High-Yield RVU Generation in Emergency Medicine

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Top three RVU pearls for clinicians in the trenches.

Sharpen your focus and you will succeed

When your start your next shift, optimal RVU generation will likely not be your top priority.


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As emergency physicians, our core mission is to care for others, facilitate healing and “stomp out disease” whenever we find it. For the great majority of clinicians, our drive is to prioritize patients first and chart (and reimburse) later. In terms of our long-term financial well-being, what we document does make a difference.

Our compensation in Emergency Medicine relies largely on our RVU-productivity. As such, pay attention to the high-yield pearls that follow. Your proper reimbursement will ensure you and your patients will have the resources needed for longevity in the years to come.

This article will show you how to optimize your charting and reimbursement for the best. This is particularly important in 2021 where Emergency Medicine is faced with a reduction of payments secondary to a decrease in the Medicare Physician Fee Schedule conversion factor. You can still survive — provide your coders with the key details they need and your proper reimbursement potential can be fully realized. Clinicians, we do have an important role here.


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Cardiac Monitor Interpretations — reimburse more than you think

Remember your last elderly patient with an ankle dislocation? Perhaps this patient had a quasi-stable BP, history of CHF & atrial fibrillation, and of course, was on warfarin.  You gave incremental propofol, did a gut-check, pulled and reduced. You walked out of the room, thinking “that was awesome.” I really helped that patient and reimbursed big with moderate sedation. Not so fast — the moderate sedation portion of your service reimbursed only 0.35 RVUs!

On the flip side, charting just two of your Cardiac Monitor Interpretations generates more RVUs than the entire moderate sedation portion (10-22 minutes) of the case outlined above.

“The cardiac monitor revealed normal sinus rhythm as interpreted by me. The cardiac monitor was ordered secondary to the patient’s history of chest pain and to monitor the patient for dysrhythmia.” That’s the 14 second phrase that gets you paid in Emergency Medicine. Keep in mind these three steps: 1) When the patient’s presentation warrants, make sure there’s an actual order for the monitor; 2) Chart the rate and rhythm; and 3) Be sure to document the reason. Each of your cardiac monitor interpretations reimburses 0.21 RVUs — that’s $ 7.21 as paid by Medicare 2020.[1,2] It takes just 30 seconds to document two of these interpretations. That’s $14.42, which is more than the reimbursement for your moderate sedation service in the case above.


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Your Cardiac Monitor Interpretations definitely add up. Document eight cardiac monitor interpretations in a shift => $ 57.76 / day. For a 55,000 volume ER, multiply that by six “main-side” shifts/ day at your site => $ 346.56. Stay vigilant for the year => $ 126,494.00 reimbursed for your group. All this simply by properly charting your cardiac monitor interpretations.

Full disclosure, CMS’s “National Correct Coding Initiative” does not allow Cardiac Monitor Interpretations to be submitted on Medicare patients for which same day critical care services have also been provided.[3] Nonetheless, even at a facility with a robust critical care time average (for example 12% of patient encounters), over $80,000 can be generated from Cardiac Monitor interpretations.

Critical Care Time Statements – Realize These Are Key:

“I spent 45 minutes of Critical Care Time with this patient. This does not include time spent on separately reported billable procedures.” That’s how you reimburse. Based on the 2020 Medicare Physician Fee Schedule, Critical Care time (30- to 74-minutes) is reimbursed at $ 226.64 per encounter. This amount is $ 49.44 above the return generated for a Level 5 (CPT 99285) visit.

Noteworthy times for Critical Care reimbursement reside at 30-, 75- and 105-minutes (and increments of every additional 30 minutes). Optimize your group’s Critical Care billing by just 2%, and you can increase your reimbursement $ 50,000 annually (based on a 51,000 patient per year volume ER / Critical Care Time 8% average).

Be proactive against insurer denials — your documentation surrounding Critical Care is essential for you to receive the appropriate reimbursement. Best practice charting should outline the risk, demonstrate the medical necessity, and detail the risk/complexity of your Critical Care Time to your payers.

There are three pivotal ways you can do this: 1) Highlight unstable vital signs; 2) Always detail a Differential Diagnosis — including those considerations that are life-threatening; 3) Document all of your critical care interventions. From both a reimbursement and medical-legal perspective, these should include noting your discussions with the primary physician and medical consultants that “bear directly on the management of the patient.”

