Work rvu for outpatient psychiatry

[heysexylady]

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Quick question. For the Midwest (Illinois) would you consider 45 per wRvu low to be low for outpatient if you are seeing both child and adult.

 

[st2205]

Low. What the the other perks?

 

[heysexylady]

Low. What the the other perks?

Outpatient child and adult
$30,000 sign on bonus.
Retention bonus of $30,000 after 2 years.
Guaranteed salary $250,000 for two years after it's production.
$10,000 relocation.
4 weeks of vacation
6 holiday days
10 cme days
No call. Can have a 4 day schedule.
2 hours from Chicago.

 

[dl2dp2]

This is not a bad offer. They basically want to pay you 295k for 2 years for 40 hour outpatient no call no weekend and a 4 day schedule. I imagine it will be a busy clinic though.

You can always renegotiate RVU after 2 years after you have that 70k bonus in hand. That number right now is meaningless anyway, as you have no good sense of what kind of RVUs you'll be able to bill from that practice. The more important bit is whether this is a partnership private practice (sounds like it) or some kind of facility. If it's partnership based, you should consider formally get on the partner track and become eligible for partnership at the end of 2 years. I suspect full profit sharing is a much more lucrative aspect of this group compared to billing RVUs, hence the lower number. If it's a facility the trick is actually typically more in the workload/patient population mix.

If you are just looking around, this is not a bad place to start--just get started and have the conversation later. If your plan is to stay at that location (family etc), I'd ask about partnership track.

 

[SmallBird]

Quick question. For the Midwest (Illinois) would you consider 45 per wRvu low to be low for outpatient if you are seeing both child and adult.

That’s really a bad deal in my opinion, particularly for outpatient if it’s only productivity. We pay are inpatient covering docs $54 per RVU and it’s much easier to generate RVUs in inpatient than outpatient. That’s in the northeast, at an academic place. I would ask for $75 for straight RVU in Midwest.

 

[SmallBird]

This is not a bad offer. They basically want to pay you 295k for 2 years for 40 hour outpatient no call no weekend and a 4 day schedule. I imagine it will be a busy clinic though.

You can always renegotiate RVU after 2 years after you have that 70k bonus in hand. That number right now is meaningless anyway, as you have no good sense of what kind of RVUs you'll be able to bill from that practice. The more important bit is whether this is a partnership private practice (sounds like it) or some kind of facility. If it's partnership based, you should consider formally get on the partner track and become eligible for partnership at the end of 2 years. I suspect full profit sharing is a much more lucrative aspect of this group compared to billing RVUs, hence the lower number. If it's a facility the trick is actually typically more in the workload/patient population mix.

If you are just looking around, this is not a bad place to start--just get started and have the conversation later. If your plan is to stay at that location (family etc), I'd ask about partnership track.

For the first year its ok, but beyond there, you are looking at having to do 20 RVU's per day (4600 per year) to make 200k. A number of ways to get there but one of those ways would be 6 full new evals, which is busy. I think 200k is a good salary for 3000 RVU's per year.

 

[heysexylady]

This is not a bad offer. They basically want to pay you 295k for 2 years for 40 hour outpatient no call no weekend and a 4 day schedule. I imagine it will be a busy clinic though.

You can always renegotiate RVU after 2 years after you have that 70k bonus in hand. That number right now is meaningless anyway, as you have no good sense of what kind of RVUs you'll be able to bill from that practice. The more important bit is whether this is a partnership private practice (sounds like it) or some kind of facility. If it's partnership based, you should consider formally get on the partner track and become eligible for partnership at the end of 2 years. I suspect full profit sharing is a much more lucrative aspect of this group compared to billing RVUs, hence the lower number. If it's a facility the trick is actually typically more in the workload/patient population mix.

If you are just looking around, this is not a bad place to start--just get started and have the conversation later. If your plan is to stay at that location (family etc), I'd ask about partnership track.

It's for a hospital not a partnership track.

Thank you.

 

[heysexylady]

For the first year its ok, but beyond there, you are looking at having to do 20 RVU's per day (4600 per year) to make 200k. A number of ways to get there but one of those ways would be 6 full new evals, which is busy. I think 200k is a good salary for 3000 RVU's per year.

