Men's Health Review and STIs

0:00:01.7 Professor Walden: Alright guys, it’s professor Walden here and we are live. So I’m just gonna wait a little bit and wait for folks to pop on as usual, as I usually do, but it’s an exciting night tonight. It’s going to be really, really relevant for you. We are going to be talking about the arbitrary RVUs. And I always say are like this! Because it is the arbitrary RVUs that, is not taught, it is not discussed, people vaguely understand what is happening, and what that is, and how you get paid. And so, it is really important that we address this, and that you guys, at least you as a group, have a real understanding of what it is, how it affects you, how it affects the money you make in your clinic, and how you can use it to leverage yourself. So that’s what we are going to do. This is gonna be a great one for discussion, so if you are jumping on, that is great, please go ahead, use the chat. I will be your voice and I will be discussing for you. So today, it is John. So I’m gonna, again, let John introduce himself, but he has a wealth of knowledge, you guys.

0:01:21.4 Professor Walden: It is fantastic and the future is super super bright for him. Things are looking up. I will not tell all his secrets. But he is so very knowledgeable about RVUs and one of the few people that you can find online and in our industry that discusses it and breaks it down for us, that we can understand. So it’s gonna be really important that you pay attention. So I’m gonna pop him on. There we go. Hello, John.

0:01:51.1 John Canyon: Hi. Hi, guys. John Canyon. I am a nurse practitioner out of Texas. I’m family-trained, and I’m boarded in family medicine and emergency medicine, and I’ve been… Oh gosh, I’ve done everything from urgent care, Family Practice, inpatient medicine, emergency medicine, and most of my time has been spent in the emergency medicine. But along the way, we had a couple of contracts that were RVU based, so we had to learn what that meant. And nobody told us about it. Nobody gave us any instructions on it. So we actually had to go and learn this ourselves. And I found out that nobody knows about it. And this is something… You can’t find anything, you can’t find…

0:02:30.4 Professor Walden: You really can’t.

0:02:30.9 John Canyon: Anything in the literature. There’s nothing. Nobody talks about it. Nobody talks about contracts. Nobody talks about any of that stuff. So you have to actually learn how to do this on your own. And man, some of it is pretty tough.

0:02:42.0 Professor Walden: Right. Right.

0:02:43.0 John Canyon: If you don’t understand the base concepts and… So that’s something that… It really teaches you how you get paid. And how you get reimbursed for what you do. And how you can understand how to maximize what you’re doing. And it also lets you know what value you add to the practice.

0:03:04.3 Professor Walden: Right.

0:03:04.5 John Canyon: You can actually calculate your RVUs, and figure out what value you particularly and personally bring to a practice. And that makes all the difference in the world when we’re talking about income generation and what’s my… One question I hate is, What’s the average salary in my region? And the reason that I hate that question is because there’s not a solid answer to it. It really depends on what you bring to the practice and how much value you generate. So you can actually… So for instance, if we’re both working in the same practice and you’re bringing in $100,000 a year, and I’m bringing in $700,000 a year, should we be getting paid the same? That’s kind of where the problem gets in. And if you have an RVU based system, it allows you to get reimbursed at better productivity… It’s essentially they are productivity systems, right? So you get paid based off of what you do, is generally how they work. But if you understand how they work, you can… ‘Cause most places won’t give you what your actual value is. They won’t say, Hey, you made this amount of money this year, right? They won’t say, You made $300,000 this year, $450,000 is what we brought in for you. They don’t wanna tell you that because they don’t want you to know what your value is, ’cause they don’t want you ask them for more money. They want you to work cheaply, right? So if I can get you for $60,000 a year, I’ll take it. And I’m making $400k off of your labor.

0:04:36.6 John Canyon: So if you don’t understand what value you bring in… And RVUs may not give you that exact number, but at least it’ll give you an idea. So you have a starting point that you can work from and try and figure out what’s going on.

0:04:48.3 Professor Walden: Right.

0:04:48.6 John Canyon: So let’s see, I’m in… Let’s see if I can…

0:04:51.7 Professor Walden: Let’s go ahead and you’re…

0:04:53.4 John Canyon: There we go. Quick. There we go.

0:04:55.1 Professor Walden: Yeah.

0:04:55.2 John Canyon: Okay, alright, let me click the… Start the…

0:04:58.7 Professor Walden: I am gonna let you start going and I’ll…

0:05:00.6 John Canyon: Perfect. Alright so…

0:05:01.0 Professor Walden: I will jump in as usual.

0:05:05.1 John Canyon: This is how I explain RVUs to people. Okay, what are RVUs? RVUs is… The definition is a Relative Value Unit. And what that means is it’s designed to determine the value of the time spent with a patient, based off the skill, effort, mental effort, judgment, and stress to a provider. That’s the definition of what it is. And essentially what happened is a bunch of old docs got together in a room and tried to figure out what was the best determination of value of time. And that comes back when you… You can evaluate it based off of your CPT codes. So every CPT code will have an RVU associated with it. So you can determine what the value of that particular CPT code is. Okay, and that’s how we determine our RVUs. So your CPT code is your code that gives you the number. And you… 99213… Most people are Family Practice here, I presume. That’s the majority. So 99213, if you’re in Family Practice, is the base CPT code that you use, right?

