RVUs

[Dansk2011]

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

That wrvu amount is legit!! Do you have a base salary as well? My current gig in the Southwest is a mix of stuff but primarily msk/neuro outpatient. My base is high for the specialty but my wrvu is only around $42 per rvu which sucks. Unfortunately that is the amount the other docs agreed to that I work with who have been at the hospital for a while. They wanted everyone to get the same compensation so I didn't have much bargaining power. Probably will try to renegotiate in some time.

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[DMBandFan86]

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.

I mean if you could spell it out clearer how you are documenting based on complexity for team conference days?

The decision to hospitalize in level 3 has a high risk of morbidity. I use this on admission when I also said they would be here 2-3 weeks. So do you also use this daily? Or just weekly? I’m not sure my coders would buy it.

Talking with the team and setting discharge are not listed on the complexity chart. It might count as a category 3 depending on documenting discussion about management. In my team, they literally took all talk about management away and insurance pretty much dictates LOS.

 

[runfastnow]

For a different perspective/set up:
We are a small/medium ortho/PMR private practice and we do not track RVUs in any way. It is all collection based.
We charge 3x Medicare rates and then collect what insurance pays and patient co-pays with a little bit of cash pay services (mainly PRP).
Collection rate ~40% and have ~48-50% overhead.

Charge $2mil -> collect $800k -> take home ~$400-415k

 

[Haxx]

That wrvu amount is legit!! Do you have a base salary as well? My current gig in the Southwest is a mix of stuff but primarily msk/neuro outpatient. My base is high for the specialty but my wrvu is only around $42 per rvu which sucks. Unfortunately that is the amount the other docs agreed to that I work with who have been at the hospital for a while. They wanted everyone to get the same compensation so I didn't have much bargaining power. Probably will try to renegotiate in some time.

I had a salary guarantee my first year, but then transitioned to 100% production. My first year salary will be very easily met in my second year with the group.

 

[Iamnew2]

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

Who covers weekend admits and the other day in the week?

 

[RangerBob]

I mean if you could spell it out clearer how you are documenting based on complexity for team conference days?

The decision to hospitalize in level 3 has a high risk of morbidity. I use this on admission when I also said they would be here 2-3 weeks. So do you also use this daily? Or just weekly? I’m not sure my coders would buy it.

Talking with the team and setting discharge are not listed on the complexity chart. It might count as a category 3 depending on documenting discussion about management. In my team, they literally took all talk about management away and insurance pretty much dictates LOS.

I don't have access to the EMR right now for the little blip he developed. But it has to do with discussing the dc, rationale for continued rehab/hospitalization, setting/adjusting dc date, team discussion, etc. We don't let insurance dictate LOS, though it is certainly a factor we consider.

We don't use the decision to hospitalize to justify a 99233 daily (though the hospitalists here do). Just weekly for team conference, since that's really the only time we talk about it thoroughly. You're correct it's not listed in the complexity chart--PM&R got thoroughly hosed by the CPT changes since the majority of any 99233s we billed were based on time.

How do you use a level 3 on admission? Shouldn't that be a 99223? Or do you mean the day after admission? We usually bill a 99233 the day after admission (since we're following up on labs, consulting internists, determining if the pt is stable enough to remain on rehab, etc., and for team conference, and that's about it.).

 

[Iamnew2]

I don't have access to the EMR right now for the little blip he developed. But it has to do with discussing the dc, rationale for continued rehab/hospitalization, setting/adjusting dc date, team discussion, etc. We don't let insurance dictate LOS, though it is certainly a factor we consider.

We don't use the decision to hospitalize to justify a 99233 daily (though the hospitalists here do). Just weekly for team conference, since that's really the only time we talk about it thoroughly. You're correct it's not listed in the complexity chart--PM&R got thoroughly hosed by the CPT changes since the majority of any 99233s we billed were based on time.