Thank you so much for the $75 pee wrvu. The guaranteed is actually for two years not one year.

 

[SmallBird]

Thank you so much for the $75 pee wrvu. The guaranteed is actually for two years not one year.

If you think about about private practice, a child psych new eval is $350 in an average market which is $105 per 'RVU' if you figure it out that way.

 

[heysexylady]

If you think about about private practice, a child psych new eval is $350 in an average market which is $105 per 'RVU' if you figure it out that way.

Oh, no one has ever pointed it out that way. But that 305 would be for like dc, LA, NYC, or Chicago areas.... I can't imagine most places paying that much.

 

[SmallBird]

Oh, no one has ever pointed it out that way. But that 305 would be for like dc, LA, NYC, or Chicago areas.... I can't imagine most places paying that much.

$350 is very standard for an initial evaluation for child. In NYC you are going to be paying $500 or more.

 

[trophyhusband]

$350 is very standard for an initial evaluation for child. In NYC you are going to be paying $500 or more.

Pretty sure you've never been 2 hours outside of Chicago (where this job is located) if you think $350 is a realistic amount being charged for a new C&A eval. Most of the folks out there are going to be on Medicare/Medicaid along with some commercially insured. I mean there's not much out there 2 hours from Chicago west or south... Rockford... Bloomington and Peoria if you want to stretch the definition of 2 hours. 2 hours north is Milwaukee and I'm guessing the OP would have used that as a reference point if the job was in WI.

At any rate OP. Here's something someone linked to before: 207 statistics on physician compensation | 2017

It shows a median wRVU as roughly $62.50 ($254,942/4,079 RVU) and that'd be a decent amount to aim for if you want to maintain your $250,000 salary after the guarantee (as the RVUs needed to maintain that are ~4,000). You can certainly ask for $75 but they may just write you off as hopelessly unrealistic (depends on how bad they need a Psychiatrist I guess). You might be able to argue that the numbers in the linked article are based on general psych so you deserve $5 more per RVU and then work your way down... that would seem more realistic to me. The bad thing about being so far out from Chicago is that the hospitals out there are much more dependent on Medicaid (for the most part) and Illinois has a bad habit of not paying Medicaid bills on time. I'm guessing that'll be the insurance for quite a lot of your C&A panel.

 

[dl2dp2]

It's for a hospital not a partnership track.

Thank you.

Something is funky. I suspect the case load is high. You need to be careful with this one in this case--what it means is that the facility may be desperate and losing money on you to get you to start working. They will expect another negotiation at the end of 2 years, as it's unclear if such a job 1) generates enough RVUs for 300k total comp 2) at that point their payer mix will reimburse that amount per RVU.

Your intuition is correct. 2 hours outside of Chicago generally means it's a mix of Medicare and Medicaid, and nobody will be able to afford cash $350 for an intake. That rate is for mainline suburbs. Major markets can afford more than $350 (sometimes substantially more), but this is not at all what facilities are doing.

Just very simplistic math: 99213+90833 ~ 2-4 RVUs. Let's call it 3. 3*45*50*48 = 320k. Can you squeeze in 10 complicated C&A f/us per day, 5 days a week, plus documentation, admin etc? Maybe you can--depending on acuity, etc..., right? So that's what I'm saying about trick for facility is in the details. Depends on things like no-show rates, how many people are stable, etc. the same job on paper can be a totally different job in reality. I would nicely ask for actual numbers of RVUs per billing code, and rough census count of current physician's billing...and talk to existing clinicians there about patient mix.

 

[splik]

Just very simplistic math: 99213+90833 ~ 2-4 RVUs. Let's call it 3. 3*45*50*48 = 320k. Can you squeeze in 10 complicated C&A f/us per day, 5 days a week, plus documentation, admin etc? Maybe you can--depending on acuity, etc..., right? So that's what I'm saying about trick for facility is in the details. Depends on things like no-show rates, how many people are stable, etc. the same job on paper can be a totally different job in reality. I would nicely ask for actual numbers of RVUs per billing code, and rough census count of current physician's billing...and talk to existing clinicians there about patient mix.

99213+90833 = 1.95wRVUs - maybe you are thinking tRVUs?