0:06:20.7 John Canyon: And that’s a return visit Level 3. So if we look at that, that was 0.97 RVUs as of the beginning of last year. As of the first of this year, it changed to 1.3 RVUs, so we actually got an increase in our salary at the beginning of the year. I bet everybody didn’t know that. It’s about a 30% increase in your reimbursement at the beginning of last year. Okay, and this… What you do with RVUs is trying to determine how difficult or how complex the care is that you’re given, because as we know not every patient is the same. And this gives us a way to determine how difficult the case is, how difficult the patient is and how much time we’re having to spend with the patient. So they’re trying to give us… Because there’s no way to determine from each individual patient which one was more difficult, which one took more time, and this is a way to do that.

0:07:22.2 Professor Walden: So if we have a patient that has more complex medical issues as we know, that requires us to have more of what we call technical skill, effort and mental effort and judgment in order to determine how best to take care of the patient, okay. So when we come back, we can determine, for instance, a patient comes in with a cough and a fever, and they’re 20 years old, has no medical problems, has no surgical history, he’s not allergic to anything and has never been sick in their life, and they’re mildly ill when they come in, their vital signs are stable, their temperature is 99, but they’re calling it a fever. We know based off of our exam that is most likely a viral upper respiratory infection. However, you have the same person come in…

0:08:11.2 John Canyon: I’m sorry, let’s say the temp is 100, 100.9, whatever, so it’s close to… It is a fever. And you have somebody who comes in who’s 65, has a coronary artery disease, severe provisional peripheral vascular disease, has diabetes, hypertension, has chronic renal failure, but they’re not on dialysis yet, so let’s say chronic kidney disease, stage four, and they have… Let’s give them a renal transplant, so they have… They’re on immune suppressant in addition to that. The difference in time that you have to take with those two patients is monumental. Even though the complaint is the same, so we can’t really base our reimbursement off the complaint through the diagnosis either. Makes sense? Everybody following?

0:09:02.0 Professor Walden: Yes, everyone…

0:09:02.1 John Canyon: So you all know, I’m kind of interactive. So if you have a question or anything, you guys stop me and we can go over it. Okay?

0:09:12.9 Professor Walden: No that’s okay.

0:09:13.3 John Canyon: So this is an example of how our views are calculated. So this is not the actual numbers, this is just an example, this is not… So if you look at that and say at 99214, that’s not where 3.01 RVUs. Understand that. This is just an example to give you an idea of how they break these numbers down, okay? So if the office visit for a 91… 99214 was worth three RVUs, the value of that RVU is 3.01. And it’s broken down into how much work it took you to do it? So one and a half hours. How much expense it took the practice? 1.4, professional liability insurance that you have to pay in order to cover the patient, and that’s what gives you the total amount of the RVU.

0:09:52.7 John Canyon: Okay, that makes sense? Okay, so that’s kinda how you determine what goes into making an RVU. That’s how we calculate it, okay. That’s how we figure out what it’s worth. Now, actual Medicare value of RVU is $55 per RVU. This is an average number. It depends…

0:10:10.4 Professor Walden: One second, John.

0:10:12.8 John Canyon: Yeah. Go ahead.

0:10:12.9 Professor Walden: Are you going by your slide ’cause I’ll hit the…

0:10:17.0 John Canyon: Yeah. I’m kind of slipping through.

0:10:17.7 Professor Walden: Okay, no, no, no, you’re fine. Just put it on the slide show so that we can…

0:10:21.6 John Canyon: Oh, did I not do that? Oh my goodness.

0:10:24.3 John Canyon: Go team. Okay, hold on, let me try. There, does that show up now?

0:10:29.1 Professor Walden: Yeah, we hit it again, maybe that little slide show button…

0:10:33.2 John Canyon: No. Didn’t work. How about I just click through it? Let’s see. Is that…

0:10:40.2 Professor Walden: It not on the… It’s not super big, is what we’re saying.

0:10:44.9 John Canyon: Okay, let me see if I can hit it again. Did that make it bigger? ‘Cause I can’t tap out and see…

0:10:53.0 Professor Walden: Oh no, you’re… It’s not, but it’s okay, we can…

0:10:55.1 John Canyon: Does not make it any bigger. Okay.

0:10:57.3 Professor Walden: If we can get the slides from you later and we’ll just…

0:11:00.4 John Canyon: Let me see, let’s go… Can we see that? I don’t know how to make it bigger… Let’s go, resume slide show. Did that work?

0:11:09.0 Professor Walden: Nope.

