Starting salary and RVU expectation in the first job

[Green Man]

Hi everyone,

I'm a US citizen, finishing PCCM fellowship next year. Recently, I started looking for mixed pul/CC private practice jobs in small cities in the West Coast. Could anyone share a general idea of compensation to RVU ratio and expected RVUs in clinic or ICU settings (as a new physician coming out of fellowship), please? So far, 350k as base salary seems like a magic number for most places but the pay structure/schedule varies a lot. I'm still trying to navigate the process. Any help/advice would be appreciated..

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[bashwell]

I've heard MGMA has all this information (RVUs by percentiles, salaries for non-academic and academic, etc) and that groups and hospitals even use it for benchmarks so maybe that would be the place to start?

 

[Green Man]

Yeah, but it's pricey $$$. Wondering if any practicing physicians could give a rough idea. For example, one place calculated 20RVU/clinic day x $60/RVU for the first year.

 

[Soccer171983]

Hi everyone,

I'm a US citizen, finishing PCCM fellowship next year. Recently, I started looking for mixed pul/CC private practice jobs in small cities in the West Coast. Could anyone share a general idea of compensation to RVU ratio and expected RVUs in clinic or ICU settings (as a new physician coming out of fellowship), please? So far, 350k as base salary seems like a magic number for most places but the pay structure/schedule varies a lot. I'm still trying to navigate the process. Any help/advice would be appreciated..

I am kind of in the same situation as you. Most offers around Las vegas are 300-400k starting for mixed pulm and ICU in terms of base. The call schedules, benefit packages seem to vary quite a bit however.

 

[tartesos]

Hi everyone,

I'm a US citizen, finishing PCCM fellowship next year. Recently, I started looking for mixed pul/CC private practice jobs in small cities in the West Coast. Could anyone share a general idea of compensation to RVU ratio and expected RVUs in clinic or ICU settings (as a new physician coming out of fellowship), please? So far, 350k as base salary seems like a magic number for most places but the pay structure/schedule varies a lot. I'm still trying to navigate the process. Any help/advice would be appreciated..

I'm in a mixed setting( 2 weeks of clinic and 2 weeks of hospital rounds) avg rvu per month is 600+( 500+ to 800) and I am on my first year, clinic not full.
Most of the rvu on your hospital rounds until your clinic fills up. Bear that in mind with large groups where you are out of the hospital rotation for several weeks.
That's where salary guarantee comes in, until you build up.

So many things I wish I knew to ask before my first contract....

If you register as a physician with sdn, go by the practicing physician forum and we can go into details


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[bronx43]

Yeah, but it's pricey $$$. Wondering if any practicing physicians could give a rough idea. For example, one place calculated 20RVU/clinic day x $60/RVU for the first year.

Only 20 RVU per clinic day? How many patients are you seeing?

 

[Green Man]

Thank you all for your inputs.

bronx43,
That RVU is projected for first year based on AMGA data according to the hospital. Didn't say how many patients. That's why I was trying to figure out what would be the number of patients in clinic per day.

 

[bronx43]

Thank you all for your inputs.

bronx43,
That RVU is projected for first year based on AMGA data according to the hospital. Didn't say how many patients. That's why I was trying to figure out what would be the number of patients in clinic per day.

I mean, maybe they're projecting that it would take a long time for you to build up a practice. 20 RVU/day is pretty low in clinic. If you consider that a new level 4 pt is 2.5-3 RVU and each level 4 return is going to be 1.5, then you're talking like <10 pts a day.

 

[Green Man]

I mean, maybe they're projecting that it would take a long time for you to build up a practice. 20 RVU/day is pretty low in clinic. If you consider that a new level 4 pt is 2.5-3 RVU and each level 4 return is going to be 1.5, then you're talking like <10 pts a day.

Thanks! That gives me a better idea.

 

[EasyRider]

There are private practice pulm/crit care doctors getting $60-80/RVU and get 12-15000 RVUs a year.

You can make a lot of money in Pulmonary/Critical Care

 

[EasyRider]

Only 20 RVU per clinic day? How many patients are you seeing?

That seems low. You figure average RVU per patient is in the 1.5-2.0 range. Thus 10-13 patients a day? You can get audited for under billing as well

 

[jdh71]

I'm in a mixed setting( 2 weeks of clinic and 2 weeks of hospital rounds) avg rvu per month is 600+( 500+ to 800) and I am on my first year, clinic not full.
Most of the rvu on your hospital rounds until your clinic fills up. Bear that in mind with large groups where you are out of the hospital rotation for several weeks.
That's where salary guarantee comes in, until you build up.

