WRVUs / Productivity for Hospital Employment

[florida.podiatry]

Can anyone with experience being employed by a hospital based MSG group break the following down for me:

Say I sign a contract with a hospital for 2 years, the contract advises it will pay the greater of either a base salary $2xx,xxx or sum equal to wRVUs performed.

In the instance I’m seeing at least 25-30 patients a day with an estimated 3-4 days of clinic + 1-2 days of surgery, would it be feasible to make over 300k in the first year with wRVU productivity?

Additionally I haven’t been able to find many resources to convert CPT codes to wRVUs, I’ve stumbled across some outdated PDFs on the web but in your experience, how many wRVUs is a new patient visit for an MSK related issue VS a follow up?

Thank you for explaining like I am five!

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[florida.podiatry]

What value are you given per wRVU?

25-30 patients a day (non nails) with 1 day surgery a week is >400k at $50 wRVU

Not including inpatient care/after hours cases.

wRVU calculator (that for some reason always takes awhile to load).

Thank you for your response.

Fortunately they have foot care nurses who assist with nails so I won’t be seeing any nails.

So far they’ve come to the table with $54/ wRVU & this is in the Midwest.

 

[Feeter]

You'll easily hit 300k with the scenario you are describing. Probably closer to 400 if you are seeing 25 to 30 pts a day for 4 days a week.

I don't know what the going rate is for Midwest but I think $54 per wRVU seems decent.

I wouldn't worry about how many wRVUs you'll be able to do if it is a big group. You'll easily hit 6 to 7k annually once you are established.

Congratulations on this job offer!

 

[air bud]

Can anyone with experience being employed by a hospital based MSG group break the following down for me:

Say I sign a contract with a hospital for 2 years, the contract advises it will pay the greater of either a base salary $2xx,xxx or sum equal to wRVUs performed.

In the instance I’m seeing at least 25-30 patients a day with an estimated 3-4 days of clinic + 1-2 days of surgery, would it be feasible to make over 300k in the first year with wRVU productivity?

Additionally I haven’t been able to find many resources to convert CPT codes to wRVUs, I’ve stumbled across some outdated PDFs on the web but in your experience, how many wRVUs is a new patient visit for an MSK related issue VS a follow up?

Thank you for explaining like I am five!

Pick up any optum podiatry coding book and there is a chart at the end of each code description outlining RVu, wRVU, global etc.

 

[Shiyuan]

Pick up any optum podiatry coding book and there is a chart at the end of each code description outlining RVu, wRVU, global etc.

Would you recommend Dr Mike Warshaw’s coding book or an optum book?

 

[Sweatshirt]

Would you recommend Dr Mike Warshaw’s coding book or an optum book?

Definitely Optum coding companion. I use it almost every day and every time I book a surgery

 

[air bud]

Would you recommend Dr Mike Warshaw’s coding book or an optum book?

Optum. Gives some nuance about what is included and what is not. Warsaw book is pointless, just aggregation of data.

 

[Feli]

AMPA Coding RC (.org) is ~$400-600/yr (depends if member of start-some-new-pod-schools org) and it's good if you want a web-based to use anywhere for codes, rvu for work or NF, globals, cpt>icd, mods etc. They do a free trial.

Optum is $200 good but basically my backup... pretty much collects dust.
I have it, but I bet I check it maybe once every month or two, no joke... 99% of the time, online is just quicker and can be used in ER, pacu, office, hospital, home, wherever.

 

[florida.podiatry]

Pick up any optum podiatry coding book and there is a chart at the end of each code description outlining RVu, wRVU, global etc.

Thank you, I am going to order it right now!

 

[florida.podiatry]

AMPA Coding RC (.org) is ~$400-600/yr (depends if member of start-some-new-pod-schools org) and it's good if you want a web-based to use anywhere for codes, rvu for work or NF, globals, cpt>icd, mods etc. They do a free trial.

Optum is $200 good but basically my backup... pretty much collects dust.
I have it, but I bet I check it maybe once every month or two, no joke... 99% of the time, online is just quicker and can be used in ER, pacu, office, hospital, home, wherever.