How do you use a level 3 on admission? Shouldn't that be a 99223? Or do you mean the day after admission? We usually bill a 99233 the day after admission (since we're following up on labs, consulting internists, determining if the pt is stable enough to remain on rehab, etc., and for team conference, and that's about it.).

We use a 99223 when we admit patient. 99233 for team conference notes.
How do your hospitalists do daily 99233? That is begging for an audit.

 

[Ogliodendrocyte]

I don't have access to the EMR right now for the little blip he developed. But it has to do with discussing the dc, rationale for continued rehab/hospitalization, setting/adjusting dc date, team discussion, etc. We don't let insurance dictate LOS, though it is certainly a factor we consider.

We don't use the decision to hospitalize to justify a 99233 daily (though the hospitalists here do). Just weekly for team conference, since that's really the only time we talk about it thoroughly. You're correct it's not listed in the complexity chart--PM&R got thoroughly hosed by the CPT changes since the majority of any 99233s we billed were based on time.

How do you use a level 3 on admission? Shouldn't that be a 99223? Or do you mean the day after admission? We usually bill a 99233 the day after admission (since we're following up on labs, consulting internists, determining if the pt is stable enough to remain on rehab, etc., and for team conference, and that's about it.).

I'd also be interested in knowing how it's spelled out in documentation for billing level 3 on Team conference days

 

[RangerBob]

We use a 99223 when we admit patient. 99233 for team conference notes.
How do your hospitalists do daily 99233? That is begging for an audit.

I should have clarified they do daily 99233 for their med-surg patients, not rehab patients. At least that's what I'm told they do--I do not actually see their charges, and it's just one member of their group that told me this.

I agree it's still likely begging for an audit regardless.

 

[j4pac]

That wrvu amount is legit!! Do you have a base salary as well? My current gig in the Southwest is a mix of stuff but primarily msk/neuro outpatient. My base is high for the specialty but my wrvu is only around $42 per rvu which sucks. Unfortunately that is the amount the other docs agreed to that I work with who have been at the hospital for a while. They wanted everyone to get the same compensation so I didn't have much bargaining power. Probably will try to renegotiate in some time.

Ouch. Best of luck with the negotiations. Honestly, with that type of compensation I’d have a good plan B and be willing to walk away. Your co-workers are fools to be content with accepting below market value.

 

[Iamnew2]

I should have clarified they do daily 99233 for their med-surg patients, not rehab patients. At least that's what I'm told they do--I do not actually see their charges, and it's just one member of their group that told me this.

I agree it's still likely begging for an audit regardless.

Regardless, unless the med-surg patients are coding daily, there is no reason for daily 99233.

 

[DMBandFan86]

How do you use a level 3 on admission? Shouldn't that be a 99223? Or do you mean the day after admission? We usually bill a 99233 the day after admission (since we're following up on labs, consulting internists, determining if the pt is stable enough to remain on rehab, etc., and for team conference, and that's about it.).

Thank you. Yes, I now try to bill a level 3 on admission, 99223. Either I reach it by complexity or time. Time with chart review, lab/image review, orders, admit meds, and seeing patient. If I end up doing admit orders and most of my note one day and seeing them the next day, then I don’t time bill. As long as I review an image and discuss with the hospitalist, then I feel like I meet 99223 on complexity (with hospitalization factored in). Honestly, I think I meet both time and complexity at level 3 for most of my admissions, and my notes reflect that.

But that’s the only time I had been documenting a decision to hospitalize. So I was just curious. If you get a chance to post specifics I think it would be helpful. The difference in wRVUs between a level 2 and level 3 follow up is huge. And of course, I always want to make as much money as I can without worrying about an audit or over billing.

Family conferences, on the other hand, usually last long enough that I code a level 3 on time and sometimes bill prolonged time.

However, I still struggle with column 1 (number and complexity of problems) as I think it is vague and can be interpreted many ways. Anyone using that to get level 3?