So many things I wish I knew to ask before my first contract....

If you register as a physician with sdn, go by the practicing physician forum and we can go into details


Sent from my iPhone using SDN mobile app

You're busier than I'd want to be. But probably making more money. Don't get me wrong I've had 800+ rvu months a few times but these were busy unit months. I'm usually a 400 to 450 kind of a guy.

I refuse to grind in the clinic. I take an hour for a new patient and 30 minutes for returns. First patient at 8, last at 4, and a lunch at noon. + or - pfts depending on a rotating schedule. Admin so far has been fine with that. I always walk out with my documentation done this way too.

I only do 15 "shifts" per month. I mean could work more but why? Especially when my kids are young and my wife is still hot. I also only work every 6th weekend (sometimes 7th).

My rvu bonus kicks in around 5600 and I usually don't quite make it there in a year. So I figure I'm close enough to making my salary that no one is complaining (yet) and I get to live and practice the way I want (for a busy specialty full of the sick and complicated like ours).

 

[tartesos]

You're busier than I'd want to be. But probably making more money. Don't get me wrong I've had 800+ rvu months a few times but these were busy unit months. I'm usually a 400 to 450 kind of a guy.

I refuse to grind in the clinic. I take an hour for a new patient and 30 minutes for returns. First patient at 8, last at 4, and a lunch at noon. + or - pfts depending on a rotating schedule. Admin so far has been fine with that. I always walk out with my documentation done this way too.

I only do 15 "shifts" per month. I mean could work more but why? Especially when my kids are young and my wife is still hot. I also only work every 6th weekend (sometimes 7th).

My rvu bonus kicks in around 5600 and I usually don't quite make it there in a year. So I figure I'm close enough to making my salary that no one is complaining (yet) and I get to live and practice the way I want (for a busy specialty full of the sick and complicated like ours).

I'm busier than I want to be right now!




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[Green Man]

You're busier than I'd want to be. But probably making more money. Don't get me wrong I've had 800+ rvu months a few times but these were busy unit months. I'm usually a 400 to 450 kind of a guy.

I refuse to grind in the clinic. I take an hour for a new patient and 30 minutes for returns. First patient at 8, last at 4, and a lunch at noon. + or - pfts depending on a rotating schedule. Admin so far has been fine with that. I always walk out with my documentation done this way too.

I only do 15 "shifts" per month. I mean could work more but why? Especially when my kids are young and my wife is still hot. I also only work every 6th weekend (sometimes 7th).

My rvu bonus kicks in around 5600 and I usually don't quite make it there in a year. So I figure I'm close enough to making my salary that no one is complaining (yet) and I get to live and practice the way I want (for a busy specialty full of the sick and complicated like ours).

Thanks, good to know various models out there. May I ask how much of the time do you work in ICU day/night shifts or in clinic among 15 shifts?

 

[jdh71]

Thanks, good to know various models out there. May I ask how much of the time do you work in ICU day/night shifts or in clinic among 15 shifts?

I'm about 45% ICU and 55% clinic.

I'd like to have a bit more ICU time closer to 55-60% ICU but kind of waiting on one partner to scale back or retire. And then I want to focus my pulmonary practice more on nodules and cancer diagnosis having more of a bronchoscopy related practice (having more ICU time give me more day to day flexibility for procedures that I don't have in clinic), plus ILD and pulmonary hypertension (because almost everyone else in my group isn't fantastic at it)

 

[jdh71]

The other confounding variable right now in the pulmonary and critical world is sleep. Most of the old guys do it and most of us coming out now don't. This will eventually bring down the rvu tables to a more realistic level for those doing pulmonary and critical care only as the old dogs retire.

 

[Green Man]

Great information..Thanks, jdh!

 

[deleted547339]

What would a reasonable estimate of first-year, full-time academic intensivist rvu production?

 

[Nephro critical care]

What would a reasonable estimate of first-year, full-time academic intensivist rvu production?

I was on the job trail and saw a $310 K job in Houston about 16-17 shifts a months, 18-19 pt census. Another job in Indianapolis roughly $400 K for 13 nights. That’s a job I liked but ended up being taken by an EM/CC guy.
Both of these were big university hospital associated although not completely resident driven. As CC gets more complicated and residency becomes more outpt you can’t rely on residents for a lot.

