RVU's

[Bornforcutting]

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What are you guys doing in CHCS II to increase your RVU's added with your work hrs? I always put that I worked 8 hrs even if I work more than that day. I don't think the coders are helping the providers and any key pointers will help us. How are you managing your clinic template/schedule per week so you are productive at the end of the year? Thanks.

 

[backrow]

What are you guys doing in CHCS II to increase your RVU's added with your work hrs? I always put that I worked 8 hrs even if I work more than that day. I don't think the coders are helping the providers and any key pointers will help us. How are you managing your clinic template/schedule per week so you are productive at the end of the year? Thanks.

If you want to play their game (which I personally detest) the key to generating RVU's in a PCM type setting is to make sure you understand what generates RVU's. Ask for the guide on what get's you a 99214 etc etc.

You will find that you likely already do the stuff to get you the higher codes, but since you don't input it "correctly" you aren't getting credit for it.

Procedures help increase RVU's as well. Basically you have to educate yourself on the system in order to learn how to make it give you credit for what you do.

Or they could hire coder's instead of making Dr's do the work.

 

[Homunculus]

currently generating my own RVU's, i will post what has helped our clinic (we're doing very well on the RVU front) extract the most RVU's out of our visits later when i get time.

--your friendly neighborhood 99214 churning caveman

 

[mitchconnie]

I'm not just being cynical, I'm really interested in whether maximizing RVU's makes any difference at all in the setting of your average military clinic. I tried hard for while to maximize all my visits to 99214 (or whatever) under the assumption that our clinic would get more resources, equipment, ancillary staff, etc. if we documented more RVU's, but I never really saw any changes. My impression is that RVU production is just a bullet point for the commander on her OPR--i.e. "I increased RVU output by 30%." Overall budget might increase for high-RVU MTF's, but odds of seeing any trickle down to an individual clinic are probably low.

I think the only reason it's important to learn RVU-maximization techniques is that you'll need those skills once you leave the military.

 

[VHADOC]

I'm not just being cynical, I'm really interested in whether maximizing RVU's makes any difference at all in the setting of your average military clinic. I tried hard for while to maximize all my visits to 99214 (or whatever) under the assumption that our clinic would get more resources, equipment, ancillary staff, etc. if we documented more RVU's, but I never really saw any changes. My impression is that RVU production is just a bullet point for the commander on her OPR--i.e. "I increased RVU output by 30%." Overall budget might increase for high-RVU MTF's, but odds of seeing any trickle down to an individual clinic are probably low.

I think the only reason it's important to learn RVU-maximization techniques is that you'll need those skills once you leave the military.

Ditto.

RVUs, like any service based funding model (at least in the govt setting), are simply a means developed to determine just how we are going to divide up a limited supply of resources (money). But what does this really mean? At best their value reflects the relative value that the average physician places in jumping through those hoops required to document them. I place little value in documenting non-medically relevant information.

In the world I've been living in, 99213 is a free pass: patient shows up, doctor saw patient, patient hasn't been seen in a while, patient doesn't die, no one asks questions. 99214? You'd better add some documentation.

I'd bet a year's salary that every physician has pen-whipped, at least occasionally if not every note, that documentation required to substantiate a 204/214+. Do you really ask all those ROS questions in your pre-formatted note every time? As bad or worse than pen-whipped notes are notes that perfectly document everything required to substantiate the billing code but are perfectly useless from a medical documentation standpoint.

As time goes on the coding requirements become more onerous, require effectively more time, yet don't improve patient care. At some point physicians need to quit playing the BS coding game and stick to medicine.

 

[BlackFrancis33]

One huge problem is the coders. Coders cannot over code. Overcoding gets them in trouble. Therefore, they will code you down to cover their ass. This is a problem if you don't 'own' your coders and they are some contractor working in the bowels of the hospital. It falls to you to learn how to code up to the higher codes. I get emails from the coders about over coding, I never an email about under coding.