Abscess Incision & Drainage — The Difference is in The Details:

Distinguishing “Complex” from “Simple” Abscess Incision and Drainage in your charting is the final reimbursement pearl in this article. Remain attentive here — the result is a surprising difference in the reimbursement you receive. A properly documented “Complex or Multiple” Abscess Drainage generates 5.21 RVUs = $188.03 (as paid by Medicare 2020). In contrast, a “Simple or Single” Abscess Drainage is assigned only 2.87 RVUs = $ 103.58. Thus, for those encounters involving complex abscesses, $ 84.45 is the greater amount realized when you properly document the details of your service.

Three factors that characterize a “Complex or Multiple” abscess drainage include wounds that: 1) involve multiple abscesses, 2) Are probed to break up loculations or 3) Are packed after drainage. Thus, when appropriate, your charting should look like this: “Procedure — Complicated Abscess Incision and Drainage” => “Making two incisions, multiple abscesses were drained” and/or “Using sterile forceps, the wound was probed to break up loculations” and/or “The wound was packed with iodoform gauze.” That’s what it takes to get properly paid for the service you provide.

You Hold the key to Success:

As you can see, what you document can make a sizable impact. The reality is high-yield RVU generation in Emergency Medicine relies on more than just our patients per hour and their overall acuity. In order to assign the proper RVUs for patient encounters, medical coders need to “see” all of the service we provide. Therefore, be attentive to your charting and you can fully optimize your reimbursement. Some of the areas of interest in the next article include laceration repair, hip reductions and CPR pearls. Stay engaged and you can reimburse for the best.

References:

  1. 2020 National Physician Fee Schedule Relative Value File, GPCI20, National Physician Fee. Schedule Relative Value File Calendar Year 2020, MCR-MUE-Practitioner Services. Published by CMS. Effective: Jan. 1, 2020.
  1.  AMA Current Procedural Terminology (CPT) 2020 Professional Edition. 4th ed.
  2. Reference: CMS: National Correct Coding Initiative Coding Policy — Manual for Medicare Services; Jan. 1, 2020

 

ABOUT THE AUTHOR

Dan Magdziarz, DO, is an emergency physician at Palos Hospital in Chicagoland. He is also CEO and founder of ChartOptima.com: 2018 Emergency Medicine reimbursement teaching website. You can follow on Twitter @EMreimbursement.  Share your interests and comments: dmagdziarz@chartoptima.com.

9 Comments

  1. Dan Magdziarz, DO on

    Take heart – the whole goal of this is to optimize (not maximize) our reimbursement in Emergency Medicine. Emergency Physicians should get paid appropriately for the care they provide – nothing more, and nothing less. Proper reimbursement will ensure clinicians and their patients have the resources needed for longevity in the years to come. Our charting can make a difference!

  2. Unfortunately medicine, specifically billing and coding has morphed into a game where those who know and play by the rules are reimbursed more than those who don’t know the rules despite providing the same exceptional patient care. Payors certainly use all the rules in their favor to decrease our reimbursement.

    In order to code and then bill for monitor interpretation is there a requirement to have an archived copy of the rhythm strip – The following is from ACEP reimbursement docs @ https://www.acep.org/administration/reimbursement/reimbursement-faqs/x-ray—ekg-faq/#question0

    “If you bill for a rhythm ECG one should be part of the patient record separate from the one contained on most ECG’s. It is not appropriate to use the rhythm ECG codes for reviewing telemetry monitors.”

  3. A couple of added bits of information on billing 93042 for cardiac monitor interpretations.

    • From the CPT Manual, “Codes 93042 is appropriate when an order for the test is triggered by an event, the rhythm strip is used to help diagnose the presence or absence of an arrhythmia, and a report is generated.”

    These are scenarios where something has occurred that prompted the physician to order the rhythm strip. Encounters where the rhythm strip is performed by protocol or standing orders, are not eligible to report 93042.

    • The patient cannot be on continuous monitoring. Per CPT, “It is not appropriate to use these codes for reviewing the telemetry monitor strips taken from a monitoring system.”

    This makes it challenging to report 93042 for many ED patients. Most patients presenting with cardiac issues are put on the monitor upon arrival and stay hooked up until discharge.

    • Medicare and most other payers will not pay 93042 for a rhythm strip interpretation when there is also an EKG (93010) performed during the same encounter.

    Many patients with complaints that warrant a cardiac monitor often have an EKG performed also.

    The example listed in the article is an example of an encounter where none of the above issues is a factor. But most cardiac ED patients will have an issue that prohibits reporting 93042.

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