 

[DMBandFan86]

Regardless, unless the med-surg patients are coding daily, there is no reason for daily 99233.

As long as they are interpreting labs daily and having discussions on management then I can see it being a level 3. In post-acute care, I am just thinking we don’t have the acuity to bill a level 3 daily.

 

[Dansk2011]

Ouch. Best of luck with the negotiations. Honestly, with that type of compensation I’d have a good plan B and be willing to walk away. Your co-workers are fools to be content with accepting below market value.

Yeah I'm not sure why they were OK with that wrvu amount but neither has had another job so maybe that's it. Didn't know any better. That being said I work 4 days a week with minimal call with a really strong base salary guaranteed for 3 years and got a massive sign on. Massive. After 3 years my base salary guarantee drops a bit but my wrvu threshold drops as well. Also 7 weeks of vacation. If I didn't make bonus I'd be happy with my salary alone but it's still the principal of it.

 

[Iamnew2]

Yeah I'm not sure why they were OK with that wrvu amount but neither has had another job so maybe that's it. Didn't know any better. That being said I work 4 days a week with minimal call with a really strong base salary guaranteed for 3 years and got a massive sign on. Massive. After 3 years my base salary guarantee drops a bit but my wrvu threshold drops as well. Also 7 weeks of vacation. If I didn't make bonus I'd be happy with my salary alone but it's still the principal of it.

what is a massive sign on? are you interventional or inpt?

 

[Dansk2011]

what is a massive sign on? are you interventional or inpt?

Mostly general outpatient with focus on msk, spasticity, etc. Do some inpatient coverage on small unit as well help with rotation of weekend call. Sign on was more then I'd ever heard of or seen. Easily 2-3x what I'd been offered in sign on with other positions. Some what validated the low wrvu amount I guess as I felt if I were to spread it over the term of my contract I was making a decent bonus every year essentially. That being said would still like a higher wrvu amount especially as it is much lower then what I think is consider fair market now a days.

 

[Iamnew2]

Mostly general outpatient with focus on msk, spasticity, etc. Do some inpatient coverage on small unit as well help with rotation of weekend call. Sign on was more then I'd ever heard of or seen. Easily 2-3x what I'd been offered in sign on with other positions. Some what validated the low wrvu amount I guess as I felt if I were to spread it over the term of my contract I was making a decent bonus every year essentially. That being said would still like a higher wrvu amount especially as it is much lower then what I think is consider fair market now a days.

what area of the country are you? where do you guys get referrals from?

 

[Dansk2011]

what area of the country are you? where do you guys get referrals from?

Southwest. PCPs, other physiatrists in my practice, ortho and neurosurgery. Trying to be as broad with my practice as I can for the most part.

 

[DOctorJay]

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?

RVUs are not the same as wRVUs. Read up on the differences.

 

[j4pac]

RVUs are not the same as wRVUs. Read up on the differences.

This is a really important distinction that I haven’t seen made.

 

[lejeunesage]

This is a really important distinction that I haven’t seen made.

Please elaborate. What's the difference?
I've never been employed, so all this stuff is Greek to me.

καταλαβαίνεις;

 

[runfastnow]

RVU has three components:
- Work RVU - physician skill/time
- Practice Expense RVU - practice resources, keep lights on, etc.
- Malpractice RVU - self-explanatory.

People throw around RVU and wRVU as if they are interchangeable. Definitely not. Also why private practice doesn't typically care about RVUs or wRVUs and only collections. Can't take an RVU to the bank - only the dollars you collect.

 

[j4pac]

Please elaborate. What's the difference?
I've never been employed, so all this stuff is Greek to me.

καταλαβαίνεις;

An RVU includes the total compensation given for a particular CPT code, which includes the physician compensation component (wRVU), practice expense, and malpractice.

The wRVU is typically about half of the total RVU. So when you are being offered a contract, you must ensure that you know which is being discussed.

