of the logistics otherwise she would have gone home early. She came in with a CVA. Then had a mild GI bleed so she went out to the hospital, I suggested since the patient was going to be discharging anyways in a couple of days, to have her go home. Team almost chewed me out as to how we should admit her under "debility" and have her come back. I said that's not appropriate. She had a stroke, was doing well and we were going to dc her anyways. We had another patient literally that was going to dc today to SNF, she went out because of AMS bu they want to bring her back as a debility. I said no we were going to dc to SNFtoday I can't make up this stuff guys I can't and won't make up diagnosis and like you said I keep on explaining to them that debility is due to something! I keep telling them this is medicare fraud and it's not appropriate, and they rag on me non stop. I find this delusional. And no the home visit is something different - this patient they were going to do a home evaluation as they do for all strokes but because she went out as an acute transfer to the hospital they said well we have to do the home eval - maybe she needs SNF!

Yes they don't care about medical necessity -I keep telling them Medicare requires medical necessity. They don't care. I even tried to explain to them - how can we readmit a patient that we were going to discharge today and fabricate a debility? The liaisons even lie to me and fabricate FIM scores (which I didn't know that they came up with the FIM scores until recently!!!) to make them seem lower functionally than they are, and once they are at the hospital they want to keep patients for 4, 5 plus days after they are mod I- despite me explaining to them once they are mod I patients have reached their goals and outside of medical issues they go home!!!!

I deny inappropriate patients, but now they are ignoring my recommendations and having the Medicine team admit them - despite them not being pm&r physicians. They say they are "double credentialed" as rehab/medicine doctors - despite the fact that they have no PM&R training, and they write PM&R notes despite the fact that they are not PM&R doctors. I have told them all of this is not legal.

I feel like I'm in the twighglitht zone - then I had the director of patient outcomes literally insult me in the hallway - I reported him to HR.

" go out for something completely unrelated means." -what I mean by this is this patient for example had a CVA as initial diagnosis for rehab, then they had a mild GI issue and had to go out to the acute care transfer. So the reason for why they went out had nothing to do with the initial diagnosis. They want me to do a whole new readmission under "debility" - patient was min A and walking with a RW!!!

They want to at times admit patients that are supervision!! Yeah I'm out of there shortly. I won't do shady stuff. They have had like 8 or 9 medical directors in like 10 years - it's not shocking why!

Dear God. I've seen my share of shady stuff but this is next level.

 

[lejeunesage]

I love you Ranger Bob! (In an academic sort of way!) Yes this is exactly what I tell the team. So we had a patient that would be going home in two days, and that was simply because of the logistics otherwise she would have gone home early. She came in with a CVA. Then had a mild GI bleed so she went out to the hospital, I suggested since the patient was going to be discharging anyways in a couple of days, to have her go home. Team almost chewed me out as to how we should admit her under "debility" and have her come back. I said that's not appropriate. She had a stroke, was doing well and we were going to dc her anyways. We had another patient literally that was going to dc today to SNF, she went out because of AMS bu they want to bring her back as a debility. I said no we were going to dc to SNFtoday I can't make up this stuff guys I can't and won't make up diagnosis and like you said I keep on explaining to them that debility is due to something! I keep telling them this is medicare fraud and it's not appropriate, and they rag on me non stop. I find this delusional. And no the home visit is something different - this patient they were going to do a home evaluation as they do for all strokes but because she went out as an acute transfer to the hospital they said well we have to do the home eval - maybe she needs SNF!

Yes they don't care about medical necessity -I keep telling them Medicare requires medical necessity. They don't care. I even tried to explain to them - how can we readmit a patient that we were going to discharge today and fabricate a debility? The liaisons even lie to me and fabricate FIM scores (which I didn't know that they came up with the FIM scores until recently!!!) to make them seem lower functionally than they are, and once they are at the hospital they want to keep patients for 4, 5 plus days after they are mod I- despite me explaining to them once they are mod I patients have reached their goals and outside of medical issues they go home!!!!

I deny inappropriate patients, but now they are ignoring my recommendations and having the Medicine team admit them - despite them not being pm&r physicians. They say they are "double credentialed" as rehab/medicine doctors - despite the fact that they have no PM&R training, and they write PM&R notes despite the fact that they are not PM&R doctors. I have told them all of this is not legal.