 

[dl2dp2]

99213+90833 = 1.95wRVUs - maybe you are thinking tRVUs?

Ugh yeah you are right--I thought it's 2.5ish wRVU? The math is even worse. I can only think in terms of tRVUs (in PP for too long lol). You'd have to squeeze in more like 15 f/us a day to get to 300k. Yuck.

I've been to these clinics. People bill 99213+90833 for 15 min med checks. It's really fraud but hey...who's looking at the clock as long as you document "correctly"...for "counseling and care coordination." America--land of loopholes and gray zone behavior.

 

[st2205]

99213+90833 = 1.95wRVUs - maybe you are thinking tRVUs?

Correct me if I’m wrong, but I’m seeing 0.97 wRVU (99213) + 1.5 wRVU (90833) = 2.47.

 

[SmallBird]

Pretty sure you've never been 2 hours outside of Chicago (where this job is located) if you think $350 is a realistic amount being charged for a new C&A eval. Most of the folks out there are going to be on Medicare/Medicaid along with some commercially insured. I mean there's not much out there 2 hours from Chicago west or south... Rockford... Bloomington and Peoria if you want to stretch the definition of 2 hours. 2 hours north is Milwaukee and I'm guessing the OP would have used that as a reference point if the job was in WI.

I'm talking about cash private practice - $350 is about the amount I see people charging in smaller cities, suburbs, etc. Of course there are places that don't even sustain cash practice markets, but thats not what I'm referring to.

 

[trophyhusband]

I'm talking about cash private practice - $350 is about the amount I see people charging in smaller cities, suburbs, etc. Of course there are places that don't even sustain cash practice markets, but thats not what I'm referring to.

But you're providing advice on a job that's based in one of those places that can't sustain a cash practice market. I mean I guess the OP could go back to them and say hey this is the RVU equivalent I'd receive if I opened my own cash practice in suburb X but they'd probably just say ok best of luck with that.

 

[heysexylady]

So, I called them and they told me that every year they average the past three years for the current wRvu. The number quoted in the article was just an example to explain how the money will be given out and would not be for someone in my field. This year the average was like 61.79.

Good deal?

Pretty sure you've never been 2 hours outside of Chicago (where this job is located) if you think $350 is a realistic amount being charged for a new C&A eval. Most of the folks out there are going to be on Medicare/Medicaid along with some commercially insured. I mean there's not much out there 2 hours from Chicago west or south... Rockford... Bloomington and Peoria if you want to stretch the definition of 2 hours. 2 hours north is Milwaukee and I'm guessing the OP would have used that as a reference point if the job was in WI.

At any rate OP. Here's something someone linked to before: 207 statistics on physician compensation | 2017

It shows a median wRVU as roughly $62.50 ($254,942/4,079 RVU) and that'd be a decent amount to aim for if you want to maintain your $250,000 salary after the guarantee (as the RVUs needed to maintain that are ~4,000). You can certainly ask for $75 but they may just write you off as hopelessly unrealistic (depends on how bad they need a Psychiatrist I guess). You might be able to argue that the numbers in the linked article are based on general psych so you deserve $5 more per RVU and then work your way down... that would seem more realistic to me. The bad thing about being so far out from Chicago is that the hospitals out there are much more dependent on Medicaid (for the most part) and Illinois has a bad habit of not paying Medicaid bills on time. I'm guessing that'll be the insurance for quite a lot of your C&A panel.

Something is funky. I suspect the case load is high. You need to be careful with this one in this case--what it means is that the facility may be desperate and losing money on you to get you to start working. They will expect another negotiation at the end of 2 years, as it's unclear if such a job 1) generates enough RVUs for 300k total comp 2) at that point their payer mix will reimburse that amount per RVU.

Your intuition is correct. 2 hours outside of Chicago generally means it's a mix of Medicare and Medicaid, and nobody will be able to afford cash $350 for an intake. That rate is for mainline suburbs. Major markets can afford more than $350 (sometimes substantially more), but this is not at all what facilities are doing.