0:11:09.2 John Canyon: Yeah, that’s not… Oh yeah. All right, so we’ll just do it…

0:11:14.3 Professor Walden: Yeah, it’s fine.

0:11:15.3 John Canyon: We’ll do the best we can, okay. So this is kind of a breakdown on the example, and we’re gonna go back to… The actual Medicare value of an RVU is $55 per RVU. Now this is an average across the country, it may vary in your location, it does vary by zip code. It also varies in medically underserved areas. Medically underserved areas have a significantly higher value per RVU than non-medically underserved areas. So if you work in an area that is medically underserved, you’re prototypically getting about $20 to $30 more per RVU. And that’s because the expectation is that your volume is going to be lower, so in order for you to be able to make it in a medically underserved area, they give you higher per patient encounters. And if you use the previous visit code, which is not accurate, but we’re gonna use it. 3.01 RVU gives us a total of 165-55 for Level 3, okay. That’s how you calculate it, you just do straight math on it, and you can do a straight math on that at the average of 55 to give you an idea of what the work RVU is. Does that make sense? Everybody get that? I have lost my mouse cursor. Okay. Everybody got that?

0:12:49.8 Professor Walden: Yes.

0:12:50.0 John Canyon: Okay. Alright, so what does this mean? If you understand that, then you can understand how to calculate and utilize RVUs, you benefit yourself and your practice. Okay, so you can determine based off of the number of RVUs that you have, what the actual value you are generating for your practice. And if you are using an RVU compensation model, you can determine how to get to that level in a timely fashion. Generally in a Family Practice, or a practice setting type environment, you will work off quarterly RVU incentives. So you’ll have a set number of RVUs that you need to hit per quarter, and this will give you an idea of how much you’re supposed to hit in order to meet your salary and how much you get above. That makes sense? Okay. So this is what the actual numbers are for RVUs. If you look, a 99213, which is the most common in Family Practice, is worth 1.3. A 99214 worth 1.92. A 99215 is worth 2.8. I’ve added some extras there at the end. We’ll talk about those as well.

0:14:08.1 John Canyon: So maybe I spelled it wrong. No, I didn’t. Okay. So if you’re looking at a 99213, and if you bell-curve your numbers in a Family Practice setting, your CPT codes should peak over at 99213, if you’re in a Family Practice. If you’re internal medicine or a specialty, you should bell-curve over a 214. Okay, so that gives you an idea of where your base RVU should be. So we can determine based off of that, what our value is going to be moving forward, Okay. And we calculate that pretty easily. Okay. 18 patients a day is 23.4 RVUs per day. Okay, five days a week is 117 RVUs, 52 weeks a year is 6000 RVUs. If they’re all Medicare, which there’s very few practices that are all Medicare. And we based this number on Medicare because Medicare is the lowest payer, unless of course you’re Medicaid, or you’re in a position where you have a medically underserved area that is only… The clinic is only kept alive by donations. If you’re in one of those situations, then this is probably not gonna be beneficial to you. But this is something that’s helpful if you at least understand, then you can understand what your valuation should be.

0:15:29.3 John Canyon: Okay, so if you work 52 weeks a year, you’re at 6000 RVUs. And at the Medicare reimbursement rate, that’s the total income that you’re bringing in of $334,620. Now, that’s what your total income brings in, that does not mean that’s what it’s fair to pay you for your services. When we talk about how to get reimbursed for your services, you have to understand that, if you’re working for yourself is one thing versus if you’re working for somebody else. And in most cases, most of us are working for someone else. So we’re employed in some fashion. That means we have to cover our cost for overhead, we have to cover our cost of the electricity, we have to cover our cost for the nurses salary for instance, if you have your own nurse, you have to cover their salary with your income. You have to cover your portion of the lights, the electricity… I’m sorry, the electricity, the internet, the water, the sewage, any cleaning services. You also will generally have a split between the office manager and the front office staff, meaning you will not have a solo front office staff for yourself or an office manager for yourself. So you have a practice manager who covers, I don’t know, 10 or 12 providers.

0:16:51.6 John Canyon: So you get one tenth or one twelfth of her salary you have to cover. And then the person who answers the phone or front office staff, you have to cover their salary split based off of how many providers you have. So you have to break that down based off of the income. So if we take that off, say our nurses staff $30,000 a year, our front office staff is 15 and we’ll take half of that and then we’ll take the office manager’s salary, which is $45,000, we take… We’ll say $40,000 for math’s sake, $20,000 off of that. You see how that reduces the total income that you’re bringing in. Does that makes sense? So now we’re down to $300,000, then we’re down to 280, then we’re down to 260. And then we have to give the… The business has to make a profit off of us as well. So generally a 60, 40 split. So they get 40%. Okay, and we should get 60 over that. So if you’re at $200,000, 50% of that is 100,000. 60% should be 110, right? But we’re generally bringing in significantly more than $200,000 after our overheads cost is calculated, and that’s how we determine what we’re working with. Does that make sense?

0:18:13.6 Professor Walden: It does.

