wRVUs and compensation

[BigSib]

I received some education about RVUs and am relatively knowledgeable with CPT codes and billing and such, but I'm wondering what types of RVUs are typically included into a standard RVU-based physician compensation package. For example, we bill for nurse visits and Medicare's Chronic Care Management here, but those are not included on my monthly reports and I feel they should be. I have a meeting scheduled with my employer to review these questions further, but I'm hoping someone can point me in the right direction for further resources on the matter so I go in equipped. FYI I work Mon-Thu only, except when on for hospitalist or newborns and that is only a quick 2-3 hr hospital trip early in the morning.

OUTPATIENT
All the standard office visit types are there per usual (New/Established, Consults, TCM, Preventive visits, Medicare AWV, School/Sports Physicals, etc.). Examples of non-office visit related RVUs generated on my list include:

• Standard Family Med Procedures: abscesses, biopsies, OMT, joint injections/aspirations, earwax removal, and other odd ball procedures etc.
• Electrocardiogram interpretation
• Immunization administration
• Smoking cessation counseling
• Goals of care counseling ("Advanced care planning")
• CPAP ventilation, initiation & management
• Rarely prolonged service codes
• Pap smear collection

Chronic Care Management and nurse visit codes are way under-reported compared to reality. I have prepared some examples where it has happened, was billed, and has not shown on up my RVU list. Am I missing any obvious or easy RVU generation here? I could probably do more Annual Wellness Visits and/or OMT but there's not much time for it.

INPATIENT
I also do hospitalist shifts and get paid hourly for that (2hr base pay regardless plus $/hr for any additional hours that are reported). Sometimes Hospital Care Initial/Discharge and Observation Care shows up on my monthly reports, but it seems very inconsistent with reality and makes me question where they are pulling the data. On the other hand I do get paid hourly so I feel like any RVUs showing up is like double dipping to me (paid hourly + paid for RVU generation)... I almost hesitate to even bring this up for that reason.

L&D
I also see newborns in the hospital and do circumcisions. We get paid a weekly stipend for being on call, but any newborn care is included into the monthly RVU total. That includes circumcisions and standard newborn hospital care (H&P, DC, etc.). On occasion I will assist with a crash Cesarean and get surgical assistant for that (16 RVU's yeah!) as well as neonatal resuscitation.

NURSING HOME
I go to a nursing home for a few hours once per week. The typical nursing home visit codes are there. We are getting long term patients enrolled into our Chronic Care Management program so we can capture some there (we have an actually rather comprehensive CCM program here with a lot of ancillary staff). I don't really do any special procedures or anything there otherwise.

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[Ironheme]

I'm a resident, so take this with a grain of salt:

Advance care management goes through our MSW. The welcome to medicare visits/medicare wellness we bill for, which it seems is what is happening for you. I'm not sure I follow you with the nursing visits. You're saying you want to have the nurse visits count under your RVU?

One of the docs I know kills it in terms of RVU, and he does it via MCW/annual visits. He has his nursing staff calling patients to schedule their annuals. One thing I would recommend is talking to your partners, particularly your highest earner and see what they're doing differently. Also, as a side note, I appreciate how organized your post was with bolded titles and bullet points, bet your clinic notes are nice to read as well.

 

[DoubleBogey]

I received some education about RVUs and am relatively knowledgeable with CPT codes and billing and such, but I'm wondering what types of RVUs are typically included into a standard RVU-based physician compensation package. For example, we bill for nurse visits and Medicare's Chronic Care Management here, but those are not included on my monthly reports and I feel they should be. I have a meeting scheduled with my employer to review these questions further, but I'm hoping someone can point me in the right direction for further resources on the matter so I go in equipped. FYI I work Mon-Thu only, except when on for hospitalist or newborns and that is only a quick 2-3 hr hospital trip early in the morning.

OUTPATIENT
All the standard office visit types are there per usual (New/Established, Consults, TCM, Preventive visits, Medicare AWV, School/Sports Physicals, etc.). Examples of non-office visit related RVUs generated on my list include:

• Standard Family Med Procedures: abscesses, biopsies, OMT, joint injections/aspirations, earwax removal, and other odd ball procedures etc.
• Electrocardiogram interpretation
• Immunization administration
• Smoking cessation counseling
• Goals of care counseling ("Advanced care planning")
• CPAP ventilation, initiation & management
• Rarely prolonged service codes
• Pap smear collection

Chronic Care Management and nurse visit codes are way under-reported compared to reality. I have prepared some examples where it has happened, was billed, and has not shown on up my RVU list. Am I missing any obvious or easy RVU generation here? I could probably do more Annual Wellness Visits and/or OMT but there's not much time for it.