Just very simplistic math: 99213+90833 ~ 2-4 RVUs. Let's call it 3. 3*45*50*48 = 320k. Can you squeeze in 10 complicated C&A f/us per day, 5 days a week, plus documentation, admin etc? Maybe you can--depending on acuity, etc..., right? So that's what I'm saying about trick for facility is in the details. Depends on things like no-show rates, how many people are stable, etc. the same job on paper can be a totally different job in reality. I would nicely ask for actual numbers of RVUs per billing code, and rough census count of current physician's billing...and talk to existing clinicians there about patient mix.

 

[trophyhusband]

So, I called them and they told me that every year they average the past three years for the current wRvu. The number quoted in the article was just an example to explain how the money will be given out and would not be for someone in my field. This year the average was like 61.79.

Good deal?

The average $ per wRVU for Psychiatry was $61.79? Not sure if that's what you're trying to convey or not. But that's essentially the same as the $62.50 so you can work off of either. Like I said, if it were my wife I'd tell her to start $5 higher because she's C&A as well and work down from there but not below $62.50. Which gets you back to your $250,000 guarantee when you hit 4,000 wRVU.

At 4,000 wRVU you'd have 261 working days in 2018. Take out your holiday and vacation (26 days) you're at 235 days to cover that 4,000 or ~17 a day.

Now whether $250k is worth it to live 2 hours outside of Chicago only you can decide. But my wife currently works a position with no weekends and no call and she's super happy with that particular arrangement thus far.

 

[hamstergang]

I've been to these clinics. People bill 99213+90833 for 15 min med checks. It's really fraud but hey...who's looking at the clock as long as you document "correctly"...for "counseling and care coordination."

Not sure if I'm misintrepreting, but just in case: Counseling and coordination of care have to do with billing 99211-99215 based on time. That's unrelated to the psychotherapy of 90833 and can't be used with a 90833.

 

[dl2dp2]

Not sure if I'm misintrepreting, but just in case: Counseling and coordination of care have to do with billing 99211-99215 based on time. That's unrelated to the psychotherapy of 90833 and can't be used with a 90833.

That's exactly my point. These clinics make up whatever documentation is required to bill that 90833...it's ALL MADE UP! Jees I don't even know what it is, and I read the APA coding guide like 10 times...

 

[Merovinge]

That's exactly my point. These clinics make up whatever documentation is required to bill that 90833...it's ALL MADE UP! Jees I don't even know what it is, and I read the APA coding guide like 10 times...

You need 16 minutes of psychotherapy and then whatever it takes to do the E&M, however some people have argued that some of the time with the E&M could be part of the psychotherapy (which is garbage but it seems to fly). This technically lets people do 3 99213+99833 in 1 hour, if you live in magical christmas land where patients walk out of your office and the next steps foot in immediately. Obviously there is a lot of "little" fraud in the system but it certainly is not uncommon or widely out of practice standards. I imagine this is why this billing code is rumored to be getting the axe, which is really unfortunate for folks who actually do both.

Edit: If this does get axed, it will also really hurt training sites where they actually practice this way 🙁. As if academics could be any less revenue generating.

 

[hamstergang]

some people have argued that some of the time with the E&M could be part of the psychotherapy (which is garbage but it seems to fly).

Just to be clear for all reading this, the rules clearly state that the time must be separate for the 90833 and E&M components. No overlapping of the times is allowed.

 

[dl2dp2]

...if you live in magical christmas land where patients walk out of your office and the next steps foot in immediately...

This magical christmas land is called cash private practice lol. This is my daily MO. In fact, if the patient's late, I still end on time.

If 90833/90836 gets axed, facility based jobs will take a hit with salary which is a big problem as there's already a shortage for that type of jobs. I suspect hospitals are not gonna do this without a fight, though perhaps many could care less. People with the means will pay cash for med management (hint, it's really not that much). My intuition is that salaries from W2 jobs went up mid 2013 because of the add on codes (though have no solid backup of this opinion.) With this, competitiveness of the specialty, hype on SDN, rumor of psych being "the next derm", etc.

Med students don't really understand that median salary etc is very much affected by macro-policy with which they have little control. They really need to like the core aspect of the job (i.e. use meds, in combination with therapy and case management, when available, to address some fairly sick patient's issues)... the "lifestyle" aspect, while is available to some, is not the core of the specialty.