Thank you Feli! I can use my CME and have the best of both worlds!

 

[Redsting]

You'll hit it no problem. The hospital I am at 3 days a week about 22-24 pts a day (including nails) and a couple surgeries a week I did over 6800 wrvus last year, the year before was 5500, this year I'm guess it will be around 6300.

If you're doing more days and more surgery and not doing any nails then I wouldn't be surprised if you're touching 10k wruvs.

 

[Shiyuan]

You'll hit it no problem. The hospital I am at 3 days a week about 22-24 pts a day (including nails) and a couple surgeries a week I did over 6800 wrvus last year, the year before was 5500, this year I'm guess it will be around 6300.

If you're doing more days and more surgery and not doing any nails then I wouldn't be surprised if you're touching 10k wruvs.

Seriously? Dang.

I feel better about my next gig 😁

 

[Feli]

Seriously? Dang.

I feel better about my next gig 😁

A lot depends on if it's what you get paid on (collect)... or just the wRVUs of what CPTs you bill out.

At a lot of hospital jobs, you can unbundle surgery like crazy (requires cooperation of hospital billers) and get credit for most/all of it. Others, not so much.
[*disclaimer: same stuff does not work in PP pod/MSG/ortho owner/associate and can cause one bigtime problems]

This same concept can also work against you if you are hospital FTE billing appropriate/aggressive... yet hospital billers are pumping the brakes on you. That kills you RVUs (in both surgery and clinic).

...Talk to friends who work as FTEs of facilities (not slothy govt ones) if you can't figure it out. Hospital DPM is basically exact opposite of PP in many insurance, coding, scheduling, etc facets.

 

[heybrother]

A lot depends on if it's what you get paid on (collect)... or just the wRVUs of what CPTs you bill out.

At a lot of hospital jobs, you can unbundle surgery like crazy (requires cooperation of hospital billers) and get credit for most/all of it. Others, not so much.
[*disclaimer: same stuff does not work in PP pod/MSG/ortho owner/associate and can cause one bigtime problems]

This same concept can also work against you if you are hospital FTE billing appropriate/aggressive... yet hospital billers are pumping the brakes on you. That kills you RVUs (in both surgery and clinic).

...Talk to friends who work as FTEs of facilities (not slothy govt ones) if you can't figure it out. Hospital DPM is basically exact opposite of PP in many insurance, coding, scheduling, etc facets.

This is a source of amusement to me. I was recently sent an op report where an orthopedist turned a 1st MPJ fusion into 8 procedures (28292, 282750, 28306, 28310, 28315, 28088, 11055, 76000, yeah). What's amusing to me about it is - Medicare's NCCI software is instantly going to spit most of that back out.

 

[DYK343]

At a lot of hospital jobs, you can unbundle surgery like crazy

Not my billers. They over bundle surgery.

One of them tried to convince me that a shortening 2nd osteotomy was included in a hammertoe correction. Criminal.

I obviously won that battle. But wow. This is a fairly large hosptial system. 10ish 100-300 bed hospitals bundled together over multi-states

I have learned to review all my surgical billing records. Adds a ton of time but I dont trust them in any way/shape/form.

Also, I am not the only DPM in the system. They hire a lot of DPMs and have for a long time. I dont understand why I am finding all these errors in billing.

My point of this post? Ask for all the billing info. What you say you did in an op report (and legally did...) and what was billed may be quite different. I suspect DPMs get first year grad billers.

...Just like we get student C arm techs and student scrub techs EVERY CASE.

 

[Feli]

Not my billers. They over bundle surgery.

One of them tried to convince me that a shortening 2nd osteotomy was included in a hammertoe correction. ...

Are you putting your CPTs (and ICDs) in your op reports? And clinic notes?
If you are, and its still getting bumbled, I would arrange a meeting about you making surgery superbills.