 

[j4pac]

RVU has three components:
- Work RVU - physician skill/time
- Practice Expense RVU - practice resources, keep lights on, etc.
- Malpractice RVU - self-explanatory.

People throw around RVU and wRVU as if they are interchangeable. Definitely not. Also why private practice doesn't typically care about RVUs or wRVUs and only collections. Can't take an RVU to the bank - only the dollars you collect.

Lol beat me too it.

There are advantages to wRVU model. If you have a high percentage of government payers, including Medicaid…$/wRVU is the way to go. I also like wRVU from the standpoint of equity and access to care. Collections model is the reason why retired military on Tricare can’t get care. Working for wRVU takes the payer out of the equation and you can just focus on getting patients in front of you…not getting a specific type of patient in front of you.

 

[lejeunesage]

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.

That's exactly what I do. I have conferences every day. We focus on 5-6 patients at a time, depending on census.
I usually bill 99233 on the conferenced patients and 99223 on admissions. Everything else gets a 99232, unless there is a huge medical complication or a huge time sink.
Most discharges get a 99239 unless they're super easy.

 

[lejeunesage]

Also, this has been such a helpful thread. Thank you so very much to everyone who's contributed.

 

[DOctorJay]

Check out some of his other videos to learn more.

 

[RangerBob]

Here's our blip for team conferences that my partner developed.

If any of you have recs on how to improve it we're all ears.

"Today the physician led the rehabilitation team in understanding the admission rehabilitation diagnosis that poses threat to function; reviewed the other physician’s progress notes, reviewed labs and medications, and led comprehensive interdisciplinary care planning conference with rehabilitation therapists, nurse case manager, social worker, administration and the patient staff’s nurse; and determined need for continued hospitalization including anticipated length of stay."

I'm sure some inpatient docs are trying to justify the "threat to function" to bill level 3's often, but my partner and I felt that we could reasonably only bill level 3's for the first follow up (when we're consulting with IM, reviewing admit labs, determining if pt can remain on rehab) and for team conference days. And the occasional day where you're ordering stat imaging/etc.

On that note--an internist said you can bill critical care hours for rapid responses (assuming you respond). Do any of you do this? Usually I've just up-coded to a level 3 that day if it wasn't a level 3 already, ocassionally use a prolonged service code if I'm there a while. If they transfer then sometimes I do a dc code and a prolonged service, again depending on the amount of time I was there.

 

[Iamnew2]

Here's our blip for team conferences that my partner developed.

If any of you have recs on how to improve it we're all ears.

"Today the physician led the rehabilitation team in understanding the admission rehabilitation diagnosis that poses threat to function; reviewed the other physician’s progress notes, reviewed labs and medications, and led comprehensive interdisciplinary care planning conference with rehabilitation therapists, nurse case manager, social worker, administration and the patient staff’s nurse; and determined need for continued hospitalization including anticipated length of stay."

I'm sure some inpatient docs are trying to justify the "threat to function" to bill level 3's often, but my partner and I felt that we could reasonably only bill level 3's for the first follow up (when we're consulting with IM, reviewing admit labs, determining if pt can remain on rehab) and for team conference days. And the occasional day where you're ordering stat imaging/etc.

On that note--an internist said you can bill critical care hours for rapid responses (assuming you respond). Do any of you do this? Usually I've just up-coded to a level 3 that day if it wasn't a level 3 already, ocassionally use a prolonged service code if I'm there a while. If they transfer then sometimes I do a dc code and a prolonged service, again depending on the amount of time I was there.

So do most of you bill 3 for team conf? I normally do and most of my colleagues here do as well. All of a sudden I noticed that the billers have downgraded all my 3 to 2’s!!
Who doesn’t bill a code 3 for team conf?

 

[RangerBob]

So do most of you bill 3 for team conf? I normally do and most of my colleagues here do as well. All of a sudden I noticed that the billers have downgraded all my 3 to 2’s!!
Who doesn’t bill a code 3 for team conf?