I feel like I'm in the twighglitht zone - then I had the director of patient outcomes literally insult me in the hallway - I reported him to HR.

" go out for something completely unrelated means." -what I mean by this is this patient for example had a CVA as initial diagnosis for rehab, then they had a mild GI issue and had to go out to the acute care transfer. So the reason for why they went out had nothing to do with the initial diagnosis. They want me to do a whole new readmission under "debility" - patient was min A and walking with a RW!!!

They want to at times admit patients that are supervision!! Yeah I'm out of there shortly. I won't do shady stuff. They have had like 8 or 9 medical directors in like 10 years - it's not shocking why!

Now, as far as I understand, rehab docs don't have to be PM&R trained, as far as Medicare is concerned. They just need to have rehab experience, which is really loosely defined. It could be SNF experience. So, that part is not necessarily an issue. I've had internists cover for me when I'm on vacation. The problem I see is the systematic invention of reasons to admit patients to IPR when they obviously don't meet criteria.

 

[Iamnew2]

Now, as far as I understand, rehab docs don't have to be PM&R trained, as far as Medicare is concerned. They just need to have rehab experience, which is really loosely defined. It could be SNF experience. So, that part is not necessarily an issue. I've had internists cover for me when I'm on vacation. The problem I see is the systematic invention of reasons to admit patients to IPR when they obviously don't meet criteria.

Well they certainly shouldn't be writing notes as "PM&R" physicians or having them admit them when I say no. Particularly because the only reason I say no is when they don't meet criteria. This constant desire to admit supervision, across the board min A patients is just nuts, or to continue keeping patients longer than they should. We had a patient that was mod I, ambulating close to 500ft with no AD, and they wanted another week. I almost passed out.

 

[lejeunesage]

Well they certainly shouldn't be writing notes as "PM&R" physicians or having them admit them when I say no. Particularly because the only reason I say no is when they don't meet criteria. This constant desire to admit supervision, across the board min A patients is just nuts, or to continue keeping patients longer than they should. We had a patient that was mod I, ambulating close to 500ft with no AD, and they wanted another week. I almost passed out.

Well, sounds like you're making the right call getting out of there.
Sounds like the kind of place that admits anything with a pulse.

They definitely shouldn't be writing "PM&R" notes but I think for the purpose of Medicare, they can write "Rehab face-to-face" notes. Someone correct me if I'm wrong.

 

[RangerBob]

If the patient is transferred to acute that could potentially qualify them for a new rehab stay. "Mild GI bleed" isn't normally what I'd think of, but if the patient is at a lower functional level than when they discharged from rehab (or the team thinks there's still a lot of functional potential) then bringing under a new diagnosis of debility is reasonable, assuming debility is the primary driver of disability. Often we just bring them back under the original diagnosis because we never finished their rehab in the first place (ie., we still needed another week or so to get them home).

It doesn't sound like that's the case here. If the patient has met their functional goals, then it would be hard to justify bringing them.

Same if they were destined for SNF. We rarely take acute patients who we know need to go to SNFs, but we make exceptions if we think they can carry those gains and maintain them at a SNF (younger patient, cognitively intact, motivated, etc.). We're very limited on beds as well, so we have to be picky. But there's no question if the patient had already done rehab and was destined for SNF, we wouldn't take them back just to send to a SNF again.

We admit patients who are MinA all the time, but we usually have a goal of ModI for them. I don't admit patients who are at supervision level, unless maybe they're a 30 year old stroke patient, and are maybe speech heavy and we're trying to help the patient.

Having the IM docs admit patients you decline is pretty sketchy.

I agree IM shouldn't write "PM&R" notes, but I do believe lejuneesage is correct that they can write "Rehab" notes.

 

[DMBandFan86]

There is nothing fraud about keeping someone longer on rehab. Medicare only pays you for the rehab stay, doesn’t matter how long they stay. Private insurances will not pay for it. So there is nothing fraud, your facility just gets less money due to costs of overhead and lost revenue. If the administration doesn’t care about the money, then I’m not sure why it matters. You still get paid the same.

If you keep someone 8 weeks and only got paid for 3 weeks, that’s not fraud, just poor profitability.