If you are doing clear codes, and they're changing - or omitting - some, that's illegal in most places. They can't change a physician's intended CPTs without agreement. Hospitals can try to use the "well, the hospital/facility is the one we are billing for... the doc employee is just an agent of the hospital, and we're ultimately in charge of coding for the hospital." (BS)

In their defense, some docs are lazy (or just ignorant) about coding, and they trust hospital coders or their PP billers to sort it out. This thinking has all but died with the EMR age, though... possible exception to VAs and other rare places docs are still on basically straight salary. We aren't usually looking up bunion proc and dx codes in paper books and typing or dictating them anymore... most have templates, electronic or web lists of codes, EMR, etc. It's important docs learn fast and stick to their chosen CPT codes being ones submitted (billers just inform of rejected or possible miscodes). Nobody knows the anatomy, procedures, and encounter like the doc who performed it.

The think that putting CPT and ICD codes in EMR note or op report or whatever is greedy or gets you audited or will inflame patients who may read it is antiquated. The codes are descriptors. They're the fastest way to communicate what you did. Most EMRs and billing software requires the doc input them. Use them as intended, and enforce that your codes are the ones to be submitted to payers... since that's aka the law.

 

[DYK343]

Are you putting your CPTs (and ICDs) in your op reports? And clinic notes?
If you are, and its still getting bumbled, I would arrange a meeting about you making surgery superbills.

If you are doing clear codes, and they're changing - or omitting - some, that's illegal in most places. They can't change a physician's intended CPTs without agreement. Hospitals can try to use the "well, the hospital/facility is the one we are billing for... the doc is just an agent of the hospital, and we're ultimately in charge of coding for the hospital." (BS)

In their defense, some docs are lazy (or just ignorant) about coding, and they trust hospital coders or their PP billers to sort it out. This think has all but died with the EMR age, though... possible exceptionto VAs and other rare places docs are still on basically straight salary. We aren't usually looking up bunion proc and dx codes in paper books and typing or dictating them anymore... most have templates, electronic or web lists of codes, EMR, etc. It's important docs learn fast and stick to their chosen CPT codes being ones submitted (billers just inform of rejected or possible miscodes). Nobody knows the anatomy, procedures, and encounter like the doc who performed it.

The think that putting CPT and ICD codes in EMR note or op report or whatever is greedy or gets you audited or will inflame patients who may read it is antiquated. The codes are descriptors. They're the fastest way to communicate what you did. Most EMRs and billing software requires the doc input them. Use them as intended, and enforce that your codes are the ones to be submitted to payers... since that's aka the law.

They specifically stated when I started here to never put CPT codes in the post op note. Whole hospital policy. It was part of my onboarding. I thought it was odd but I specifically remember them saying that.

I put in diagnosis on op report but not ICD-10 with it. I would typically say something along the lines of:
Bunion right foot
Hammertoe right 2nd toe
Deformity right 2nd metatarsal
Pain in right foot


Under procedures performed I would typically say something along the lines of:
Right foot bunionectomy with 1st metatarsal cuneiform fusion
Right 2nd hammertoe correction with PIPJ fusion
Shortenting Right 2nd metatarsal osteotomy

I spell out the procedures performed and they still change it sometimes. I agree it should be illegal or at least they should speak with me about it if they want to change.

 

[Hybrocure]

Anyone else out there just googling their cpts

 

[soccerfeet]

2023 in all white
2024 in yellow and white.
Its bad up in WA state

 

[air bud]

Damn. I know of one recent job that was tiered at 45 47 49 then 51.... basically came out to about 48. So that was good.

Makes those Kaiser jobs and the 322 salary/Benny's even better.

 

[soccerfeet]

Damn. I know of one recent job that was tiered at 45 47 49 then 51.... basically came out to about 48. So that was good.

Makes those Kaiser jobs and the 322 salary/Benny's even better.

Yes it’s very disheartening. You work your ass off only for them to cut your $/RVUs. And this is high cost of living western WA

 

[heybrother]

The Medcare conversion factor next year is like $32.

I went ahead and used the APMA tool to complain to my representatives. I will credit the APMA and say the tool was incredibly easy to use. I got back the most vague empty response from my senator. To be expected, but still somewhat amusing for just how many words it used to say so, so little.