INPATIENT
I also do hospitalist shifts and get paid hourly for that (2hr base pay regardless plus $/hr for any additional hours that are reported). Sometimes Hospital Care Initial/Discharge and Observation Care shows up on my monthly reports, but it seems very inconsistent with reality and makes me question where they are pulling the data. On the other hand I do get paid hourly so I feel like any RVUs showing up is like double dipping to me (paid hourly + paid for RVU generation)... I almost hesitate to even bring this up for that reason.

L&D
I also see newborns in the hospital and do circumcisions. We get paid a weekly stipend for being on call, but any newborn care is included into the monthly RVU total. That includes circumcisions and standard newborn hospital care (H&P, DC, etc.). On occasion I will assist with a crash Cesarean and get surgical assistant for that (16 RVU's yeah!) as well as neonatal resuscitation.

NURSING HOME
I go to a nursing home for a few hours once per week. The typical nursing home visit codes are there. We are getting long term patients enrolled into our Chronic Care Management program so we can capture some there (we have an actually rather comprehensive CCM program here with a lot of ancillary staff). I don't really do any special procedures or anything there otherwise.

You’ve pretty must listed everything. From the inpatient side, at some places, coders will up-code/down-code notes based on note/documentation.

From the nursing home perspective, I sometimes include discharge management - if I saw a person for admission 1 wk ago, then I’m there next wk and they are being discharged in the next 48hrs, I will see them and bill for discharge management.

I haven’t delved into nursing home annual visits - is this something you have been doing?

 

[BigSib]

... From the nursing home perspective, I sometimes include discharge management - if I saw a person for admission 1 wk ago, then I’m there next wk and they are being discharged in the next 48hrs, I will see them and bill for discharge management.

I haven’t delved into nursing home annual visits - is this something you have been doing?

I need to read up on nursing home documentation / billing. I'm basically just doing the required 30/60-day visits for my partners. I didn't even know discharge management was a thing (lol). There's probably some extra revenue to capture over there I can imagine.

... One of the docs I know kills it in terms of RVU, and he does it via MCW/annual visits. He has his nursing staff calling patients to schedule their annuals. ...

We are working to actively increase our Medicare Annual Wellness Visit capture rate. Basically we have a dedicated AWV nurse for the building who does everything and then I swoop in the review, unless they're scheduled specifically with me for an AWV for their annual exam or something. Overall the numbers could improve but as the new guy on the block people still want to come to talk about problems and it's hard to play the prevention game right off the bat.

... I'm not sure I follow you with the nursing visits. You're saying you want to have the nurse visits count under your RVU?

For example, if I have someone come in for RN to check BP, review new med, administer a shot or something (Prolia, etc.) - this is all something I'm coordinating and expect that it ought to be captured under my RVUs as a 99211 or 99212 (what I am calling a 'nurse visit' because only the nurse is seeing them).

 

[Bacchus]

The MWV is low hanging fruit. I do it routinely with a regular follow up, the documentation isn't arduous at all. Routinely audited by the organization, have hundreds of docs doing it this way, totally legit. Bill the MWV with a 25 modifier and a 213 or 214.

 

[deleted87716]

The MWV is low hanging fruit. I do it routinely with a regular follow up, the documentation isn't arduous at all. Routinely audited by the organization, have hundreds of docs doing it this way, totally legit. Bill the MWV with a 25 modifier and a 213 or 214.

Ditto.

 

[VA Hopeful Dr]

Me three. Easiest 2.X RVUs you can get

 

[Bacchus]

Me three. Easiest 2.X RVUs you can get

Awesome when your patient is compliant and not needy and you can knock it out in one slot instead of 2.

 

[VA Hopeful Dr]

Awesome when your patient is compliant and not needy and you can knock it out in one slot instead of 2.