I also don’t see an issue with admitting min-A patients, even supervision sometimes. Depends on the situation. Being S level for many means not safe enough to go home. If you expect they will get to mod-I with rehab in 5-12 days then I don’t see an issue with it.

Medical necessity is something a lot of us struggle with. It is completely subjective in my opinion. Private insurance companies use it to keep people out of rehab. But, we are also allowed to admit people from home that are stable. Couldn’t find 2 people who agree exactly what medical complexity is.

 

[Iamnew2]

There is nothing fraud about keeping someone longer on rehab. Medicare only pays you for the rehab stay, doesn’t matter how long they stay. Private insurances will not pay for it. So there is nothing fraud, your facility just gets less money due to costs of overhead and lost revenue. If the administration doesn’t care about the money, then I’m not sure why it matters. You still get paid the same.

If you keep someone 8 weeks and only got paid for 3 weeks, that’s not fraud, just poor profitability.

I also don’t see an issue with admitting min-A patients, even supervision sometimes. Depends on the situation. Being S level for many means not safe enough to go home. If you expect they will get to mod-I with rehab in 5-12 days then I don’t see an issue with it.

Medical necessity is something a lot of us struggle with. It is completely subjective in my opinion. Private insurance companies use it to keep people out of rehab. But, we are also allowed to admit people from home that are stable. Couldn’t find 2 people who agree exactly what medical complexity is.

Continuing to keep patients longer once they have met goals is fraud in my view or continuing to admit the same patient with the same diagnosis is fraud as is making patients seem lower on a Pas when they are much higher than they are, or admitting people that are able to go home but the liaisons tell them you have to come to therapy etc.

 

[Iamnew2]

If the patient is transferred to acute that could potentially qualify them for a new rehab stay. "Mild GI bleed" isn't normally what I'd think of, but if the patient is at a lower functional level than when they discharged from rehab (or the team thinks there's still a lot of functional potential) then bringing under a new diagnosis of debility is reasonable, assuming debility is the primary driver of disability. Often we just bring them back under the original diagnosis because we never finished their rehab in the first place (ie., we still needed another week or so to get them home).

It doesn't sound like that's the case here. If the patient has met their functional goals, then it would be hard to justify bringing them.

Same if they were destined for SNF. We rarely take acute patients who we know need to go to SNFs, but we make exceptions if we think they can carry those gains and maintain them at a SNF (younger patient, cognitively intact, motivated, etc.). We're very limited on beds as well, so we have to be picky. But there's no question if the patient had already done rehab and was destined for SNF, we wouldn't take them back just to send to a SNF again.

We admit patients who are MinA all the time, but we usually have a goal of ModI for them. I don't admit patients who are at supervision level, unless maybe they're a 30 year old stroke patient, and are maybe speech heavy and we're trying to help the patient.

Having the IM docs admit patients you decline is pretty sketchy.

I agree IM shouldn't write "PM&R" notes, but I do believe lejuneesage is correct that they can write "Rehab" notes.

The problem is they want to admit everything - nausea and vomiting goes to the Er it’s a debility. Constipation debility due to constipation. 30 year old stroke that went to the Ed for foot pain? Stroke diagnosis. 95 yo who can’t move and is on deathbed? Debility due to old age. Mod I in 5 days? Let’s ask for more time from insurance!! Drives me nuts

 

[RangerBob]

Continuing to keep patients longer once they have met goals is fraud in my view or continuing to admit the same patient with the same diagnosis is fraud as is making patients seem lower on a Pas when they are much higher than they are, or admitting people that are able to go home but the liaisons tell them you have to come to therapy etc.

DMBandFan86 has a point that you can keep people past their dates, but the hospital won't get paid for it. And Medicare could in theory claw back some money they paid you the physician if the patient no longer met necessity (and likewise private insurance could stop reimbursing you as well). But they won't take money from the hospital because they only paid for x number of days anyway.

So I think they're right that it's not outright fraud, but rather stupidity. Because it costs the hospital/unit a lot of money to keep people over their days when they don't need it. The Medicare assigned days are really more guidelines--we often keep people longer, many we send out sooner. People advance at different rates.

But yes, keeping someone when they're already ModI doesn't make practical sense, particularly if that bed could go to someone else.

