TMS wRVUs

[Gubernac]

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I am in a hospital based system that compensates us based off of our wRVUs. We are currently considering adding TMS to outpatient clinic. As I understand it, the CPT code for TMS do not include any wRVU value. In interviews that I had with other job opportunities, they would compensate the physician for patients that were being treated with TMS. How does this usually work given there is no wRVU amount? Is it reasonable to expect some revenue from patients that we have treated with TMS? How would you recommend negotiating this?

 

[comp1]

Okay, I'm salary for life and this kind of discussion definitely makes me more confident about that, but it looks like you ask them to use a different kind of calculation. Or, just ask them to pay you a reasonable full time salary and don't mess around with this RVU junk. And yes, the system is getting revenue. The billing codes are covered by all major private insurance and Medicare.

M

Thread 'RVUs for TMS'

Nov 18, 2022

We will be starting TMS in our clinic and this is the first in this group. So we had lot of questions about billing and security. We sorted out most of the things but left with one question which is about RVUs. CPT codes 90867, 90868, 90869 have no RVU values. In that case, how do you negotiate the compensation with your employer?

If they compensate, what is a reasonable ask? This new TMS patient population will reduce my clinic RVUs because I have to spend time with mapping, remapping and be there if any kind of help needed for my technician.

Is it possible to use a "procedure code" and...

• mle3
• billing compensation rvus tms
• Replies: 8
• Forum: Psychiatry

• 

 

[Stagg737]

Okay, I'm salary for life and this kind of discussion definitely makes me more confident about that, but it looks like you ask them to use a different kind of calculation. Or, just ask them to pay you a reasonable full time salary and don't mess around with this RVU junk. And yes, the system is getting revenue. The billing codes are covered by all major private insurance and Medicare.

M

Thread 'RVUs for TMS'

Nov 18, 2022

We will be starting TMS in our clinic and this is the first in this group. So we had lot of questions about billing and security. We sorted out most of the things but left with one question which is about RVUs. CPT codes 90867, 90868, 90869 have no RVU values. In that case, how do you negotiate the compensation with your employer?

If they compensate, what is a reasonable ask? This new TMS patient population will reduce my clinic RVUs because I have to spend time with mapping, remapping and be there if any kind of help needed for my technician.

Is it possible to use a "procedure code" and...

• mle3
• billing compensation rvus tms
• Replies: 8
• Forum: Psychiatry

• 

The capitalistic nature of our health system I'd never want to be straight salary. I've heard too many horror stories from colleagues working salary and then having their workload cranked up to unreasonable levels without extra compensation to pursue that path. Even if it's not more patients, it's more admin duties or screening tools, etc. Only time I'd want to be salaried is in an average volume clinic or less with lots of no-shows.

To OP, where I'm at the physician does the initial mapping and re-mapping if necessary. We get 50% of collections which usually comes out to somewhere between $4-6k/patient.

 

[psych_0]

don't mess around with this RVU junk.

If I was an admin, you would be my favorite employee.

What is a "reasonable" full time salary in your eyes for an outpatient doc with a full clinic schedule M-F seeing 30 min f/u + 1 hr intakes and also doing TMS (for no extra wRVU), 5 weeks vacation and 1 week CME? Genuinely curious.

 

[comp1]

So there has to be separate dedicated time available for doing TMS. That does actually require SOME clinical time. That's the ultimate point. Time has to be be built into the work week for activities that don't generate RVUs. Salary is almost entirely location dependent, but if you were to just look at national averages and try to estimate average benefits, it's somewhere a bit north of $300k annually. Looking at Kaiser in California (which is roughly what's described in terms of time with patients), it's closer to $375k.

 

[Stagg737]

So there has to be separate dedicated time available for doing TMS. That does actually require SOME clinical time. That's the ultimate point. Time has to be be built into the work week for activities that don't generate RVUs. Salary is almost entirely location dependent, but if you were to just look at national averages and try to estimate average benefits, it's somewhere a bit north of $300k annually. Looking at Kaiser in California (which is roughly what's described in terms of time with patients), it's closer to $375k.

That’s the thing though, the only “clinical time” TMS requires is the mapping and possibly re-mapping which takes 20-30 minutes on on initial visit. The remainder of the treatments are typically just performed by nurses or techs trained for TMS, the liability is going to be on your license though.

In private practice TMS could generate A LOT of revenue if you’ve got a consistent patient stream with solid collection rates. This is just too much of a hassle or clinics can’t get consistent referrals to make it really profitable a lot of times though. Where I’m at there’s 15 TMS slots per day. At ~$400/session x ~30 sessions that’s $12k/patient charged or $6k/day. So 30 minutes of initial mapping and the rest is profit after you pay the tech their rate to run it ($20-25/hr).

This why you sound like an admin’s dream for the TMS aspect. If they’re only paying you for the clinic time it takes up then you’d get a couple hundred bucks while they keep 95%+ of what thes are actually paying while using you as the liability meat shield. Great example of how a salaried position can screw physicians out of income.