0:18:14.7 John Canyon: Everyone understand that?

0:18:15.1 Professor Walden: But someone has a question about… With the federal… The FQHC… And most of those patients are Medicaid.

0:18:21.5 John Canyon: Right. So that’s the problem where you get into a situation where you’re determining your value, you can’t actually determine what the income is, because the income is significantly different than the value. Does that make sense? Because you don’t have Medicare, doesn’t bring in the same amount of money. So what you’re doing is trying to determine if they’re paying you fairly for your services, right? That’s what we’re working on. Okay? Does that make sense?

0:18:52.2 Professor Walden: Yes.

0:18:53.6 John Canyon: If you’re working for a federally qualified health care or an entity that is supported completely through donations, so it’s not even a federal entity, it’s just a donation-driven entity, what you’re trying to do by utilizing this, it’s not necessarily trying to get more money out of that specific entity, what you’re trying to do is determine what your value is. Does that make sense?

0:19:20.8 Professor Walden: Yes.

0:19:21.2 John Canyon: So that way you can say, “Hey, you’re paying me $60,000 a year. I’m more significantly more than that based off of what I’m seeing, and if I’m seeing 18 patients today, this is generally what the RVUs are, and this is what we can expect off our value. So if we go back to $334,000, we take off $30,000 for our nurse, we take off $7500 for our front office staff, and then we take another $20,000 for our office manager, and then we take off $50,000 a year for other overhead expenses, that leaves us a total of about $227,000, and we say 60% of that is $136,272. So that’s what we should be making just based off of this alone. Does that make sense?

0:20:13.2 Professor Walden: It does. It does.

0:20:14.1 John Canyon: So that gives you an idea of what kind of wiggle room you have when you’re negotiating a salary, when you’re trying to figure out what value you bring to the practice. Okay, that makes it a little bit easier to understand, but go a little bit further, when you understand the RVUs, you have to understand what I like to call maximizing your revenue generation, so in order to do that, you have to understand how to build… Most of us understand how to build this is kind of the guide that I go by when you’re generating your CPT codes, I don’t know if that’s easy to see or not. Let me… I wish I can make this bigger. But okay, so essentially what you’re trying to do is determine what falls into what area appropriately. For instance, I don’t know how easy this is to see, but I’ll read it off. Most of us, we live and die on the established patient. The new patient is a once per patient visit, and that’s it. So once you get the new one, it’s all revisits is where the vast majority of your population is, is revisits, which is a 9921s. The 9920s are new visits, so we’re gonna assume that we’ve already been working for a year, so the vast majority of our patients and 9921s and we occasionally get a 9920, the 9920 is gonna be significantly more of use, but we don’t calculate based off of that.

0:21:38.7 John Canyon: And the reason that we don’t is because we want to go off the lowest common denominator, and the lowest common denominator is gonna be your revisits, that’s what’s going to get you your understanding of where your billing is, because you can’t see new patients all the time, so if we look at a 99213, which is on this graph, it’s really hard to see, but I’ll read it to you, okay. The first line is an established patient 99213 15 minutes, and the time is on there for the sole purpose of if you spend X number of time with the patient and document it, that’s the visit. Okay, nothing else has to be included, you can bill it solely based off of time. Okay, does that make sense? Yes, no, maybe so.

0:22:30.3 Professor Walden: Yes. So just time.

0:22:33.8 John Canyon: Just time alone, you can build off that, if you’re not billing solely off of time, then you have to include all the other elements, okay, so if you’re a 99213, the first one is the presenting problem, everybody gets one of those cough, congestion, running nose difficulty peeing, whatever it happens to be, and the chief complaint also required, and you can…

0:22:56.6 John Canyon: They put the presenting problem based off of severity. Self-limited or minor is the majority of what we see, there are moderate to high severity complaints as well, and we all know what the presenting problems are. Okay. Now, when you move over to your HPI, HPI for 99213 is three elements. That’s it. Okay, so if you get… Are you coughing? Yes. Do you have any fever? Yes. Are you short of breath? No, that’s three elements of your HPI you’ve met, that’s how easy it is to hit these elements.

0:23:32.9 Professor Walden: So this is why physicians, when we are in practice with them and collaborating with them, say we chart too much.

0:23:42.7 John Canyon: Well, there’s that for sure. But part of the problem is, is when we get into the documentation, a whole another conversation, we can do that all day long too. But you get into a situation where you’re putting a novel in where three words will work. Does the patient have a fever? Yes, they’ve had a fever. They’ve had a fever for the last three days, it’s been intermittent, they’ve been taking time monitoring at home, which is… That just helped it. But it keeps coming back, and they report that at home, the fever was 103 at 9 o’clock, it was 101 at 10 o’clock, it was 99 at 11 o’clock, it was back to 100 at 3 o’clock. We don’t have to put all that, you can just say intermittent fevers treated with Tylenol. It’s about getting the information in there without doing too much. Does that make sense?