 

[DMBandFan86]

I think my experience is not relatable to the poster. I have not encountered many patients that are willing to be hospitalized after reaching a true mod-I and are healthy enough to go home.

 

[Iamnew2]

I think my experience is not relatable to the poster. I have not encountered many patients that are willing to be hospitalized after reaching a true mod-I and are healthy enough to go home.

I invite you to my rehab unit then! Many Patients want to stay as long as they humanly can and at times refuse to leave in part because of poor socioeconomics. In the words of one when he was doing super well and really didn’t need any more help he said “free food! Why not”?Therapists want to frequently ask for a week plus after they are mod i. Blows my mind. We have had patients walking 800-1000ft and therapist want to keep them longer, etc. at times. I do not understand them

 

[j4pac]

Yo, this sounds shady af.
As a sporadic thing if/when something new/unexpected happened to the patient after discharge?
Sure.

Say a stroke patient goes home, falls, breaks their hip, requires a hemiarthroplasty, and now needs rehab s/p joint replacement? Sure.
But a stroke patient goes home, then is just readmitted for debility because... something something I want to get paid more? GTFOOT ASAP.

Like I said, shady af.

Lol you beat me to the shady af comment. No better way to phrase it

 

[DMBandFan86]

If you do think there is fraud, and sounds like you do, then I believe you have to report it to Medicare. You can get into trouble if you don’t. Maybe seek some legal counsel as well. Best of luck with a tough situation

 

[Iamnew2]

If you do think there is fraud, and sounds like you do, then I believe you have to report it to Medicare. You can get into trouble if you don’t. Maybe seek some legal counsel as well. Best of luck with a tough situation

I have actually spoken to legal counsel and seriously thinking about exactly that. The hospital system has been sued by the justice dept in the past a number of times for the exact same things I have expressed concerns and they have had to pay millions in fines. I guess certain places don’t learn how to run a clean business sigh

 

[Momentum70]

I constantly get into fights with our liasons/marketing/intake whatever you want to call them teams. They get paid for getting people in the doors and I feel its my job to make sure only appropriate patients with needs enter. When I started they tried to give me all sorts of people in the ED/Home with debility/weakness/etc with prior strokes with residual deficits trying to argue they were a stroke patient. GTFO with that bull!!!!, or saying medical need because "diabetes uncontrolled" in 160-200 range or "bp uncontrolled" 140-160 SBP. GTFO!! Before I started I had read article about large corporation paying lots in fines for medicare fraud for this kind of thing. Very proud during our audits only once has one of my charts escalated to review and we won that case.

 

[Iamnew2]

I constantly get into fights with our liasons/marketing/intake whatever you want to call them teams. They get paid for getting people in the doors and I feel its my job to make sure only appropriate patients with needs enter. When I started they tried to give me all sorts of people in the ED/Home with debility/weakness/etc with prior strokes with residual deficits trying to argue they were a stroke patient. GTFO with that bull!!!!, or saying medical need because "diabetes uncontrolled" in 160-200 range or "bp uncontrolled" 140-160 SBP. GTFO!! Before I started I had read article about large corporation paying lots in fines for medicare fraud for this kind of thing. Very proud during our audits only once has one of my charts escalated to review and we won that case.

The problem is that here that's the culture. One of the "SVPs"said this week that in some of their facilities they have the liaisons accept the patients without physician approval! And that they are working on something to in general not need to get physician approval.

 

[Momentum70]

The problem is that here that's the culture. One of the "SVPs"said this week that in some of their facilities they have the liaisons accept the patients without physician approval! And that they are working on something to in general not need to get physician approval.

Now I am wondering who you work for because when i first started giving a lot of grief they told me the same thing about some of our other markets. I told them that was nice but I would never allow it. Im lucky that I work in an area hard to find our specialty so I get more leeway. Im not replaceable and the fact we have had an open slot for a physician for the past 3 years proves it.

 

[DMBandFan86]

Anyone interested in posting what their average wRVUs are per year for inpatient, consults or SNF work? Also list how many patients you normally take care of and how much vacation/sick time you use on average. I've been looking at the AAPM&R compensation document from 2017 and says about 4700 - 5000 on average for general physiatrist.