 

[Information Underload]

You need 16 minutes of psychotherapy and then whatever it takes to do the E&M, however some people have argued that some of the time with the E&M could be part of the psychotherapy (which is garbage but it seems to fly). This technically lets people do 3 99213+99833 in 1 hour, if you live in magical christmas land where patients walk out of your office and the next steps foot in immediately. Obviously there is a lot of "little" fraud in the system but it certainly is not uncommon or widely out of practice standards. I imagine this is why this billing code is rumored to be getting the axe, which is really unfortunate for folks who actually do both.

Edit: If this does get axed, it will also really hurt training sites where they actually practice this way 🙁. As if academics could be any less revenue generating.

Where did you hear that psychotherapy codes were getting the axe? I think this would be most unfortunate. I feel that taking this extra time with my patients is truly invaluable and therapeutic.

 

[MedMan80]

Where did you hear that psychotherapy codes were getting the axe? I think this would be most unfortunate. I feel that taking this extra time with my patients is truly invaluable and therapeutic.

I'm sure it is for many, but many are also abusing the system and over-billing..

 

[eaglepsych]

I'm sure it is for many, but many are also abusing the system and over-billing..

If 90833 were indeed to get the axe, hundreds of private practice psychiatrists around the country who currently take insurance would likely be looking to switch to cash only, which would be a major headache for insurers if they can’t provide access to psychiatry for their patients.

Many PP psychiatrists would switch to cash only instead of needing to switch to 15 minute visits, esp when they’re used to being able to provide psychotherapy in addition to medical treatment for their patients.

 

[AD04]

If 90833 were indeed to get the axe, hundreds of private practice psychiatrists around the country who currently take insurance would likely be looking to switch to cash only, which would be a major headache for insurers if they can’t provide access to psychiatry for their patients.

Many PP psychiatrists would switch to cash only instead of needing to switch to 15 minute visits, esp when they’re used to being able to provide psychotherapy in addition to medical treatment for their patients.

Don't you just love the big F U factor in psychiatry?

 

[ziggyhope]

Hi all, I was just looking into the RVU system and how it works. I found the article where the $62.5 per RVU came from, though by looking at various other sources, the trend seems to be outstripping the RVU based compensation. So I'm just wondering what is the actual landscape at this point, or is the $62.5 still the "fairest" way when looking at facility jobs. I attached a file that averages reported compensation for psychiatry from various reports in 2017.

 

[MedMan80]

If 90833 were indeed to get the axe, hundreds of private practice psychiatrists around the country who currently take insurance would likely be looking to switch to cash only, which would be a major headache for insurers if they can’t provide access to psychiatry for their patients.

Many PP psychiatrists would switch to cash only instead of needing to switch to 15 minute visits, esp when they’re used to being able to provide psychotherapy in addition to medical treatment for their patients.

I really doubt that most insurers have that foresight, I mean just the other day I had insurance decline my celexa script citing that i should be sending 90 day supplies for a 'chronic illness', mind you celexa is 4$/mo at walmart..

 

[finalpsychyear]

Ugh yeah you are right--I thought it's 2.5ish wRVU? The math is even worse. I can only think in terms of tRVUs (in PP for too long lol). You'd have to squeeze in more like 15 f/us a day to get to 300k. Yuck.

I've been to these clinics. People bill 99213+90833 for 15 min med checks. It's really fraud but hey...who's looking at the clock as long as you document "correctly"...for "counseling and care coordination." America--land of loopholes and gray zone behavior.

Seems like doctors are the least fraudulent overall in healthcare. Everyone else in healthcare as far as insurance companies, pharmaceuticals etcs commit heinous crimes that only god knows for the betterment of the dollar or they pay $millions in lobbying groups so for example drugs cannot be imported from countries like canada and all the pre-auth or claim rejections insurance companies do is just to ultimately screw you out of money thinking you won't put the effort in to get it. So essentially, people need to realize for the large part in all of medicine big businesses lik e pharma and insurance companies, everyone is committing ethically sketchy business. Some just have the money to make it legal. The only people who care the most for the patients are the doctors/nurses but seem to get the bottom of the barrel when it comes to compensation in the grand scheme of things. Sounds fair i guess.