0:24:37.5 Professor Walden: Yes.

0:24:38.6 John Canyon: It’s hard to emphasize that…

0:24:41.0 Professor Walden: Getting the point across with minimal words as possible.

0:24:44.8 John Canyon: Yeah, and you wanna make sure that you don’t, you don’t… Okay, so we don’t wanna spend all night… Doing this either, you know, I mean, 99213 is let’s see… Is 71 bucks. One patient. That’s all the reimbursement you’re getting for it 71.50. I don’t wanna spend all night doing that, right? It’s not beneficial to you, it’s not beneficial to the patient, it’s not beneficial to your lifestyle, it’s not beneficial to anybody. You’re not adding value, right? And when we document, we need it to add value to the chart. Either from a medical legal dispense standpoint or for understanding what’s going on with a patient. Those are the goals, right? We wanna document what happened. And then defend ourselves, and make it easy for one of our colleagues to figure out what we did and why we did it.

0:25:38.1 Professor Walden: Right.

0:25:38.4 John Canyon: That’s it.

0:25:40.2 Professor Walden: Yep.

0:25:40.3 John Canyon: Outside of that, you really don’t need a whole lot more from a documentation standpoint. For instance, medical decision making, some people put, paragraphs upon paragraphs upon paragraphs, in the MDM. It’s not necessary. Your documentation should give you the MDM… Your medical decision-making as you go, if you have an MDM, it needs to be anything extra that was not included in your HPI, ROS, past family-social exam, right?

0:26:05.7 John Canyon: Anything that’s not included in there, then you add in the MDM. For instance, do you go, patient comes in with sour throat, fever, started two days ago, progressively worse, and was exposed to strep by the girlfriend who had a positive strep screen yesterday, or three days ago, whatever. And ROS, “Patient has fever, sour throat, food and fluid as well. Does have some painful swallowing, past family-social: The patient’s a smoker. Drinker, occasionally. No drugs. Exam: The patient has erythematous acute tonsillitis. Tonsils are three plus.” and the rest of your exam and then your MDM, “the strep screen came back negative, however, due to the recent exposure to strep from the significant other we’re gonna cover with antibiotics at this time.” That’s it. You don’t need to go a whole lot further than that. That’s all you need to do for your MDM. If you’re adding something that doesn’t make sense to the rest of the chart, because if you go through the rest of the chart, even though there was exposure, you had a negative strep, do you really need to cover them? Well, yeah, I think so. Because I mean we have a positive exposure to somebody you’ve been playing tonsil hockey with for the past month.

0:27:16.9 Professor Walden: Right.

0:27:17.0 John Canyon: It would probably put you at higher risk, right.

0:27:18.5 Professor Walden: Right.

0:27:18.5 John Canyon: So that’s reasonable. But that’s the kind of thing you include in your MDM. We don’t need to include that her aunt’s cousin’s second third brother’s nephew on Facebook said he may have had it at once too. That’s not germane to the issue.

0:27:37.4 Professor Walden: Okay.

0:27:37.5 John Canyon: So that’s… The MDM, put what you have to put and then move on. Now, some people have dot phrases, etcetera, for whenever they change hypertensive medications, or whenever they change anti-diabetic medications, etcetera…

0:27:52.5 Professor Walden: Yes.

0:27:52.7 John Canyon: That stuff’s fine, but it needs to be dot phrases or a dictation phrase. And if you don’t have the ability to do that in your documentation, make a note and… Or a Word document and copy and paste it. Save yourself some time. Those kinds of things will save you… Because that’s what you do, you say this everytime somebody… You change your anti-hypertensive medications, we’re gonna have you back in two weeks. Make sure you take your blood pressure twice a day. Keep a log and bring it back with you whenever you come back. If you had any other symptoms, let us know sooner, if you get light-headed, dizzy, or if you have any other conditions, make sure you go to emergency department, whatever your verbiage is for that, if you have that and you say it every time when you do a specific thing, then you need to make it a dot phrase or a short-cut, or just have a Word document.

0:28:45.0 John Canyon: And if you make your own Word document at home, you can email it to yourself, if you can check your email at work. Or you can re-do it at work and then have it and copy and paste it. Those kinds of things, people are really generally really okay with you having, because it makes your life easier. Makes the chart better. Makes it better legally defensible, etcetera. Okay?

0:29:06.2 Professor Walden: Okay.

0:29:06.3 John Canyon: Makes sense? So when you look at the HPI, just 103 elements. The ROS for a 213 is one element and one element is “fever positive.” That’s it. That’s it. You’re done at that point for ROS. Of course, you wanna hit all other negative accept “S.” And we always hit our pertinent negative, those kinds of things, but that’s all you need from an element perspective. And when you go to exam, it says “systems and bullets,” so 6-11 systems with bullets, so you need to have… Actually, sorry, 6-11 bullets, the system comes in on the five. So if you have a head and you go to, “normocephalic,” “atraumatic.” That’s two bullets, right? Does that makes sense? It’s not each individual system as a bullet. It’s each bullet. So “normocephalic,” “atraumatic,” would be two bullets. And you only need six.