 

[comp1]

There is only liability if something can be proven to be done outside the community standard followed by related harm. If the tech doing the treatments after mapping really is the community standard, then that is really it. What exactly is the liability with TMS? Further, how would this be handled in the setting of an owner/operator who has all the profit and all the liability? Would the MD owner avoid the tech all together and sit there all day with the patients? If not, that is not the community standard. I don't think I have ever even read about a TMS related malpractice suit. I can conceptualize somehow causing a seizure, but that is purely theoretical for malpractice and it is also an anticipated possible adverse reaction of ideal of treatment that patients sign off on

 

[Stagg737]

There is only liability if something can be proven to be done outside the community standard followed by related harm. If the tech doing the treatments after mapping really is the community standard, then that is really it. What exactly is the liability with TMS? Further, how would this be handled in the setting of an owner/operator who has all the profit and all the liability? Would the MD owner avoid the tech all together and sit there all day with the patients? If not, that is not the community standard. I don't think I have ever even read about a TMS related malpractice suit. I can conceptualize somehow causing a seizure, but that is purely theoretical for malpractice and it is also an anticipated possible adverse reaction of ideal of treatment that patients sign off on

You seem to latched onto the lawsuit idea since I briefly mentioned it, but that's not really the issue. TMS requires a physician be present, though not directly present in the room with the patient. So you can be in clinic seeing other patients while the tech performs TMS, but you are required to be available if needed. It's less liability meat shield and more that institutions cannot administer TMS without a licensed individual (per standard of care).

The real question is how little are you willing to receive to rent out your license to them, which is the part relevant to OP's question. As I mentioned, where I'm at we get 50% of collections, so a pretty solid cut. I wouldn't even bother doing it if they were just going to pay me for the time spent on the initial mapping, it's basically just renting your license out for free.

ETA: For the lawsuit issue, that's not how lawsuits work. When someone has a bad outcome and sues, the lawyers typically name everyone under the sun on the chart and then drop the cases against people where they don't think it'll go through or be relevant later. You better bet your butt that as the supervising physician you would be named. Even if the case has no teeth, you're still typically going to have to report it to the board, which can cause licensure issues if the case is still active or at the very least lead to an annoyance explaining why you were named in the lawsuit when you re-up your license. Not sure if you've just been insulated from this being a VA employed doc or just are unfamiliar, but I've seen how much of a pain it's been for some of my colleagues who weren't even involved in the incident but were named because they saw the patient at one point during a hospitalization.

 

[comp1]

Lawsuits suck. Yes, everyone gets named, including medical students. Yes, they are terrifying and time destroying. Yes, settlements often have to be reported to the National Practitioner's Data Bank which could result in challenges with license renewals. Given the trauma they inflict that is often unrelated to the care provided, the relatively low involvement with malpractice suits was something that attracted me to psych and I'm sure it does many others. That said, in this case, I'm genuinely interested in how malpractice suits relate to TMS in specific since I think that is what someone most commonly thinks of immediately when they consider liability as a phrase. Google searching only seems to show criminal lawsuits for fraudulent billing for TMS that wasn't provided or civil lawsuits for insurer's not covering. That said, it appears that liability here was maybe meant more in reference to something akin to "clinical responsibility." Of course you should be reimbursed for clinical responsibility, salaried or not.

 

[psydocc]

That’s the thing though, the only “clinical time” TMS requires is the mapping and possibly re-mapping which takes 20-30 minutes on on initial visit. The remainder of the treatments are typically just performed by nurses or techs trained for TMS, the liability is going to be on your license though.

In private practice TMS could generate A LOT of revenue if you’ve got a consistent patient stream with solid collection rates. This is just too much of a hassle or clinics can’t get consistent referrals to make it really profitable a lot of times though. Where I’m at there’s 15 TMS slots per day. At ~$400/session x ~30 sessions that’s $12k/patient charged or $6k/day. So 30 minutes of initial mapping and the rest is profit after you pay the tech their rate to run it ($20-25/hr).

This why you sound like an admin’s dream for the TMS aspect. If they’re only paying you for the clinic time it takes up then you’d get a couple hundred bucks while they keep 95%+ of what thes are actually paying while using you as the liability meat shield. Great example of how a salaried position can screw physicians out of income.

As someone with a very high volume TMS clinic (multiple chairs/techs, max capacity of 112 sessions/day), I wish insurance paid out $400 per session!

 

[Stagg737]

As someone with a very high volume TMS clinic (multiple chairs/techs, max capacity of 112 sessions/day), I wish insurance paid out $400 per session!

Out of curiosity how much do you average per session? Where I’m at our university gets somewhere between $300-400/session*. That is a high volume clinic though, we just have one chair here.

ETA* number are estimates based on what we get.

 

[psydocc]

Out of curiosity how much do you average per session? Where I’m at our university gets somewhere between $300-400/session. That is a high volume clinic though, we just have one chair here.

$200-300/session, average being around $230. I assume this is geography related since even my 99214 and 90833 payout is on the lower side of the numbers I see posted on here.

 

[splik]

Out of curiosity how much do you average per session? Where I’m at our university gets somewhere between $300-400/session. That is a high volume clinic though, we just have one chair here.

That is quite low for an academic center. They are either also getting large facility fees on top of that, are lying about the revenue, or terrible and negotiating contracts.

In the community $250-400 is the average range for 90868, it should be more for 90867 and 90869. When I was in academics some yrs ago the clinic was getting $500-700 for 90868 from what I recall. I don't do TMS but my private practice contracts that I was offered (and I declined) was $750 for 90867, $380 for 90868, and $1060 for 90869 at the higher end and $255 for 90867, $230 for 90868, and $540 for 90869 and the lower end before any negotiating.