At our unit we do

My billers bill exactly what we tell them too, unless they think we’re being fraudulent (like billing for 8 admits and 30 level 3 follow ups on the same day—just not physically possible). They fired a doc who did that.

 

[lejeunesage]

So do most of you bill 3 for team conf? I normally do and most of my colleagues here do as well. All of a sudden I noticed that the billers have downgraded all my 3 to 2’s!!
Who doesn’t bill a code 3 for team conf?

I do as well unless the discussion is super duper short.

 

[DMBandFan86]

Here's our blip for team conferences that my partner developed.

If any of you have recs on how to improve it we're all ears.

"Today the physician led the rehabilitation team in understanding the admission rehabilitation diagnosis that poses threat to function; reviewed the other physician’s progress notes, reviewed labs and medications, and led comprehensive interdisciplinary care planning conference with rehabilitation therapists, nurse case manager, social worker, administration and the patient staff’s nurse; and determined need for continued hospitalization including anticipated length of stay."

I'm sure some inpatient docs are trying to justify the "threat to function" to bill level 3's often, but my partner and I felt that we could reasonably only bill level 3's for the first follow up (when we're consulting with IM, reviewing admit labs, determining if pt can remain on rehab) and for team conference days. And the occasional day where you're ordering stat imaging/etc.

On that note--an internist said you can bill critical care hours for rapid responses (assuming you respond). Do any of you do this? Usually I've just up-coded to a level 3 that day if it wasn't a level 3 already, ocassionally use a prolonged service code if I'm there a while. If they transfer then sometimes I do a dc code and a prolonged service, again depending on the amount of time I was there.

Thank you,

I'd say my coders want me to be specific. So, they'd probably would want me to spell out what is the diagnosis that is posing threat to function and why. They wouldn't want the same template phrase in every note.

"Threat to function" is such a vague term. I think many diagnoses could be interpreted indefinitely as a treat to function (i.e. DM).

But when I've talked to coders they don't buy it. They want something acute and critical and ongoing. But, then again, some coders don't. I find it all very ambiguous.

So do most of you bill 3 for team conf? I normally do and most of my colleagues here do as well. All of a sudden I noticed that the billers have downgraded all my 3 to 2’s!!
Who doesn’t bill a code 3 for team conf?

If I spend the amount of time on the encounter or have medical complexity to bill level 3 then yes. I actually think I did that twice today with team, but one I think I met on complexity alone. But I do not bill as a default to level 3 just because I have team. But it sounds like several people do. Maybe I should, but I am still hesitant for whatever reasons. Also, if I billed that many people a day on time an audit would likely easily discover that I am not at the hospital that many hours in a day.

 

[RangerBob]

Thank you,

I'd say my coders want me to be specific. So, they'd probably would want me to spell out what is the diagnosis that is posing threat to function and why. They wouldn't want the same template phrase in every note.

"Threat to function" is such a vague term. I think many diagnoses could be interpreted indefinitely as a treat to function (i.e. DM).

But when I've talked to coders they don't buy it. They want something acute and critical and ongoing. But, then again, some coders don't. I find it all very ambiguous.


If I spend the amount of time on the encounter or have medical complexity to bill level 3 then yes. I actually think I did that twice today with team, but one I think I met on complexity alone. But I do not bill as a default to level 3 just because I have team. But it sounds like several people do. Maybe I should, but I am still hesitant for whatever reasons. Also, if I billed that many people a day on time an audit would likely easily discover that I am not at the hospital that many hours in a day.

It is rather generic, but we spell out all the details elsewhere in the note.

Technically with the new changes we don’t have to document much at all. HPI/exam really isn’t needed at all if we just explain why it’s a complicated visit/meets criteria. We can all write surgeon notes now if we wanted… Almost…

I still document quite a bit in the HPI/exam and A/P out of habit/comfort.