0:30:06.0 Professor Walden: Got it.

0:30:06.1 John Canyon: Right.

0:30:06.2 Professor Walden: So, that mean…

0:30:06.3 John Canyon: So, heart. Regular rates. Regular rhythm. Four bullets. I’m sorry, regular rate is one. Regular rhythm is two. No murmur is three. So we’re at five bullets and we’ve only covered two systems.

0:30:24.1 Professor Walden: That makes sense.

0:30:24.3 John Canyon: See how quick and easy it is to get through that. People tend to not understand that. That one is a little bit confusing… Because, of course, nobody teaches it, so. But if you go into the 99215, high severity, two complaints required, you need four plus elements for your HPI, which is not real hard to get to, alright? 10 dots on your ROS, right? And you need two to three elements of the past family-social, right? Do you drink? Do you smoke? Do you do drugs? That’s three. You’ve hit the level five requirement with your routine questions on your family-social history. Okay.

0:31:00.5 John Canyon: Pretty easy to get to. Now, we never want to over-bill, but we also never want to under-bill. And as nurse practitioners, we are what the literature calls chronic under-billers. We bill twos instead of threes, threes instead of fours, fours instead of fives, and never a fives, even when it’s appropriate. Okay? I know this thing’s hard to see. Latrina you might be able to cut this and send it to ’em, make it a little bit easier to read. But if you follow this metric that’s up here, you will never be wrong. You just have to follow the elements. If you meet the elements, then you bill appropriately, you’d never be wrong. I had a…

0:31:45.5 John Canyon: So one of my clients was… Works at a specialty practice, and the vast majority of the people, including the physicians in her practice bill over… They curve out over a three. And they’re in a specialty practice. And as we talked about earlier, a specialty practice, you should bell curve over a four. So I taught her how to do this. She started billing it a four. They were RVU-based. She started making more money than the docs. The docs got pissed, turned her into Medicare. Medicare came and reviewed her charts and said, She’s good. And they didn’t understand, because they didn’t know how to bill. Okay? Understanding how to appropriately bill makes all the difference in the world, especially when you’re in a place that has reimbursement. If you’re in a place that does not, for instance, free or a federally-qualified healthcare, then you’re not looking at billing. What you’re doing when you’re doing this and document it appropriately, one, saving yourself, two, you’re learning how to do it, and three, what you’re doing is, is you’re able to come back and review your RVUs to determine what your actual value is. If you’re billing out over a four instead of a three, significantly higher reimbursement.

0:33:06.3 John Canyon: We can go back. Look up here. A 99214 bills 1.92 her events. And if we go to our calculations, and we look at… Sorry. Average 18 patients a day times 1.92, it’s 34, 56 per day, five days a week, 52 weeks a year, and then we multiply that times 55, suddenly we’re bringing in 49,4208 per year. So it significantly increases your value to the practice. Even if you are not bringing in anything, you can still use it as a negotiating point to say, Hey, look, Susie’s bringing in 150,000 a year. I’m bringing in 500,000 a year. Why are you paying us the same? That makes sense?

0:34:01.3 Professor Walden: Yes. This is also important, like you said, just kind of even when you are starting and walking into the door.

0:34:08.3 John Canyon: Mm-hmm. It helps you understand what your value is. If you know what the expected patients per day is when you walk in, you can calculate what your value is very easily. You can calculate what your… At least get an idea of what you expect to bring in, so that you can determine what your starting salary should be, which is why I recommend that no NP coming out even going into Family Practice make less than a 100,000 a year to start…

0:34:37.3 Professor Walden: So this is an important question when you’re…

0:34:38.0 John Canyon: Just because that value you’re bringing in.

0:34:40.1 Professor Walden: Right. And when you’re interviewing, guys, this is a question, when they ask you, Do you have any questions? Yes.

0:34:48.0 John Canyon: Yes.

0:34:49.0 Professor Walden: How many patients do you expect me to see per day? This way you can go home, calculate things, figure out what your value is, and then when they start that negotiation process of the salary, you have a base number of which you will not go lower than.

0:35:03.9 John Canyon: Yeah. You have a base number. Your base number should automatically be 100k. That should be your base. You should not go below that if it’s at all possible. Now, there are some areas where we’ve become so saturated that it’s an issue, and that you’re having people undercut other people. But that’s a whole ‘nother conversation. And if you do have to go in low, make… This will allow you to re-negotiate after a year. Okay? And when you’re brand new, learning how the practice is just as important, just as important as… ’cause you have to learn not only how to practice, but how you individually practice. Okay? And that makes all the difference in the world, because if you don’t learn how to practice, then you don’t even know how you’re going to practice, because at the end of the day, we all do this a little different. Okay? Not everybody’s the same, and that’s okay. That’s okay. That’s appropriate, as long as we’re following similar things. But some people are a little slower on things, some people a little faster on things, some people do things a little bit different than other people, and it just… And that’s okay. It’s okay how to do that. And if you understand these things, you can understand how to approach dealing with these.