There is no real penalty in our system for over coding for encounters. However, under coding gets the attention of the bean counters and gets you a visit from the department chief. In my opinion, you should error on the side of over coding as it is the coder's job to fix it. I am not saying I blatantly commit fraud. If I think it was a 99215 and I met all the criteria, I code it as such and let the coders correct it. Obviously, this strategy would not fly in the civilian world.

 

[a1qwerty55]

I'm not just being cynical, I'm really interested in whether maximizing RVU's makes any difference at all in the setting of your average military clinic. I tried hard for while to maximize all my visits to 99214 (or whatever) under the assumption that our clinic would get more resources, equipment, ancillary staff, etc. if we documented more RVU's, but I never really saw any changes. My impression is that RVU production is just a bullet point for the commander on her OPR--i.e. "I increased RVU output by 30%." Overall budget might increase for high-RVU MTF's, but odds of seeing any trickle down to an individual clinic are probably low.

I think the only reason it's important to learn RVU-maximization techniques is that you'll need those skills once you leave the military.

With prospective payment - RVU's definitely matter - I generally hate the concept, but the reality is I can buy equipment and people if I can generate enough RVU workload to warrant them.

I also know my Department is compared to others in the Army and this data (often highly flawed) in determining physician allocation.

One key concept which is essential to to not overreport clinical time - because doing so ends up telling the bean counters you are inefficient based on their RVU/Hour metrics.

I also agree that knowing how to document to gain the highest appropriate code is essential in the civilian world. I mean, when using one term versus another equals a loss of money, you learn quickly. RVU's were conceived by the AMA, not the government or the military so you can thank that worthless organization.

 

[backrow]

RVU's were conceived by the AMA, not the government or the military so you can thank that worthless organization.

Can I get an "AMEN"??

 

[notdeadyet]

RVU's were conceived by the AMA, not the government or the military so you can thank that worthless organization.

Not true. It was designed at Harvard and sent to the CMS where Bush Sr. signed it into law for Medicare payment schedule.

The AMA later endorsed it and made modifications, but saying that they "conceived" it is wrong. I have my own set of beefs with the AMA, but inventing the RVU ain't one of them.

 

[Mirror Form]

One key concept which is essential to to not overreport clinical time - because doing so ends up telling the bean counters you are inefficient based on their RVU/Hour metrics.

Yeah, that is an important point. It doesn't matter if you were in the clinic 10 hours, make sure to still only report 7 (typical clinic day should be at least 7 hours of clinic and 1 hour admin). If you have admin roles you can decrease your clinic time further and increase the amount you allocate into admin further. The higher your ratio of clinic hours to RVU's, the better.

 

[Mirror Form]

I'm not just being cynical, I'm really interested in whether maximizing RVU's makes any difference at all in the setting of your average military clinic. I tried hard for while to maximize all my visits to 99214 (or whatever) under the assumption that our clinic would get more resources, equipment, ancillary staff, etc. if we documented more RVU's, but I never really saw any changes. My impression is that RVU production is just a bullet point for the commander on her OPR--i.e. "I increased RVU output by 30%." Overall budget might increase for high-RVU MTF's, but odds of seeing any trickle down to an individual clinic are probably low.

I think the only reason it's important to learn RVU-maximization techniques is that you'll need those skills once you leave the military.

I wonder the same thing. My assumption is that when I ask for equipment, the hospital command will be more likely to spend on my clinic if it's producing a good number of RVU's.

 

[former military]

at one point,
david grant medical center had a link that I would look up RVUs for any department or physician in the hospital.
I worked very hard and saw a ton of clinic, operated a lot, and did tons of office procedures. I personally led our hospital in RVUs many months.

I can tell you it meant absolutely nothing in terms of getting help or equipment to get things done. It did nothing at all for me or the clinic benefit wise.

If they told me I needed better access or to work harder I kept citing that I led the hospital in RVUs and to stuff it.

They finally took down that site so I couldn't see it and compare their business model to reality.

Chasing RVUs in the military is as worthless endeavor in the military as could ever exist.

 

[VHADOC]

Please forgive my ignorance/naivety but I have a couple questions about the RVU vs clinic hour situation on active duty.