 

[IM2GI]

You're busier than I'd want to be. But probably making more money. Don't get me wrong I've had 800+ rvu months a few times but these were busy unit months. I'm usually a 400 to 450 kind of a guy.

I refuse to grind in the clinic. I take an hour for a new patient and 30 minutes for returns. First patient at 8, last at 4, and a lunch at noon. + or - pfts depending on a rotating schedule. Admin so far has been fine with that. I always walk out with my documentation done this way too.

I only do 15 "shifts" per month. I mean could work more but why? Especially when my kids are young and my wife is still hot. I also only work every 6th weekend (sometimes 7th).

My rvu bonus kicks in around 5600 and I usually don't quite make it there in a year. So I figure I'm close enough to making my salary that no one is complaining (yet) and I get to live and practice the way I want (for a busy specialty full of the sick and complicated like ours).

Even this far into your career you want an hour for a new patient? Seems excessive and I'm surprised they let you block your schedule like that.

 

[jdh71]

Even this far into your career you want an hour for a new patient? Seems excessive and I'm surprised they let you block your schedule like that.

In pulmonary I usually have to review a good amount of old records, the pfts, old images and compare, actually get a history because it's important and do a very thorough exam - many clues are found on exam outside of the lungs themselves that help explain clinical symptoms. Talking with surgeons or radiology or radiation oncology as appropriate. Discussion with the patient about what I think is going on and my detailed plan. Answering questions. Possibly scheduling brinchoscopy. Writing rx's and then documentation.

Sometimes I do get a straight forward COPD that the PCP is too lazy to think a little bit about and I finish quickly and then drink coffee and read the news that is the exception not the rule though. By the time patients make it to me they are looking for an expert level evaluation and opinion. They get it.

I do wonder though if a a scope jockey should be telling an actual clinician how much time they should or should not "need" to do a proper new patient evaluation? And it seems about right to me actually. How would you know? I wonder? What is your experience in pulmonary medicine? You were board certified in pulmonary medicine when and have how many years practicing pulmonary medicine?

 

[IM2GI]

In pulmonary I usually have to review a good amount of old records, the pfts, old images and compare, actually get a history because it's important and do a very thorough exam - many clues are found on exam outside of the lungs themselves that help explain clinical symptoms. Talking with surgeons or radiology or radiation oncology as appropriate. Discussion with the patient about what I think is going on and my detailed plan. Answering questions. Possibly scheduling brinchoscopy. Writing rx's and then documentation.

Sometimes I do get a straight forward COPD that the PCP is too lazy to think a little bit about and I finish quickly and then drink coffee and read the news that is the exception not the rule though. By the time patients make it to me they are looking for an expert level evaluation and opinion. They get it.

I do wonder though if a a scope jockey should be telling an actual clinician how much time they should or should not "need" to do a proper new patient evaluation? And it seems about right to me actually. How would you know? I wonder? What is your experience in pulmonary medicine? You were board certified in pulmonary medicine when and have how many years practicing pulmonary medicine?

Geez strike a nerve? We all would love an hour with every patient. Our PCP friends would love an hour but only get 10 minutes. I'm just surprised that is your standard template and that your group lets you do that.

Anyway wasn't trying to be critical or pick a fight.

 

[jdh71]

Geez strike a nerve? We all would love an hour with every patient. Our PCP friends would love an hour but only get 10 minutes. I'm just surprised that is your standard template and that your group lets you do that.

Anyway wasn't trying to be critical or pick a fight.

You said "seems excessive". Maybe if you weren't implying anything you should choose your words better?

Is an hour with a new outpatient consult more than a PCP gets with a new patient? I don't know. But if it is, that is too bad. We do a disservice to those who are trusting in us by giving them short shrift of our time. And places that insist on less and less time for patients, especially new visits, for the sake more bills per day seems at odds with the calling of the profession.

40 minute (or even faster) new patient spots can be probably right in many specialties, especially some of the surgical subs. Ophthal cones to mind for instance (my father's specialty). It really only matters what the visual acuity and slit lamp exam demonstrates for almost any and all cases. He can see 30-35 patients in a day without too much strain, especially because the documentation is fairly streamlined too.