My current job I need over 5000 wRVUs to start production and I'm trying to get a new average of how busy I need to get to reach that.

 

[lejeunesage]

For those of you who are employed, would you be willing to share the exact dollar amount you get paid per RVU?
I'm trying to understand how this employment thing works and I'm a bit confused.

Medicare only pays about $34.5 per RVU. My local commercial insurers pay 1.75 X the Medicare rate.
But a 99223 is 3.5 RVUs.
That should translate into $103.5 for a 99223.
Instead, the maximum billable amount is something like $190 for a 99223.
I don't know how to reconcile those two figures.

Can someone help?

 

[Iamnew2]

For those of you who are employed, would you be willing to share the exact dollar amount you get paid per RVU?
I'm trying to understand how this employment thing works and I'm a bit confused.

Medicare only pays about $34.5 per RVU. My local commercial insurers pay 1.75 X the Medicare rate.
But a 99223 is 3.5 RVUs.
That should translate into $103.5 for a 99223.
Instead, the maximum billable amount is something like $190 for a 99223.
I don't know how to reconcile those two figures.

Can someone help?

I am not sure it exactly works like that. If I'm wrong which I guess I can be, someone please correct me.
RVU is typically set by where you work - for example my current employer sets RVU at $55. However because it's a prominent organization they have contracted rates at a higher than average compared to other institutions (I saw a physician at the same hospital where I work recently and they charged for example over $500 for a level two consult, which they got reimbursed close to $300 by insurance. I simply use the as an example). So when we bill a 99223 for example the amount of money that is reimbursed by the insurance company/MCR will vary depending on the contracted rate. At this institution it's much higher than my former institution. I still get the same amount of money though because it's RVU based. If I was an independent contractor, I'd get more money per patient.
The RVU however is set by the institution - in this case for us I believe a 99223 is set to 3.92 RVU if I remember correctly (I'd have to check).
I think you'd have to find out
a) how much each RVU is set to wherever you want to work at
b) how many RVUs each code is set to.

Hope that helps

 

[lejeunesage]

I am not sure it exactly works like that. If I'm wrong which I guess I can be, someone please correct me.
RVU is typically set by where you work - for example my current employer sets RVU at $55. However because it's a prominent organization they have contracted rates at a higher than average compared to other institutions (I saw a physician at the same hospital where I work recently and they charged for example over $500 for a level two consult, which they got reimbursed close to $300 by insurance. I simply use the as an example). So when we bill a 99223 for example the amount of money that is reimbursed by the insurance company/MCR will vary depending on the contracted rate. At this institution it's much higher than my former institution. I still get the same amount of money though because it's RVU based. If I was an independent contractor, I'd get more money per patient.
The RVU however is set by the institution - in this case for us I believe a 99223 is set to 3.92 RVU if I remember correctly (I'd have to check).
I think you'd have to find out
a) how much each RVU is set to wherever you want to work at
b) how many RVUs each code is set to.

Hope that helps

This is really interesting!

I'd always avoided employment models like the plague because I assumed that the hospital would just eat part of my lunch.
What I hadn't considered was that the hospital would be able to negotiate a higher reimbursement rate (both in number of RVUs and in amount per RVU) with Medicare and other insurers.

I'm finally asking my institution what an employed model would look like. I like the fact that I get to keep 100% of my collections (minus 6% to the billing company) but a lower percentage of a higher reimbursement rate might actually land me ahead of where I currently am.

Plus I wouldn't have to worry about benefits and and billing company.

I hadn't realized just how much it could suck to have a terrible billing company. It's fine to have all those theoretical billings but if you don't actually collect the money, what's the point? The thing is, it's so cumbersome to switch companies and so uncertain that the next company will be better that more and more I'm leaning towards an employment contract, assuming the dollar per RVU amount is competitive enough.

 

[Iamnew2]

This is really interesting!

I'd always avoided employment models like the plague because I assumed that the hospital would just eat part of my lunch.
What I hadn't considered was that the hospital would be able to negotiate a higher reimbursement rate (both in number of RVUs and in amount per RVU) with Medicare and other insurers.

I'm finally asking my institution what an employed model would look like. I like the fact that I get to keep 100% of my collections (minus 6% to the billing company) but a lower percentage of a higher reimbursement rate might actually land me ahead of where I currently am.