Is it correct that the military situation is such that:
1) you code to maximize RVUs
2) maximizing RVUs is done, amongst other reasons, to show you are productive
3) your clinic is theoretically allocated more resources proportionate to your RVU production
4) for ~efficiency reasons you only report working 8 hours even if 10 hours for the work was required?

It would seem counterproductive to maximize RVUs (in effort to suggest hard work) while simultaneously pretending the same amount of work was done in less time (more efficient). In other words, bean counters could surmise "hey, they're working hard there...we should reward them with more resources....oh, but wait...they're more efficient, they don't need more resources."

Sorry for the simplistic views, but does this make sense?

 

[a1qwerty55]

Please forgive my ignorance/naivety but I have a couple questions about the RVU vs clinic hour situation on active duty.

Is it correct that the military situation is such that:
1) you code to maximize RVUs
2) maximizing RVUs is done, amongst other reasons, to show you are productive
3) your clinic is theoretically allocated more resources proportionate to your RVU production
4) for ~efficiency reasons you only report working 8 hours even if 10 hours for the work was required?

It would seem counterproductive to maximize RVUs (in effort to suggest hard work) while simultaneously pretending the same amount of work was done in less time (more efficient). In other words, bean counters could surmise "hey, they're working hard there...we should reward them with more resources....oh, but wait...they're more efficient, they don't need more resources."

Sorry for the simplistic views, but does this make sense?

1. true
2. true
3. somewhat true - depends if your hospital distributes funds based on RVU production - some definitely do.
4. Its a catch 22. If you have a lot of admin duties, and make the mistake of listing let's say 6 hours of clinical time but only have 3 hours worth of patient encounters to support it, you look tremendously inefficient. If you list 3 hours of clinic time and 5 hours of admin, then they say, well you are underutilized and need fewer resources. You can't really game it. Best bet is to accurately report the time you are in clinic since the RVU/hr value seems to mean more than the time you are in clinic.

 

[a1qwerty55]

The following link is pretty accurate and explains the AMA's role in this dysfunctional RVU system.

Funny how the system is designed to support proceduralists and penalize non-invasive specialties. Bizarre since much of the cost of medical care in America stems from a lack of clinical acumen - a test or procedure is easier than a well formed differential and selective testing. While designed to make reimbursement "fair" RVU's have probably dramatically increased costs as physicians have learned to up code and do more than is often indicated.

 

[Jet915]

I've never bothered with that kind of stuff. We'd have someone come by and check our patient encounters once in awhile to make sure we were coding everything correctly and I was told I was doing fine so I just keep doing what I was doing.....

 

[BlackFrancis33]

RVU's per encounter is what is held up as most important. Although, at a previous institution the hospital commander had to come in and mandate X number of patient encounters per day as folks got really good at cooking the numbers to make themselves look productive while seeing as few patients as possible. The only real motivation is to do just enough to keep the clipboard commandos off your back. Any benefits from meeting some RVU goal are indirect, at best. The hospital gets more 'money' and 'resources'. You may not get s#@%.

 

[Mirror Form]

4) for ~efficiency reasons you only report working 8 hours even if 10 hours for the work was required?

This is correct. And never more than 7 of those hours should be clinic, b/c everyone gets at least one hour for admin daily.

It would seem counterproductive to maximize RVUs (in effort to suggest hard work) while simultaneously pretending the same amount of work was done in less time (more efficient). In other words, bean counters could surmise "hey, they're working hard there...we should reward them with more resources....oh, but wait...they're more efficient, they don't need more resources."

Sorry for the simplistic views, but does this make sense?

Yeah, I can definitely see that happening. Who knows how it will play out in each clinic. If you want equipment and resources, there are much more effective methods of getting them approved then simply RVU's. That is, you're better off developing a good relationship with your commander, if that is possible. Or at least schmoozing and trying to get them understand the reasons you want such and such equipment. You'd be amazing how little most clinics need that ******edly high cost equipment we beg for.