Our group has a bunch of MAs that call any patients eligible for an AWV the week before their next scheduled appointment and do 99% of the AWV over the phone. All I do is look at the responses and order appropriate vaccines/tests/referrals. I've yet to have it take more than 5 minutes so it always gets done with the appointment in one spot.

 

[gguerrab]

Similar situation here. RVUs from hospital work not accounted for total productivity pay, just the shift pay (otherwise, double dip).
Seems like you are billing for everything you are doing.
Here is a good article about this topic: What You Should Do Now to Get a $100k Raise Next Year

 

[Ironheme]

Ditto.

Can you really do the MCW visit with 13 or 14? I was taught can't do both, as Medicare won't reimburse if I get labs/give shots that day plus the visit.

 

[VA Hopeful Dr]

Can you really do the MCW visit with 13 or 14? I was taught can't do both, as Medicare won't reimburse if I get labs/give shots that day plus the visit.

Yes you can. I almost never do the AWV by itself.

You give the 99213/4 a 25 modifier and you're fine.

 

[deleted87716]

Can you really do the MCW visit with 13 or 14? I was taught can't do both, as Medicare won't reimburse if I get labs/give shots that day plus the visit.

Yes. I do it all the time. You can do shots/labs, too, as these don't require a modifier 25.

The only thing you really have to do differently in order to avoid "double-dipping" (e.g., double-counting elements required for the E&M with those required for the AWV - essentially just the vital signs, as the AWV doesn't require any HPI/ROS/PE) is to document two sets of vital signs. Also, include a Z00.00 or Z00.01 code in your note (but don't make it the first code submitted) for the AWV.

Some Medicare HMOs (e.g., Humana) also allow you to bill an age-specific preventive care code (99387/99397) once/year, which you can also bill along with an E&M code (in those cases, I bill the Z00.0x code first, although you probably don't have to). You can't bill all three at the same time, however (e.g., preventive, AWV, and E&M) because you can only bill one other service using modifier 25. Most of my Medicare patients are seen at least twice/year, so in order to capture all the codes, I'll bill the AWV with their first E&M visit, and the preventive care code - if eligible - with their second (provided they're due on the given date - my staff tracks that). Of course, when you bill a preventive care code, you have to actually address preventive care issues in your note (even if they're current on everything), so don't overlook that.

 

[VA Hopeful Dr]

Yes. I do it all the time. You can do shots/labs, too, as these don't require a modifier 25.

The only thing you really have to do differently in order to avoid "double-dipping" (e.g., double-counting elements required for the E&M with those required for the AWV - essentially just the vital signs, as the AWV doesn't require any HPI/ROS/PE) is to document two sets of vital signs. Also, include a Z00.00 or Z00.01 code in your note (but don't make it the first code submitted) for the AWV.

Some Medicare HMOs (e.g., Humana) also allow you to bill an age-specific preventive care code (99387/99397) once/year, which you can also bill along with an E&M code (in those cases, I bill the Z00.0x code first). You can't bill all three at the same time, however (e.g., preventive, AWV, and E&M) because you can only bill one other service using modifier 25. Most of my Medicare patients are seen at least twice/year, so I'll bill the AWV with their first E&M visit, and the preventive care code - if eligible - with their second (provided they're due on the given date - my staff tracks that). Of course, when you bill a preventive care code, you have to actually address preventive care issues in your note, so don't overlook that.

I specifically have two different notes for the encounter to make a hundred percent sure that isn't an issue.

 

[deleted87716]

I specifically have two different notes for the encounter to make a hundred percent sure that isn't an issue.

Our EHR generates a separate note for the AWV, but since it's being billed using modifier 25, I make sure that my office note references the AWV along with any other services that I perform/order related to it. Think of the AWV as a procedure note.

 

[VA Hopeful Dr]

Our EHR generates a separate note for the AWV, but since it's being billed using modifier 25, I make sure that my office note references the AWV along with any other services that I perform/order related to it. Think of the AWV as a procedure note.

My setup is similar and the default note that I use for regular visits will pull in the problems from the AWV as well.

 

[Ironheme]

Thanks for the detailed info. That was an eye opener. I was getting dinged for doing labs on the same day as a medicare wellness visit, being told it wasn't covered. It sounds like you get around this by doing a 13/14 at the same time. This would make patients happier as well.