Specialty PMR Practice RVUs?

[MichiganSpine]

I am hoping someone here can help me or point me in the right direction (up to and including a paid consultant!). We have a small southwest Michigan spine specialty physiatry practice. We run outpatient 5 week days from 8-5. We do EMG/NCS, lumbar injections under fluoro, assorted trigger point injections, etc. We have recently had an evaluation that indicates that our RVUs per provider FTE are low. We are at about 3000 RVUs per FTE provider. We are scrambling with finding an answer. So...if our schedules are full (not over-booked and 45/15 minutes per visit), our no show rate is 5% or less, what am I missing? Is someone out there willing to share what their mix is in terms of #visits and procedure mix? I think there are procedures we are just not doing to account for the difference in RVUs. We have gone through successful coding audits for several years that back up the fact that we are coding appropriately (not missing codes, over or under coding). Please help. The information that I have is that national RVU median for PMR is 4900...

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[Jitter Bug]

Something is up, when I worked on an RVU basis I made on average 4300-4500 RVU's per year only doing a smattering of procedures.

If you are coding appropriate for the complexity of your visits, then I recommend looking at ways to complete a more complex visit in less time-templating and getting your docs to create good quick comprehensive exams and thorough histories can help with this.

You can lose alot of RVU's simply by neglecting a few seemingly unimportant pieces of history or physical exam items. Assuming payors use medicare rules.

You don't need a consultant who is a coder, because a coder can't tell you how to creat a good quality medical exam that can be coded high. you need a consultant who is (or was) an efficient physician in your field.

 

[PMR 4 MSK]

Consider time you may be wasting that can be spent better. 45 min for new pt is a lot of time. If you have someone else do most of the history and charting (we call them "historians") just on new pts, it can cut your time with the pt way down.

Ideally, procedures should be set up so you have little-to-no prep/set-up and can just fire away.

Have someone survey your practice to see if you are coding E&M correctly. Often people code level 3s that could be 4s, e.g. Also, are you capturing codes for procedures - billing everything you can, and utilizing modifiers correctly for maximum payment?

Each person who works in your office should be seen as an investment - they improve your ability to run your practice efficiently and/or profitably. If they are not, you don't need them.

Bill for what you do, and do what you bill for.

 

[Sanchik]

as someone who just graduted and gotzero experience in coding, I can't help you.
But i am wondering if anyone has been to the AAPM&R coding/billing workshop. I am thinking of going this year to make up for my lack of training on the subject.

 

[Tenesma]

3000 RVU ?!?!?!.... i generate that in 3 months.... a new patient generates about 3.5 wRVU - so just seeing 80 NP per month x 11 months = >3,000 RVU... you guys really need to re-eval your practice...

1) how many patients per day per physician - how many NP/FUs per day? how many fluoro spine procedures per month?

 

[specepic]

By what you describe, assuming you are working FT, it does not make sense. Even with spending 45 min for NPs you are likely seeing 12-17 pts/day given less time for f/u's. I suspect someone is making a math error or ripping off the docs, or something like that. I easily blow way past a 3000 rvu/annum (not going to state my annual RvUs on a public forum) and I'm fresh out of training and I spend a lot of time with my pts.

I would suggest you do your own personal audit. Go back over a typical week or, even better, a month, and add up the RVUs. It will be a well spent couple of hours. 99214 = 1.5 rvu's etc, then do your totals and you will have your answer. Unless you are seeing only 6-7 pts per day something is up on the business side (embezzlement?)

 

[ampaphb]

i generate that in 3 months.... a new patient generates about 3.5 wRVU -

This, btw, is nothing short or either BS or fraud.

99205 = 3.17 RVU
99204 = 2.43 RVU
99203 = 1.42 RVU
99202 = 0.93 RVU
99201 = 0.48 RVU
http://goo.gl/XXYNC

So let's give Tenesma the benefit of the doubt, and assume he has a bell curve distribution of 3s, 4s, and 5s. At best, he averages 2.43, not 3.5. Now, most of the docs I know typically bill 3s and 4s, with only the occasional level 5. I probably average closer to 2 than 2.5 RVUs per new patient, but hey, that's 'cause I have very little interest in the OIG ever asking for money back.

Also, assuming he sees patients 3 days a week, and does procedures the other 2, that means he sees 6-7 new patients every day.