However, if your RVU/clinic hour time is good, I can say for sure that I've definitely seen that lead to getting more of your type of provider stationed at your hospital. If you don't want more of your type of provider, then you dont' want to do too good a job with recording that stuff.

 

[a1qwerty55]

RVU's per encounter is what is held up as most important. Although, at a previous institution the hospital commander had to come in and mandate X number of patient encounters per day as folks got really good at cooking the numbers to make themselves look productive while seeing as few patients as possible. The only real motivation is to do just enough to keep the clipboard commandos off your back. Any benefits from meeting some RVU goal are indirect, at best. The hospital gets more 'money' and 'resources'. You may not get s#@%.

While it may not directly benefit you, if your hospital can buy a new piece of equipment or hire a new staff member because of the RVU funding you generated, it indirectly benefits you. More importantly it benefits the patients. Hospitals are funded commensurate with their productivity/performance. This isn't just about a Commander or a nurse supervisor getting a positive bullet on their OER.

 

[Homunculus]

sorry for the late reply. totally forgot about this thread until today. . . 😳

first off, templates are key. if you can get 214's, get them. as far as i know we're not looked at to have the typical bell curve for visits like the civilian folks. i have dragonspeak templates for acutes that get me 214's on stuff i always do anyway. if you need to, talk to your coders and get the cheat sheet so you know how many bullets in how many systems, how many exam areas you must cover, etc for the different visit types.

add procedures like cerumen removal, wart freezing, developmental screens, etc.

use the ">50% of time spent" box only after you state "spent greater than X minutes talking about x, y, z." in your comment section.

learn about the -25 modifier for physicals that have those "by the way" complaints. physical + allergies or physical + URI = more RVU's.

as far as reporting hours, definitely don't do "crazy 8's". as much as a pain in the @ss as it is, you need to calculate each day by itself. you only want to claim clinic time for the time you saw patients (not for charting). so, if you had 15 patients, all 20 minute appts, you report 5 hours for your clinic, and 3 hours of admin time. only had 6 patients? report 2 hours. this works, and is how they want it, because it accurately reflects you time spent with patient care. they don't care about the "admin time" it takes to document your visits. nor do they care about T-cons (which is mind boggling to me since they take up so much time).

RVU's are not the end-all be-all for us, but they definitely are a leverage tool when we go to our commander or DCCS and ask for things. provider allocation is looked at (along with enrollment) and clinics are compard to each other when it comes to extra budget that may be available. no, it's not a slam dunk, but it certainly helps if youy are the most productive clinic or provider when you want equipment, staffing, or that CME trip.

--your friendly neighborhood RVU factory caveman

 

[Mirror Form]

as far as reporting hours, definitely don't do "crazy 8's". as much as a pain in the @ss as it is, you need to calculate each day by itself. you only want to claim clinic time for the time you saw patients (not for charting).

According to our DCCS, charting is indeed included as part of clinic time, not admin. Perhaps the rules vary from post to post.

 

[former military]

want to talk about procuring equipment....

we needed a laser- a 15 watt holmium laser for our OR. It cost about 120K or so. We were told time and time again there was no money for this. One smart doctor I worked with tried a different approach. He asked for the 100 watt laser that cost about 270K. We only used about 10% of its capability in reality and didn't need that much laser or that expensive of a laser. the issue is there was a different budget for higher ticket items and it came out of a different fund. We were able to get our 15 watt laser for double the price easily- just disguised as a 100 watt laser.
I remember our office fax machine broke. I priced it's replacement at office max as about 199 dollars. the government through it magical contracts had to buy from a source that charged us $800 dollars for the same one. No secret security devices... the same one. It is hard not to become jaded when you are spending your tax dollars and poor people's tax dollars so uselessly.

we still saved the tax payers lots of money though. Prior to our purchase we had spent much more than that renting a laser and laser technician to do the cases and sending the patients out to local physicians who could provide that service.

there are many situations where a 100K investment would save 10 times that amount of money in cases that get commonly referred out to the community. Example: brachytherapy. We had urologists, radiation oncologists, OR access, and technical support corporations who all wanted to make that happen. The 100K came out of the commander's budget. Since, he was going to be there 2 years before he moved on... he didn't want to spend the money. He wouldn't see the savings in two years. So year after year we refer this cases out and the cost gets passed on to the tax payer. I liken it to renting a car every day of your life because you don't want to buy one.