But in pulmonary with all the crap that needs to be reviewed and gone over it's "bad" clinical practice to shorten visit by that much from where I'm sitting. You'd see two more new patients in any given day (assuming all were new that day) doing 40 minute visits. Maybe an extra new patient if you decided not to take a lunch. So you could see 8 new in a day doing hour long visits or 10 new in a day doing 40 minute visits. Those two extra new would give a guy 6.28 extra rvu per day which would add up over the year assuming a guy is working 4 days a week in clinic and taking four weeks off a year and depending on how much they are giving per rvu probably represents around $70,000 to the provider of extra work the provider could do (not to mention what would go to the clinic/group/health system which would probably be three to six times that much the differences being their "nut" in all of this). So from the business perspective you can see why they are pushing for shorter new patient visits. But I'm not convinced it's worth it to the patients. You have to find that balance. Many specialists can easily do the adaquate visit in less time. I'm arguing that I don't think less an hour is the right amount with most new pulm visits.

 

[Nephro critical care]

Geez strike a nerve? We all would love an hour with every patient. Our PCP friends would love an hour but only get 10 minutes. I'm just surprised that is your standard template and that your group lets you do that.

Anyway wasn't trying to be critical or pick a fight.

GI can’t be compared to pulm/CC. Pulm/CC has to do a history/physical. I went to my GI for abd pain and he scheduled and did an EGD/colonscopy prior to even seeing me in clinic. And on the clinic visit he told be I had mild gastritis/esophagitis on EGD and started a PPI. 5 minutes ! Bingo !

 

[IM2GI]

GI can’t be compared to pulm/CC. Pulm/CC has to do a history/physical. I went to my GI for and pain and he scheduled and did an EGD/colonscopy prior to even seeing me in clinic. And on the clinic visit he told be I had mild gastritis/esophagitis on EGD and started a PPI. 5 minutes ! Bingo !

Like most fields, the chief complaint dictates how long of a visit I typically need. A complex IBD/liver/pancreas patient is a lot more involved than a young person with bloating. Sorry to derail the thread.

 

[Doc Doc Doc Goose]

I'm in a mixed setting( 2 weeks of clinic and 2 weeks of hospital rounds) avg rvu per month is 600+( 500+ to 800) and I am on my first year, clinic not full.
Most of the rvu on your hospital rounds until your clinic fills up. Bear that in mind with large groups where you are out of the hospital rotation for several weeks.
That's where salary guarantee comes in, until you build up.

So many things I wish I knew to ask before my first contract....

If you register as a physician with sdn, go by the practicing physician forum and we can go into details


Sent from my iPhone using SDN mobile app

So in one month you’re doing two weeks of icu and two weeks of clinic? I assume 7 days straight in the icu (12 hour shifts) and alternating two weeks of clinics time ?? so ... no time off ??

 

[aafisahar]

So in one month you’re doing two weeks of icu and two weeks of clinic? I assume 7 days straight in the icu (12 hour shifts) and alternating two weeks of clinics time ?? so ... no time off ??

Welcome to real life.

 

[FunnyDocMan1234]

One thing to clarify - does a 99291 generate 4.5 RVUs only or does it automatically include 99233 so generate 6.5 RVUs?

 

[CCM-MD]

One thing to clarify - does a 99291 generate 4.5 RVUs only or does it automatically include 99233 so generate 6.5 RVUs?

Only 4.5 wRVU.

 

[chessknt]

One thing to clarify - does a 99291 generate 4.5 RVUs only or does it automatically include 99233 so generate 6.5 RVUs?

And it also encompasses 103 minutes of critical care instead of 74 so it is one of the lowest billing codes by time. Thanks CMS!

 

[FunnyDocMan1234]

How is it the lowest? 99291 is 30-74 minutes and if you spend more than 75 minutes it's 99291 +99292

 

[chessknt]

How is it the lowest? 99291 is 30-74 minutes and if you spend more than 75 minutes it's 99291 +99292

Nope, CMS changed that this year in a giant middle finger to CCM. You have to bill the entire 30 minutes to claim it now instead of 1. So a 99291 is literally 103 minutes now (of their way of looking at it is that the first 29 minutes are free to CMS). So a 99291 + 99292 would actually be 104 minutes, then for the next 99292 you need to be 133 minutes

 

[FunnyDocMan1234]

Nope, CMS changed that this year in a giant middle finger to CCM. You have to bill the entire 30 minutes to claim it now instead of 1. So a 99291 is literally 103 minutes now (of their way of looking at it is that the first 29 minutes are free to CMS). So a 99291 + 99292 would actually be 104 minutes, then for the next 99292 you need to be 133 minutes

Is that correct?