 

[soccerfeet]

The changes to the Medicare conversion is increasing reimbursement for E/M codes and cutting procedural codes, which is terrible news for podiatrists

 

[Feli]

The changes to the Medicare conversion is increasing reimbursement for E/M codes and cutting procedural codes, which is terrible news for podiatrists

Have you run the numbers?
It's a win for most PP pods (aka majority of DPMs) to get more for medical aka E&M.

I ran the calcs for my office (PP, fair bit of surgery), and it wasn't close. I did it for review and re-contract with offer of small raise on both med and surg codes or fair raise on one or the other (no changes to DME or diag testing). We took raise on medical (E&M) that was worth tens of thousands more than the other options. Thankfully, they were raising, not cutting either type... but I suppose they could in the future if MCR cuts persist.

...The point is, unless you - or your billers - subscribe to the "E&M or procedure, not both" or you do a ton of call/surgery (for MCR); then you probably do more NF RVUs and collections on E&M than procedures ("surgery" codes). This is certainly true since level 4 office visits became a lot easier and 28003 has no global.

If you run reports, it's typically better for the majority of DPMs. I think you're new out of residency, but all pods do E&M. Most do office procedures and at least some OR surgery, but most do more collections from medical codes. Some hospital or very heavy surgery ones may lean to procedure codes and not benefit or benefit as much, but those DPMs are probably paid wRVU and minimally payer-dependent anyways.

The only pods a MCR raise medical and drop surgical is definitely lame for are very surgery-heavy ortho group or MSG employee docs, who are effectively PP pods paid on collections with sizable MCR pool. It will hurt them, but that's less than 3% or 5% of DPMs.

 

[soccerfeet]

Have you run the numbers?
It's a win for most PP pods (aka majority of DPMs) to get more for medical aka E&M.

I ran the calcs for my office (PP, fair bit of surgery), and it wasn't close. I did it for review and re-contract with offer of small raise on both med and surg codes or fair raise on one or the other (no changes to DME or diag testing). We took raise on medical (E&M) that was worth tens of thousands more than the other options. Thankfully, they were raising, not cutting either type... but I suppose they could in the future if MCR cuts persist.

...The point is, unless you - or your billers - subscribe to the "E&M or procedure, not both" or you do a ton of call/surgery (for MCR); then you probably do more NF RVUs and collections on E&M than procedures ("surgery" codes). This is certainly true since level 4 office visits became a lot easier and 28003 has no global.

If you run reports, it's typically better for the majority of DPMs. I think you're new out of residency, but all pods do E&M. Most do office procedures and at least some OR surgery, but most do more collections from medical codes. Some hospital or very heavy surgery ones may lean to procedure codes and not benefit or benefit as much, but those DPMs are probably paid wRVU and minimally payer-dependent anyways.

The only pods a MCR raise medical and drop surgical is definitely lame for are very surgery-heavy ortho group or MSG employee docs, who are effectively PP pods paid on collections with sizable MCR pool. It will hurt them, but that's less than 3% or 5% of DPMs.

I work for a massive MSG that just got bought out by optum (United health care). We are paid on a wRVU scale. I hope you are right.

 

[Feli]

I work for a massive MSG that just got bought out by optum (United health care). We are paid on a wRVU scale. I hope you are right.

If you're wRVU, it is unlikely to matter.
It's up to the MSG what the wRVU rate is; they more likely set them based on area and how hard/easy it is to attract needed types of specialists (although they may key off MCR to some degree).

Just have your billers run reports... 99213, 99214, 99203, 99204, all proc codes, etc. See how many you do and what the RVU and $ rates are (for MCR and each other payer).

 

[air bud]

I work for a massive MSG that just got bought out by optum (United health care). We are paid on a wRVU scale. I hope you are right.

Welcome to the 10 percent of all doctors club

 

[air bud]

To be clear, I am just a dumb podiatrist and a caveman, these RVUs and conversion factors....I don't know the difference. I just make crap up. I often don't know what I am talking about. I am just smart enough to be dangerous.

 

[heybrother]

Some of the decrease may be a devaluation of podiatry services or perhaps robbing Peter, you, to pay Paul, a more desireable physician.