0:36:20.6 John Canyon: Now, I’m gonna go up back up for just a second and have a little look here. Oh, actually, let’s go to the next slide first. Okay. So maximizing your revenue generation. That is something that’s very, very, very, very important when you want to get a raise or you want to determine your value. Okay? So when you look at maximizing your revenue generation, and this is not committing fraud, this is understanding that we bill appropriately for the services that we’re doing. So most practices, a third of the patients, they’re smoke. And if we use the data we had before, 6084 RVUs, and we estimated that on all being level three. So that’s about 46080 patients total for the year. A third of those is 1500 patients. And if we bill appropriately for smoking suspicion, we add.02 RVUs for those patients, which is another 370 RVUs we’re generating per year, which is another $20,000 of income we’re generating just for documenting appropriately.

0:37:26.6 John Canyon: As a nurse practitioner, when you walk in the room and a patient is a smoker, when you’re going through your family social, you’re gonna stop and say, “I need you to quit smoking, that’s bad for you.” And if you give three to five minutes for them to respond, so your whole visit is three to five minutes after that, you can document smoking cessation counseling, three to five minutes, put a diagnosis of nicotine abuse or nicotine addiction, and that’ll cover you for smoking cessationing and generate potentially up to another $20,000 per year in revenue. So if you’re… When we go back up, we’re gonna look at this. Okay. So when we look at this 994006 is your counseling charge, okay? And that gives you another 0.24 RVUs per. So if we add that to here, suddenly we’ve got 1.54 RVUs per patient instead of 1.3. Does that make sense? You can see my cursor or not?

0:38:19.6 Professor Walden: Yes, yes.

0:38:22.0 John Canyon: So that makes it to where you’re billing appropriately. And many of us do cerumen disimpactions in the office because it’s an easy thing to do, we let the nurse go in and lavage the ear, fix the cerumen disimpaction, and then send the patient home. That’s not okay. Alright? If you are doing cerumen disimpactions, you need to be present for those and you need to use an instrument. Okay. So if you use an instrument for your cerumen disimpactions, you get 0.61 RVUs. That’s a half a patient in value. Okay. So one cerumen disimpaction, if your RVU-based, will get you close to having a whole another patient in value. Okay. The key is you have to use instrumentation. So when you irrigate the ear, you get your ear curette and when the cerumen impaction gets to the end of the canal, you scoop it out with the curette and you’ve done a cerumen disimpaction with instrumentation. Okay? Does that make sense?

0:39:30.7 Professor Walden: Yes.

0:39:30.7 John Canyon: Understanding the difference between that and a lavage and irrigation is massive when it comes to reimbursement. You do that, I don’t know, a couple of times a week, that just adds another patient. Another patient a week without having to see a patient value-wise. So that gets us in a position where we’re generating more money per. We generate more money per, we end up making the practice more money, we make the practice more money, we add more value to ourselves. Again, this is all depending upon what your personal reimbursement structure is at your clinic. If you’re in an FQHC or in a place that does not actually generate revenue, you’re not arguing for the generation of revenue, you’re arguing for your value as a provider. That make sense?

0:40:22.6 Professor Walden: Yeah, that makes sense.

0:40:23.9 John Canyon: So you’re looking at “Well, I add more value,” and that’s how you argue your negotiation. When you come in and you say, “I’m bringing in $500,000 a year, and the other nurse practitioners bring in $200,000 a year, why on earth are we getting paid the same? Would you want me to scale back?” “Well, no, of course not.” “Well, then you need to reimburse me appropriately.” Okay, and you have to understand the keys to that too. You have to have overhead, so we have to have the overhead costs. We have to consider that. Okay. We have to consider that whoever we’re working for needs to make a profit unless it’s an FQHC or a complete donated service. They’re not… They shouldn’t be making a profit. Their interest is in keeping the doors open. And there’s some places like that, like the donation place where they don’t have any extra money. So that’s what they have. So you work for them or you don’t. And some of those places are so tight on their budgets like that, but if you’re working for a place that’s a for-profit, man, you gotta make sure that if you were making them a lot of money, get reimbursed for what you do, and an RVU and understanding how that works is significantly better way to approach because most of them, again, will not give you what you’re bringing in. They won’t tell you how much money you bring in a year because they don’t want you to, but they will give you RVUs.

0:41:49.1 John Canyon: And the way you ask for this RVUs is you want to… “I want to make sure I’m maximizing my revenue generation for the practice,” and if you go to them in that aspect of how you wanna make sure your RVUs are being calculated appropriately, generally they’ll give you the RVUs, and once you have the RVUs, then you can calculate what your value is because they don’t think we’re smart enough to figure it out. Any questions?