 

[finalpsychyear]

This magical christmas land is called cash private practice lol. This is my daily MO. In fact, if the patient's late, I still end on time.

If 90833/90836 gets axed, facility based jobs will take a hit with salary which is a big problem as there's already a shortage for that type of jobs. I suspect hospitals are not gonna do this without a fight, though perhaps many could care less. People with the means will pay cash for med management (hint, it's really not that much). My intuition is that salaries from W2 jobs went up mid 2013 because of the add on codes (though have no solid backup of this opinion.) With this, competitiveness of the specialty, hype on SDN, rumor of psych being "the next derm", etc.

Med students don't really understand that median salary etc is very much affected by macro-policy with which they have little control. They really need to like the core aspect of the job (i.e. use meds, in combination with therapy and case management, when available, to address some fairly sick patient's issues)... the "lifestyle" aspect, while is available to some, is not the core of the specialty.

It will just go back to docs doing 10-12 min 99213 per hour which i think ends up being the same

 

[finalpsychyear]

This magical christmas land is called cash private practice lol. This is my daily MO. In fact, if the patient's late, I still end on time.

If 90833/90836 gets axed, facility based jobs will take a hit with salary which is a big problem as there's already a shortage for that type of jobs. I suspect hospitals are not gonna do this without a fight, though perhaps many could care less. People with the means will pay cash for med management (hint, it's really not that much). My intuition is that salaries from W2 jobs went up mid 2013 because of the add on codes (though have no solid backup of this opinion.) With this, competitiveness of the specialty, hype on SDN, rumor of psych being "the next derm", etc.

Med students don't really understand that median salary etc is very much affected by macro-policy with which they have little control. They really need to like the core aspect of the job (i.e. use meds, in combination with therapy and case management, when available, to address some fairly sick patient's issues)... the "lifestyle" aspect, while is available to some, is not the core of the specialty.

i don't know where this axing of these codes is coming from. They are very brand new basically since 2013-2014 ish. It would take a few years for it to go down anyways and I have seen nothing aside from he said, she said stuff.

 

[calvnandhobbs68]

i don't know where this axing of these codes is coming from. They are very brand new basically since 2013-2014 ish. It would take a few years for it to go down anyways and I have seen nothing aside from he said, she said stuff.

They’ll save more money cutting down the reimbursements for all the useless spine surgeries done on Medicare beneficiaries. There are a lot more lucrative targets to go after than add on outpatient psychotherapy codes.

 

[honsano]

@trophyhusband (or anybody)
Just to be clear, if a 99213+90833 gets you about 2.5 wRVU, is it that tough to generate 4000 wRVUs? Based on your math, to get 17 per day is 7 simple follow ups w/ add on codes. I'm suprised people aren't averaging much higher!

In Corrections I used to do way more and considered it a light day!

 

[GreenGeek]

@trophyhusband (or anybody)
Just to be clear, if a 99213+90833 gets you about 2.5 wRVU, is it that tough to generate 4000 wRVUs? Based on your math, to get 17 per day is 7 simple follow ups w/ add on codes. I'm suprised people aren't averaging much higher!

In Corrections I used to do way more and considered it a light day!

That's what I'm wondering too as I learn about this. If you see two people an hour, that's 5 RVUs/hr and even 6 hours a day gets you 30 RVU/day, right?

 

[Fabio001]

as I mentioned above, 99213 + 90833 = 0.97 + 0.98 = 1.95. So that would be 3.9 wRVuS per hour. you might be thinking tRVUs but the idea is that 1hr is approximately 3 wRVUs in the outpatient setting. of course there are people churning out 3 visits per hour and billing 99214 + 90833 (1.5 + 0.98) but that would bring you to 4.41 wRVUs, not 5 and some people would question a minute 99214 visit.

Splik, could you list your source. I've cross-referenced multiple places that have shown a 90833 to be 1.5 wRVUs.

Sent from my Pixel 2 XL using SDN mobile

 

[st2205]

Splik, could you list your source. I've cross-referenced multiple places that have shown a 90833 to be 1.5 wRVUs.

Sent from my Pixel 2 XL using SDN mobile

Correct. 90833 is 1.5.