Optimizing RVU Capture in Academic Pediatrics. Presented by Dr ...

OverviewEnhancing Clinical RVU’s1. Optimizing Coding/Documentation2. Operational EfficiencyIncentivizing the Clinician Educator1. “Academic” RVUs or EVUs2. Allocating Monetary Resources

Architecture of RVUComponents of Professional Service•Work (52%)•Practice Expense (44%)•Malpractice Expense (4%)* GPCI2011 Medicare Conversion Factor = $33.9764/RVU

Components of E/M service History Examination Medical Decision Making Counseling & Coordination Nature of PresentingProblem F2F TimeMDM –1. # of Diagnoses/Mgmt. options2. Amt. &/orcomplexity of data3. Level of risk

Coding “2-Step”The “Feel”Level 1 (Brief) -Nurse visitLevel 2 (Prob. Focused)-Easy,brief problemLevel 3 (Expanded PF)- Average,usual problemLevel 4 (Detailed)- “Oh no!”Level 5 (Comprehensive)-Postvisit “just ran a marathon!”ValidateusingE/MCodingTool

Number of Diagnoses/Management OptionsSelf-limited or minor (Stable, improved or worsened)Established problem (to examining MD); stable or 1improvedEstablished problem (to examine MD); worsening 2New problem (to examining MD); no additional work-up 3plannedNew problem (to examining MD); additional work-up 4Amount and/or Complexity of Data Reviewed PointsLab, Radiologic, Other (EKG, PFT etc)1 for each classOrdered &/or reviewed (regardless of # ordered)Discussion of diagnostics with interpreting physician 1Decision to obtain old record and/or obtain history 1from someone other than patientReview & summarize of old records &/or 2gather data from source other than patient&/or discussion with other health provider (consult)Independent review of diagnostic studies 2(not simply review of report)1

Summary of MDMNumber ofDiagnosis &Rx Options< 1Minimal2Limited3Multiple> 4ExtensiveAmt &/orComplexityof DataReviewed< 1Minimal2Limited3Multiple> 4ExtensiveHighest Risk Minimal Low Moderate HighType ofDecisionMakingStraightforwardLowComplexityModerateComplexityHighComplexityMDM = Highest 2 of 3

E/M Level HPI ROS PFSH ExamProblemFocused(Level 2)ExpandedProblemFocused(Level 3)Brief1-3Brief1-3n/a n/a > 1BodyAreaProblemPertinent> 1n/a 3-4Detailed(Level 4)Extended4+Extended2-91 of 3 5-7Comprehensive(Level 5)Extended4+Comprehensive10+2 of 3 > 8

Case 1

4 mo old in ED with fever to 104F for 24 hrs.ROS: No v/d/rash. Cough+.PFSH: No sick contacts. Imm: Not UTDPE: WD, WN. Alert. VS….Fussy. Consolable.Eyes: Nl. ENT: Nl. Lungs CTA. CV- tachycardiawithout murmur. Abd-No organomegaly ortenderness. GU nl. Skin- no rash. Neuro-Nofocal deficits. AF soft.Tests: CBC, BC, catheterized UA/UC, CxRRx: IM ceftriaxone for presumed bacteremiaDx: URI, Acute Febrile Illness99285•Location•Quality•Severity•Duration•Context•Timing•Modifyingfactors•Assoc. s/s

Number of Diagnoses/Management OptionsSelf-limited or minor (Stable, improved or worsened)Established problem (to examining MD); stable or 1improvedEstablished problem (to examine MD); worsening 2New problem (to examining MD); no additional work-up 3plannedNew problem (to examining MD); additional work-up 4Amount and/or Complexity of Data Reviewed PointsLab, Radiologic, Other (EKG, PFT etc)1 for each classOrdered &/or reviewed (regardless of # ordered)Discussion of diagnostics with interpreting physician 1Decision to obtain old record and/or obtain history 1from someone other than patientReview & summarize of old records &/or 2gather data from source other than patient&/or discussion with other health provider (consult)Independent review of diagnostic studies 2(not simply review of report)1

Summary of MDMNumber ofDiagnosis &Rx Options< 1Minimal2Limited3Multiple> 4ExtensiveAmt &/orComplexityof DataReviewed< 1Minimal2Limited3Multiple> 4ExtensiveHighest Risk Minimal Low Moderate HighType ofDecisionMakingStraightforwardLowComplexityModerateComplexityHighComplexityMDM = Highest 2 of 3