It is easier to defend military medicine until you get in these seemingly every day situations where money is wasted and care is compromised. I asked our commander if I should call the waste, fraud and abuse hotline. He didn't think that was funny.

 

[BlackFrancis33]

While it may not directly benefit you, if your hospital can buy a new piece of equipment or hire a new staff member because of the RVU funding you generated, it indirectly benefits you. More importantly it benefits the patients. Hospitals are funded commensurate with their productivity/performance. This isn't just about a Commander or a nurse supervisor getting a positive bullet on their OER.

Right, like I said it is an indirect benefit, at best. At worst, it gets you absolutely nothing, which in my experience is the case. But the clipboard commandos will count you as another clinic that generated 2.2 RVUs/FTE. It absolutely is about meeting some arbitrary productivity measure. It says nothing about quality of patient care. I will let you know when I see RVU measures benefit patients in our system. I wouldn't hold your breath. Documenting meaningless positive (and double negative) ROS findings on AHLTA does not constitute improved patient care. Many of the AHLTA primary care notes are unreadable, but generate the required RVUs. You are rewarded for checking boxes but ultimately providing horrible medical documentation. Improving patient care is not a part of the equation.

But then money is taken away from the hospital when one clinic has only 82% positive ICE evaluations because the providers only spend 5 minutes with them face to face because of the time it takes to check boxes in AHLTA to generate a 99213 or whatever. Productive, maybe. Improved patient care, probably not.

 

[VHADOC]

want to talk about procuring equipment....

....It is hard not to become jaded when you are spending your tax dollars and poor people's tax dollars so uselessly....

...It is easier to defend military medicine until you get in these seemingly every day situations where money is wasted and care is compromised....

I don't know if it's okay to post links here, but the following is a link to the service that sells off military equipment (formerly a DRMO function....the old "buy this Jeep for $44" folks): www.govliquidation.com If you have a truck and some free time you can stock a small hospital, including the OR, for a few thousand dollars if you're willing to drive around the country and purchase this used stuff. And, if you're in the market, you can buy a F-18 compressor fan blade alignment tool, new in the box, cost to govt $13k, for only $150.

It's hard to look at the items for sale and not get sick in the stomach looking at the price paid for all this stuff, often not used.

In my govt employment circumstance, I agree that there are daily situations where money is wasted and care is compromised. Penny-wise and pound-foolish is the rule of the day (current managers are responsible for the pennies; the pounds are left for the next guy to deal with). Care line managers are more focused on metrics than day-to-day bad outcomes. Truly focused on the forest without appreciable concern for falling trees (so long as they don't call their congressman).

 

[a1qwerty55]

Right, like I said it is an indirect benefit, at best. At worst, it gets you absolutely nothing, which in my experience is the case. But the clipboard commandos will count you as another clinic that generated 2.2 RVUs/FTE. It absolutely is about meeting some arbitrary productivity measure. It says nothing about quality of patient care. I will let you know when I see RVU measures benefit patients in our system. I wouldn't hold your breath. Documenting meaningless positive (and double negative) ROS findings on AHLTA does not constitute improved patient care. Many of the AHLTA primary care notes are unreadable, but generate the required RVUs. You are rewarded for checking boxes but ultimately providing horrible medical documentation. Improving patient care is not a part of the equation.

But then money is taken away from the hospital when one clinic has only 82% positive ICE evaluations because the providers only spend 5 minutes with them face to face because of the time it takes to check boxes in AHLTA to generate a 99213 or whatever. Productive, maybe. Improved patient care, probably not.

Depends where you are, my clinic receives direct cash payouts based on productivity - this can be used for equipment, training etc. It isn't a lot but it gives me some discretionary money.