However, there are actively changing financial demographics across the country.

-CMS is battling the AHA to implement Site of Service Neutrality ie. outpatient providers in hospitals/free standing hospital buildings don't deserve to be paid massively higher for performing the exact same service that private practice doctors perform. I'm under the impression CMS won a lawsuit that essentially said after 2015 new outpatient departments at hospitals, office site locations etc are not to be reimbursed using OPPS but through the classic provider outpatient fee schedule system. Commercial insurance providers are desperate for this also. The government views these sort of changes as the path to savings hundreds of billions of dollars.

-Consider: "The Medicare Payment Advisory Commission (MedPAC), which serves in an advisory capacity to Congress, issued a report in June 2023 in which it recommended that “Congress should more closely align payment rates across ambulatory settings for selected services that are safe and appropriate to provide in all settings and when doing so does not pose a risk to access.” The commission voted 17-0 in favor of the recommendation."

-I just sat through an ACO financials meeting for one of my local hospitals. Large employers are demanding that insurers battle hospitals for lower rates/charges for their members to decrease premiums etc. My local hospital related on the phonecall that they have the highest BCBS reimbursement of any hospital in their chain across the country and that it isn't going to last. This same hospital claims they lose money on Medicare. They claim they have to financially reinvent themselves. For example - my creating their own insurance products to market directly to local employers with fixed fees and risk based self insurance strategies baked in ie. make money on the plans by delivering savings... reduced services, increased preventative care etc.

-Increasing prevalence of Medicaid and Marketplace plans is likely associated with reduced hospital system reimbursement. If Medicare is bad, these are often worse. There is a podiatrist who does not post here (though I think he reads SDN) who stated that his hospital has forbidden any elective Medicaid surgery because they lose money on all Medicaid surgeries to the tune of thousands of dollars a case. Patients come to him wanting their bunion fixed and if they have Medicaid its not allowed.

-Many posters on this forum have been well served by the RVU system, but hospitals are often reimbursed lump sum for services performed during a hospitalization ie. Medicare reimburses based on DRGs. These are a lump sum of several thousand dollars and additional surgeries and services do not necessarily increase reimbursement. The hospital's financials are best served by a short length of stay and no readmission.

-If you are not already discussing with your hospital where they make money on you - you should consider asking. Consider a hospital with a risk based contract in which money is made by not offering services. Would this hospital be better served by a patient having surgery to try and resolve a wound or would the operating room cost be so high an eternity in wound care makes sense. I don't know, but the future may not be as cut and dry as is sometimes related.

The heart of the above changes is that there are no shortage of people crying out saying that hospital care and healthcare is too expensive in this country.

 

[air bud]

You are too smart for SDN.

Also, you bring up a good point. Ask the hospital how they make money off your services and figure out how to appropriately treat patients in this manner. Lots of ways to treat things, so do the one that pays the most in the most efficient way possible.

 

[Boba Foot]

Ask the hospital how they make money off your services and figure out how to appropriately treat patients in this manner.

WTF

Go back in time 10, 20 years or however long before you entered this path and ask yourself how messed up this sounds.

Asking a hospital how they can make money off of your services. Nothing about what's best for the patient. Nothing about what you think is best for the patient from a morbidity or return to mobility standpoint.

Tell me that we aren't broken. All of it. The absurd tuition that we have to pay to play. The crappy job market we have to fight to stand out in to make a decent living in once we make it through school and residency. The mediocre reimbursements we make after all that. And why? To ask a suit in a hospital how they can make money off of our patients? If this is not the most broke-ass healthcare system, I don't know what is.

Lots of ways to treat things, so do the one that pays the most in the most efficient way possible.

In the most efficient way to transfer funds from Medicare/Medicaid the C-suite bonus? Nice. Congrats. I'm sure they'll send you a Christmas card when they have to cut costs and lay your ass off because your job as a foot doctor is more disposable than corporate profits are.

 

[air bud]

WTF

Go back in time 10, 20 years or however long before you entered this path and ask yourself how messed up this sounds.