E/M Level HPI ROS PFSH ExamProblemFocused(Level 2)ExpandedProblemFocused(Level 3)Brief1-3Brief1-3n/a n/a > 1BodyAreaProblemPertinent> 1n/a 3-4Detailed(Level 4)Extended4+Extended2-91 of 3 5-7Comprehensive(Level 5)Extended4+Comprehensive10+2 of 3 > 8

Hypo-documentation•Failure to capture true severityof illness•Failure to appropriatelycategorize•Incomplete HPI &/or ROSRVU DifferentialLevel 3 vs. Level 5Visit= 2.18$$ Differential = $ 74

Office orUrgentCareTotalFacilityRVUTotalFacilityRVUInitialObsCare +DC100%MC ED100%MC100%RVU MC99202 1.44 $48.93 99282 1.22 $41.4599203 2.2 $74.75 99283 1.83 $62.18 99218 1.9 $136.9299204 3.72 $126.39 99284 3.45 $117.22 99219 3.3 $181.7799205 4.78 $162.41 99285 5.01 $170.22 99220 4.5 $225.2699291 6.52 $221.532011MC CF $33.98ObsCare DC99217 2.1

Case 2

HPI: 2 yr old with fever to 103F X 3 d, cough &coryza. Pulling @ ears now with crying in pain.APAP helps.ROS: No wheezing. Decr. appetite but drinking. Nov/dPFSH: Daycare+PE: NAD. Both TM not visualized bec of impactedcerumen. After you disimpact the cerumen withplastic curette the both TM are now noted to bebulging with pus o/w ENT nl. RS, CV, GI, Skin,Neuro-WNL.ABX + Analgesic prescription given99213-25 + 69210Use-25 modifier with E/M code to showa separately identifiable E/M serviceRVU differential = +0.96$$ differential = +$32.60

Case 3

5 yr old is brought to your ED/UCCafter falling off the “jungle gym.” Pain& STS over distal FA; TTP over distalradius. NVI. Given narcotic for pain.Radiographs - non displaced torus fx.Splinted by you or your staff. Checkedby you. FU in 1 wk.99213 (or 99283) +29125 (splint)= 1.83+1.3RVUs99283 + 25600-54modifier = 1.83+7.44RVU Differential = +5.9$$ Differential = +$200

Case 4

Mother rushes in a 28 mo old into clinic bec. he “can’tbreathe”…he has very poor AE, is ashen, somnolent &hypoxemic (SpO2 89%). PMH: Eczema, Wheeze;PE: ComprehensiveRx: SQ epinephrine is given while intensive albuterolneb being set up. He receives 3 back to backinhalation treatments, IM dexamethasone & O2.Somewhat improved.EMS called. Prolonged non contiguous bedsideattention in management, supervising Rx, d/w family& ED physician of ~ 40 min. Transferred to the ED99215 vs. 99291(99058)(94640X3, 90772X2)RVU Differential = +1.51$$ Differential = +$51

Case 5

4 yr old with recent h/o recurrent AOMs is seen forsymptoms similar to the last several illnesses. Takingprophylactic ABX. Exam is c/w AOM.Prescription of ABX + Analgesia.Discussed in detail with parent about environmental &tobacco exposure risks. Parent has been reluctant to have PEtubes placed, issue is again discussed in detail.--25 min is spent in counseling & coordination of careReferral given to ENT--10 min later is spent s/w consultant while family in officeMay use billing level b/o time ifC/C > 50% of allotted visit time99212 = 10 min99213= 15 min99214 = 25 min99215 = 40 minRVU Differential = 1.70$$ Differential = $57.76

Case 6

Child is seen in office for acute exacerbation ofasthma (established patient) with moderatedistress.•Beta agonists (2 nebs) & oral steroidsadministered•Asthma action plan, environmental triggers &medications reviewed, MDI teaching done•Mother also wants to discuss Johnny’s “actingout” behavior at school•Total of 80 min of F2F time99215(+94640X2+94664)+ 99354(+ 99058)RVU Differential = +2.63$$ Differential = +$89.36+ Prolonged services code +99354-5 if F2F > 30min above usual E/M service time

Case 7

Parent brings child for problems at school, poorgrades, difficulty getting along and inattention.Patient examined. Screening labs obtained.A Conner’s Parent & Teacher Rating Scale Revised(CRS-R) that was completed by parent & homeroom teacher is reviewed. A formal psychologicalevaluation performed, report generated withdiagnosis of ADHD. Discussed behaviormodification, possibly additional testing andmedications.99215+ 96101 (psychologicaltesting)-25 modifierRVU Differential = +2.22$$ Differential = $ 75