Personally, I take almost all the values Tenesma cites, and divide them in half

 

[Tenesma]

ampa... thank you for calling me out on my wRVU # - i was typing that off the top of my head and was recalling wRVU for an inpatient consult ... a 99223 wRVU is 3.86, instead of the appropriate wRVU for an outpatient consult (which you provided above)

so clearly my earlier statement needs revision, but my point still stands: 3,000 wRVU per annum is not a very busy practice. In fact, if you are working 8-5 and doing EMG/Fluoro injections, it just doesn't make sense - unless you are totalling only 10 encounters per day?

 

[Tenesma]

and i also completely agree that as a whole the -5 level evals for NP and FU should not be a common code in our practices...

i tend to code the level 5s for those patients that are the most emotionally draining...

 

[PM&R Doctor in Practice]

I am hoping someone here can help me or point me in the right direction (up to and including a paid consultant!). We have a small southwest Michigan spine specialty physiatry practice. We run outpatient 5 week days from 8-5. We do EMG/NCS, lumbar injections under fluoro, assorted trigger point injections, etc. We have recently had an evaluation that indicates that our RVUs per provider FTE are low. We are at about 3000 RVUs per FTE provider. We are scrambling with finding an answer. So...if our schedules are full (not over-booked and 45/15 minutes per visit), our no show rate is 5% or less, what am I missing? Is someone out there willing to share what their mix is in terms of #visits and procedure mix? I think there are procedures we are just not doing to account for the difference in RVUs. We have gone through successful coding audits for several years that back up the fact that we are coding appropriately (not missing codes, over or under coding). Please help. The information that I have is that national RVU median for PMR is 4900...

We are in exactly the same boat. There are four of us full time and we produce 3,000 to 3,300 each. We see new patients, f/u, TPI, BOTOX, joint injections, EMGs, and Fluoro/U/S injections of the spine and joints. We all seem very busy. Our coding audits have been fine. There is some hostility in our IDS regarding 'low performing' physicians and I'm afraid we will be cast in that net. I am looking into our EMR/PM system to make sure it is accurately capturing our work efforts. I can't imagine increasing my clincal volume by 50%. If you find out something MichiganSpine please share it.

 

[lobelsteve]

3000 rvu yr 50 weeks yr is 60 rvu week.

12 rvu per day.

1.5 rvu per 99214.

8 patients per day.

My assumption is that we are talking wRVU.

 

[PM&R Doctor in Practice]

3000 rvu yr 50 weeks yr is 60 rvu week.

12 rvu per day.

1.5 rvu per 99214.

8 patients per day.

My assumption is that we are talking wRVU.

Yes, we are talking wRVU.
I wish my life were as simple as you outlined. We can't just take the total and divide by 1 CPT code. I have filed 131 different CPT codes over the year in different frequencies, timings, proportions, etc.

 

[lobelsteve]

I've got it started for you.

 

[RUOkie]

Yes, we are talking wRVU.
I wish my life were as simple as you outlined. We can't just take the total and divide by 1 CPT code. I have filed 131 different CPT codes over the year in different frequencies, timings, proportions, etc.

You have got to have a problem with data capture. I've never computed my wRVU's since I'm solo, and I look at $$ only. But for giggles, I just computed my RVUs ONLY for Electrodiagnostic services (which is 60% of my practice). I had over 4000 wRVU thus far in 2013. (using the new codes). I didn't look at any of my ultrasound, joint/tendon injections or my E&M.

I didn't work very hard today. I only had 4 EMGs, 4 new patients and 4 followups. I felt like I was dragging.

 

[ampaphb]

Yes, we are talking wRVU.
I wish my life were as simple as you outlined. We can't just take the total and divide by 1 CPT code. I have filed 131 different CPT codes over the year in different frequencies, timings, proportions, etc.

You are missing the point. Steve has described a worst case scnario: you only see follow-ups - no procedures, no new patients. We assume an even distribution between 99213, 99214, and 99215, and so take the wRVU of 99214 (1.5) as an average. 3000 wRVUs are 60 RVUs a week. Asuming you work 5 days a week, that's 12 wRVUs a day. At 1.5 wRVU per 99214 visit, 3000 wRVU/yr = 8 level 4 follow-up visits a day.

Surely you are seeing more patients than that. As such, you are generating more than 3000wRVU/yr, and the numbers that are being reported to you are clearly inaccurate.