The manual (https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c12.pdf) is a bit murky but it does say:

"To bill split (or shared) critical care services, the billing practitioner first reports CPT code 99291 and, if 75 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292. "

This pretty clearly states that 75 minutes is 99292. I know that sentence refers to split/shared but it wouldn't make sense for split/shared to bill 99292 any easier than single physician.

 

[CCM-MD]

According to our billing folks @chessknt is right

 

[grt398]

@chessknt is correct. It was a big change this year. From the link you noted above, this is the specifics:

30.6.12.4 - Critical Care Furnished Concurrently by Practitioners in the Same
Specialty and Same Group (Follow-Up Care)
(Rev. 11288; Issued: 03-04-22; Effective: 01-01-22; Implementation: 02-15-22)
"...When one practitioner begins furnishing the initial critical care service, but does not meet the time required to report CPT code 99291, another practitioner in the same specialty and group can continue to deliver critical care to the same patient on the same date. The total time spent
by the practitioners is aggregated to meet the time requirement to bill CPT code 99291. Once the cumulative required critical care service time is met to report CPT code 99291, CPT code 99292 can only be reported by a practitioner in the same specialty and group when an additional 30 minutes of critical care services have been furnished to the same patient on the same date (74 minutes + 30 minutes = 104 total minutes)."

Our billers also had to clarify but yes the new rule is that you can only bill in full 30 minute increments.

 

[chessknt]

This 'rule change' went so far in the other direction it was ridiculous and targeting CCM of all fields for cost cutting after the stupid **** that just happened doubly so. I still see urology and neurosurgery making what I do in a day in about an hour in the OR but please, go right ahead and make my time even less valuable.

The logic they applied was that the time billing was being rounded up and they were getting overcharged for time not spent so they wanted to more accurately capture that time. That was why a 99291 used to be the first 'hour' of critical care, 74 minutes would get rounded down to that 60 again and 75 rounded up to 60+30=90 (99291 + 99292). They decided that ****ing basic math was too good for us now and that 29 minutes out of a half hour rounds down to 0 instead. I imagine if they rounded a 4 vessel cabg down to 1 vessel the ct surgeons would pitch a fit because of all that work they did that is no longer being captured but we all know that could never happen.

 

[bronx43]

This 'rule change' went so far in the other direction it was ridiculous and targeting CCM of all fields for cost cutting after the stupid **** that just happened doubly so. I still see urology and neurosurgery making what I do in a day in about an hour in the OR but please, go right ahead and make my time even less valuable.

The logic they applied was that the time billing was being rounded up and they were getting overcharged for time not spent so they wanted to more accurately capture that time. That was why a 99291 used to be the first 'hour' of critical care, 74 minutes would get rounded down to that 60 again and 75 rounded up to 60+30=90 (99291 + 99292). They decided that ****ing basic math was too good for us now and that 29 minutes out of a half hour rounds down to 0 instead. I imagine if they rounded a 4 vessel cabg down to 1 vessel the ct surgeons would pitch a fit because of all that work they did that is no longer being captured but we all know that could never happen.

Just curious. How often do you bill the extra CC time?
In outpatient, there’s a code for extra time as well but I don’t know many people that use it consistently.

 

[chessknt]

Just curious. How often do you bill the extra CC time?
In outpatient, there’s a code for extra time as well but I don’t know many people that use it consistently.

I used to use it on almost every new admit and on at least 1 followup patient a day, now I use it in less than half of my new admits and very rarely on a follow up. Our group billing overall is down about 15% as a result.

 

[CCM-MD]

Just curious. How often do you bill the extra CC time?
In outpatient, there’s a code for extra time as well but I don’t know many people that use it consistently.

Rarely at my old job. New job has half the census so I would use it more often had the change not been made.

 

[Benzo4every1]

Just curious. How often do you bill the extra CC time?
In outpatient, there’s a code for extra time as well but I don’t know many people that use it consistently.

whenever you do additional critical care work. Usually it is the night people who do crosscover who do the extra billing
Some do not and we underbill way too many times. People undervalue their work and time in my group unfortunately