Underutilized CodesAcute Care/ED Critical Care Time Observation Care Laceration Repair Fracture Care, Abscess IND Level 5 Caveat Moderate Sedation Deep Sedation/MAC After Hours Code* Point of Care UltrasoundAmbulatory Clinic Prolonged Service-Counseling-”Face 2 Face”Time Behavioral /Mental HealthScreening New vs. Established Patient 2011 Immunization Codes Procedure Codes-Modifiers Care plan Oversight(home health care)

Internal Billing Audit Quarterly-10 charts/provider Designate person on team Billing Reports- Revenue Cycle-Top 5-8 Codes-EOB/Payer reimbursement vs. contract Peer Benchmarks-E&M Frequency-RVU/Patient, RVUs/Hr, Patients/Hr Update “Super bill” (Charge master) Annually

Operational Efficiency inPatient Care Area

RVU “Killers” MD – involved in “non” value added services! Adequate Support Staff Pre- or Bedside-Registration Clinical Protocols Creative Scheduling Turnaround Time for Tests/Radiography Staff Initiative/Incentive Minimize Boarding /Streamline Admissions Patient Care in Teaching Environment

“Academic” RVUs orEducation Value Units (EVUs) orTeaching Value Units (TVUs)

Why incentivize Master Teachers? Attract “top” residents/fellows Nurture “skilled” physicians Recruitment of faculty Support hospital goals of safety, quality & patientsatisfaction Enhance reputation of medical school Accommodate different facultystrengths & interests (Retention) Attract philanthropic support/Grants

Funding SourcesHospital-admin jobs-committees-medicaldirectors-course directors-quality/safetywork gpsGrantsPhilanthropyAcademic Dept.AHCPracticePlanSupportClinical Revenue-clinic attending-inpatient attending-clinic for specialpopulation-taxes on clinicalcareMedicalSchool/GME-residency-fellowship-PDs-clerkshipdirectors

Academic RVUs or EVUs Administrative & Community Service (aRVUc) Teaching (aRVUt) Publications (aRVUp) Research (aRVUr)Weighted by1. Effort2. Impact3. Value to departmental goals

Weighting for TeachingAvg. Learner Rating (1-5)1 0.52 0.753 14 1.55 2.0Multiplier per Year% Effort = % Hrs devoted to Teaching(e.g. 4 hrs/wk = 10%)Academic Value :Medical Student 0.2, Residents 0.3, Fellows 0.4aRVUt = % effort X academic value X evaluation

Weighting for Community ServiceCommittee % of Effort/Yr Academic ValueNational 1% 0.4State 1% 0.3Institutional 1% 0.2RoleSociety President 5Committee Chair 4Editor in Chief 4Committee Member 1WeightingaRVUc = % effort X academic value X role

Publication WeightingType %Effort/YrPeer Reviewed 4% 1.0Non peer reviewed 2% 0.3Abstract 2% 0.5Book 20% 0.5Book Chapter 4% 0.5Book/Journal Review 2% 0.5Invited Speaker 0.8% 0.3AcademicValueaRVUc = % effort X academic value X author rank score X impactfactor

ResearchFunding SourceModifierFederal 1.0Industry 0.4Institutional 0.2PI status = 1 for PI & 0.5 for Co-PIAcademic Value α $$ Value of GrantaRVUc = % Effort X Academic Value X Funding Modifier X PIstatus

Compensation Model

EffortEffort &ScholarlyTime AmountConvert Effort to Include Scholarly TimeOutpatient Clinic with Resident/Fellow 50% 60% $90,000Inpatient Services on Teaching Unit 10% 12% $18,000Medical Director (Clinic Administration) 20% 24% $36,000Scholarly Time 20%Total 100% $150,000Reduce Clinical/Scholarly Effort by Direct FTE SupportTotal CE Effort & Compensation 100% $150,000Medical Director 24% $36,000Balance (Clinical + Scholarly Effort) 76% $114,000TotalSupport of Clinical + Scholarly EffortClinical RVUFull Time RVU Target (Benchmarking) = 2,80050% RVU Target = 1,400Rate of pay = $$/RVU $81Clinical Educator generates (50%)Supplemental Salary Support $36,000*Current Annual Compensation: $150,000;*Scholarly Time Factor: 20% 0.2

Pool for Clinician Educator* 1 Clinical RVU = 2 (Academic RVU)Total aRVU = 1,400X2= 2,800/Faculty$ 36,000/2,800 = $13 / aRVU