Plus I wouldn't have to worry about benefits and and billing company.

I hadn't realized just how much it could suck to have a terrible billing company. It's fine to have all those theoretical billings but if you don't actually collect the money, what's the point? The thing is, it's so cumbersome to switch companies and so uncertain that the next company will be better that more and more I'm leaning towards an employment contract, assuming the dollar per RVU amount is competitive enough.

The hospital still eats part of your lunch (although at my current gig they give us lunch too ha!) - if they get say $300 for a level 3 I don’t get all of that so they get part of that. But it’s all about the details - RVU also means if the hospital doesn’t get paid you still do and they eat the loss. The more you work the more you make too as opposed to just salaried employment model. The 401k also adds up I get about $1600 per mo I think in contribution from hospital plus med mail. I think independent contractor still wins if you have a good billing company but If you don’t then that blows

 

[lejeunesage]

I think independent contractor still wins if you have a good billing company but If you don’t then that blows

IF!

It took me a while to admit it but mine blows big time.
Lots and lots of payment denials. I'm just hesitant to take the plunge with another company because I'm not sure it will be much better.

 

[Iamnew2]

IF!

It took me a while to admit it but mine blows big time.
Lots and lots of payment denials. I'm just hesitant to take the plunge with another company because I'm not sure it will be much better.

Sorry yes lots of denials but they have to be resubmitted and you have to stay on top of your billing team. I have gotten tens od thousands of dollars in payment after “denials” or non payment bc I would follow up whether calling insurance Medicare etc.
I imagine my billing team doesn’t love getting my emails but it works

 

[DMBandFan86]

For those of you who are employed, would you be willing to share the exact dollar amount you get paid per RVU?
I'm trying to understand how this employment thing works and I'm a bit confused.

Medicare only pays about $34.5 per RVU. My local commercial insurers pay 1.75 X the Medicare rate.
But a 99223 is 3.5 RVUs.
That should translate into $103.5 for a 99223.
Instead, the maximum billable amount is something like $190 for a 99223.
I don't know how to reconcile those two figures.

Can someone help?

I think the avg for PMR is around 50-60 per wRVU. It can be higher though depending on your location. Rural you tend to have a higher rate. AAPMR has a survey from a few years ago with lots of data such as this if you have access.

I have base salary with an annual wRVU target. If I make less than target, I might get a slap on the wrist, but still make my salary. If I produce higher then I collect based on the overage. It can get somewhat complicated depending on what is written into your contract. That’s usually how people start at least 1-3 years then full production +\_ a base salary.

The wRVU rate is determined by the institution. It doesn’t matter what anyone pays or if they collect. The institution makes contracts with the insurance company.

 

[lejeunesage]

I think the avg for PMR is around 50-60 per wRVU. It can be higher though depending on your location. Rural you tend to have a higher rate. AAPMR has a survey from a few years ago with lots of data such as this if you have access.

I have base salary with an annual wRVU target. If I make less than target, I might get a slap on the wrist, but still make my salary. If I produce higher then I collect based on the overage. It can get somewhat complicated depending on what is written into your contract. That’s usually how people start at least 1-3 years then full production +\_ a base salary.

The wRVU rate is determined by the institution. It doesn’t matter what anyone pays or if they collect. The institution makes contracts with the insurance company.

Okay, assuming someone is on 100% production, what percentage of those wRVU values do they get?

Say you're billing 40 RVUs for the day and get compensated at $60/RVU?
Do you actually get $2400 from the hospital for that day? Or do you get a percentage? 50%? 60%? 35%?
How is that number determined?

In my case, my practice is already established. I'm not starting from scratch. if I were switching to an employment model, I'd be full on day one, so I'd be okay with being strictly on production.

 

[j4pac]

Okay, assuming someone is on 100% production, what percentage of those wRVU values do they get?

Say you're billing 40 RVUs for the day and get compensated at $60/RVU?
Do you actually get $2400 from the hospital for that day? Or do you get a percentage? 50%? 60%? 35%?
How is that number determined?

In my case, my practice is already established. I'm not starting from scratch. if I were switching to an employment model, I'd be full on day one, so I'd be okay with being strictly on production.