Asking a hospital how they can make money off of your services. Nothing about what's best for the patient. Nothing about what you think is best for the patient from a morbidity or return to mobility standpoint.

Tell me that we aren't broken. All of it. The absurd tuition that we have to pay to play. The crappy job market we have to fight to stand out in to make a decent living in once we make it through school and residency. The mediocre reimbursements we make after all that. And why? To ask a suit in a hospital how they can make money off of our patients? If this is not the most broke-ass healthcare system, I don't know what is.



In the most efficient way to transfer funds from Medicare/Medicaid the C-suite bonus? Nice. Congrats. I'm sure they'll send you a Christmas card when they have to cut costs and lay your ass off because your job as a foot doctor is more disposable than corporate profits are.

I mean I literally said figure out how to appropriately treat patients in this manner. Sorry if not more eloquent. If option 1 and 2 are both perfectly acceptable ways to treat a patient, then do the method your employer prefers. So If A then B.

So if you are in PP and you know OTC orthotics will perfectly help the patient but you know they will pay for custom (either the. Or Insurance) then it's ok since it is lining your pocket and not the c suite? Both are perfectly acceptable ways to treat plantar fasciitis.

And to be clear I'm just talking about having that conversation with them. Convenience to the patient also is important as well as convenience to myself.

For example this weekend I had a guy with very minimal osteomyelitis of his toe. Sure the hospital would probably prefer I do hyperbarics and IV antibiotics and all that type of stuff. My preference was to cut the toe off and be over and done with and not screw with any of that. Patient didn't want amputation so he is going to be inconvenienced and the hospital is going to make money. Whatever. He will eventually come back to me and ask for me to cut off his toe when none of that works.

Anyways I'm just saying have this conversation with the hospital and make sure you are all on the same page about how you can bring value to the organization.

 

[Feli]

I think we all modify our practice somewhat based on reimbursement.
That goes for hospital FTEs, PP owners, and definitely employed PP workers (pod, MSG, ortho, etc).
The employed do it by choice as well as guidance, and owners/partners just know it makes more revenue.

It is plain evidence of this inevitability that stupid podiatry - and any specialty - things with little or no EBM get popular because they pay well and/or are easy (amnio grafts, sclerosing injects, HBOT wounds, arthroeresis, endless list). It is also no wonder that docs tend to overuse what their employer/group/office owns (MRI, surgery center, nail clip pathology, ultrasound, whatever). There are tons of podiatry associates sending grandma nail clippings and referring to questionable vascular labs and putting on bogus grafts right now as they try to hit their bonus or negotiate a raise... or just make their car payment.

With the way reimbursements are, it is hard to get by just doing what's good for the patient.
I would love to do hour visits and counsel patients, but that's just not reality. I do what I can, and MAs help to speed it up. We do DME, OTC, procedures, and other things that are reasonable in order to get more than just E&M codes. I was told by a few friends who do PP that you always eventually look at your biz and try to come up with ideas of how to get more from it... adding services, doing more/less of certain procedures or pathologies, cutting hours/staff, cheaper supplies, whatever. That is not untrue.

There has to be a harmony between being a good clinician and listener... but still making a living.
Most of us are not 'academic' 8-4 docs who get 30 vacation days and can see 10 patients per day yet maintain job security.
There was probably a day when you could do fine money in podiatry on just 99213 and 11721 and occasional 20550 or 11730. Those days are gone (assuming you don't have very good local payers and/or want to see a ridiculous number of patients).

...I see nothing wrong with asking the hospital(s) which a doc works at what services they do well from that you can reasonably provide or refer. [spoiler alert: elective surgery for private insurance pts, don't use stupid expensive implants, send MRIs and other imaging, refers to PT and other specialists they employ]

Just like MDs, it generally makes more sense for most pods to work/own PP in good socioeconomic areas and work for the hospital in lower socioeconomic status areas... and that's exactly what you tend to see. Nonetheless, it never hurts to keep options open (have knowledge and connections to potentially go from hospital employ to PP/solo in area... or from PP to employee at nearby hospital). Whether the hospital is your employer or just your place to get a few refers and do your surgery or eat lunch in the lounge, it's all related.