Typically the $/RVU gives you the income. So if you get $60/RVU and earn 40 RVU, you get $2400 that day. You don’t get a percentage of that. The collections model more commonly uses a percentage.

 

[Iamnew2]

Okay, assuming someone is on 100% production, what percentage of those wRVU values do they get?

Say you're billing 40 RVUs for the day and get compensated at $60/RVU?
Do you actually get $2400 from the hospital for that day? Or do you get a percentage? 50%? 60%? 35%?
How is that number determined?

In my case, my practice is already established. I'm not starting from scratch. if I were switching to an employment model, I'd be full on day one, so I'd be okay with being strictly on production.

You’d get all of it in theory however it would be hard to get 40RVU in a day so the figure is high. Considering most patients are a level 2 particularly w the new coding changes w the occasional level 3 for new patients, consults and 99239 for dc I think you are looking at a much lower RVU per day if just straight production

 

[lejeunesage]

Typically the $/RVU gives you the income. So if you get $60/RVU and earn 40 RVU, you get $2400 that day. You don’t get a percentage of that. The collections model more commonly uses a percentage.

Whoa! That would actually be pretty sweet!

 

[lejeunesage]

You’d get all of it in theory however it would be hard to get 40RVU in a day so the figure is high. Considering most patients are a level 2 particularly w the new coding changes w the occasional level 3 for new patients, consults and 99239 for dc I think you are looking at a much lower RVU per day if just straight production

Recently, on an average day, I see almost 24 patients, including 2 admissions and 2 discharges.
I sill code my team conferences as level 3s based on time.

So it hasn't been super hard to hit 40 RVUs for the day.

 

[Haxx]

For those of you who are employed, would you be willing to share the exact dollar amount you get paid per RVU?
I'm trying to understand how this employment thing works and I'm a bit confused.

Medicare only pays about $34.5 per RVU. My local commercial insurers pay 1.75 X the Medicare rate.
But a 99223 is 3.5 RVUs.
That should translate into $103.5 for a 99223.
Instead, the maximum billable amount is something like $190 for a 99223.
I don't know how to reconcile those two figures.

Can someone help?

At my job in the upper Midwest, I get compensated $69.38 per RVU doing a mix of inpatient and outpatient primarily spine care but also neuro/MSK/EMG

 

[j4pac]

Recently, on an average day, I see almost 24 patients, including 2 admissions and 2 discharges.
I sill code my team conferences as level 3s based on time.

So it hasn't been super hard to hit 40 RVUs for the day.

If you’re able to hit 40 RVU/day regularly and not get burnt out you’d be banking. Easier said than done

 

[lejeunesage]

Whoa!!!

At my job in the upper Midwest, I get compensated $69.38 per RVU doing a mix of inpatient and outpatient primarily spine care but also neuro/MSK/EMG

Good for you!

 

[lejeunesage]

If you’re able to hit 40 RVU/day regularly and not get burnt out you’d be banking. Easier said than done

We'll see how long it lasts. I only work 4 days a week, though.

 

[DMBandFan86]

How much time do you guys spend in team?

Mine are just once per week, and I think that makes time coding harder. If I have 16 patients, I know I’m not there roughly 16 hours that day. Be easier if we did team 3-4 times per week and spread it out. Then I wouldn’t fear an audit as much.

 

[RangerBob]

How much time do you guys spend in team?

Mine are just once per week, and I think that makes time coding harder. If I have 16 patients, I know I’m not there roughly 16 hours that day. Be easier if we did team 3-4 times per week and spread it out. Then I wouldn’t fear an audit as much.

My partner, who’s much more experienced and knowledgeable than I am (and knows all the big whigs/is very involved politically for inpatient rehab with the government/insurance groups) tells me we can justify a level 3 based on complexity. Since we’re talking with the interdisciplinary team, setting the discharge date/determining need for further hospitalization, etc.

So you wouldn’t bill on time.

As a general rule, none of us can justify more than a handful of level 3’s per week (if even) based on time. You have to spend 55 minutes in that patient’s care—it’s just not going to happen much. 35 minutes? That’s not all that infrequent, but 55 is. So I have far fewer level 3’s now.

At least compensation for level 2’s went up about $10. DC code went up too. But H&P/consult fell quite a bit.