0:42:18.9 Professor Walden: No, this is good. So, this also brings up kind of what I was thinking, the other question that is usually asked, they won’t give me my numbers, if they don’t give…

0:42:29.2 John Canyon: Of RVUs?

0:42:29.5 Professor Walden: Right. So that’s fine if they don’t. Just ask for the actual RVU values.

0:42:34.0 John Canyon: Yes, the actual RVU values is… If they’re not willing to give you your actual income generation, which most are not… I’ve been in this, I guess, I don’t know, a long time, and I’ve never met a place that’s willing to give you your actual income generation, but they’re very willing to talk RVUs. And the reason is, especially in a place that’s for-profit, they’ll have Medicare numbers will be like, oh, 40%, 20%, something like that, and the rest is private insurance. And the private insurance reimburses significantly higher than Medicare. And that’s why I like to negotiate at Medicare rates because then we’re still giving them room on top of what we’re making. Does that make sense?

0:43:24.9 Professor Walden: So let’s kinda go back to that with Medicare because just to be clear in talking… I love, especially with numbers, talking to people like they’re five so that they understand, but RVUs, so this is based on, again it’s with the exception of those outliers that you mentioned like in a federally funded place or a donated place that runs off of donations, they’re assigned to everyone in every organization but they’re just based off of Medicare because they’re the lowest payer.

0:43:56.2 John Canyon: Right, so that’s why we base… That’s where we get the $55 per hour, that’s where we get our value at, so that way we have a number that we can begin to calculate at because if you… The problem is private insurance will negotiate rates independently with different organisations, so that’s how you get people who are in network and out-of-network. So the out-of-network’s always gonna reimburse higher because they want you to go to an in-network place because they have better rates and knowing… They never gonna tell you that either so you’re never gonna know what the negotiated rates are, so we do know the rate for Medicare and we always know that that’s the lowest denominator, they’re never gonna… No company’s gonna accept rates beneath Medicare, so we know what the bottom number is. Of course, Medicaid is a whole another ball game, but you almost get nothing for Medicaid most of the time, so understanding what the lowest common denominator is allows us to have at least an idea of what we can calculate our value at.

0:45:00.5 Professor Walden: Okay.

0:45:00.5 John Canyon: That make sense?

0:45:01.2 Professor Walden: Yes.

0:45:01.7 John Canyon: So that way we can say, “Hey, a 213 is worth 1.3 RVUs, that averages out to $71, that’s $71.50 per patient that I’m bringing in. You’re paying me $25 per patient, that’s not fair. Oh, by the way, there’s another thing, the average RVU reimbursement per over your salary is 27-35, okay, that’s industry standard. So if you’re significantly beneath that number, you understand that there’s a lot of room to work with. Okay. Now, generally how this works is you’ll have a base number of RVUs you need to make per quarter like we talked about, so on average, they expect you to make about 5000 RVUs per year, so divided by four, that’s 1250 per quarter, so divide that by three and you have about 416 per month. Okay. Kinda see how we’re getting what we expect out of the RVUs?

0:46:02.8 Professor Walden: Yes, these are the raw numbers, the one point, whatever.

0:46:04.6 John Canyon: Right, this is raw numbers. And it depends, every place is a little bit different. A lot of places are actually starting the RVU requirements for the year in the 3000 range, so you can determine what they think your value is based off of what the expected RVUs are per year. So if you’re at a place that requires 3250 RVUs per year and your salary is $100,000, take your $100,000 and divide it by 3250, and they’re giving you a value of 30.7 RVUs or 30.7 per RVU, make sense?

0:46:43.8 Professor Walden: Yes, make sense.

0:46:44.6 John Canyon: So that’s what they’re determining your salary is valued that. And so if you know that, then you can say, “Hmm, well, if I make over 3200 RVUs per year, I should be getting 30… ” And they’re like, “Oh no, no, no, no, we’re gonna give you five,” “But no, that’s not okay man, let’s make it appropriate. This is what you’re expecting my salary to be based off what the expectation is,” and 3200 RVUs is not hard to get per year, so 3200 divided by four is 800 divided by three is 266 RVUs a month. Okay. Alright, well, let’s round it up to 267 ’cause there’s a lot of extra sixes in that decimal spot. Alright, so at a 267, divide that by 1.3, okay, that’s 205 patients in a month, that sounds like a lot.

0:47:34.0 Professor Walden: Yeah.

0:47:34.0 John Canyon: But divide that by four weeks in a month, so you’re 51 per week, and divide that by five days a week, that’s 10 patients a day.

0:47:46.1 Professor Walden: Yes, and depending on where you are, your organisation, your clinic, I mean taking…

0:47:50.4 John Canyon: Right, it all depends on what your baseline work is but the premise is the same. So we did this based off of Family Practice numbers and CPT codes because that’s the baseline where the vast majority of people work, but the premise is the same, it doesn’t matter what area you work in, your… You take your CPT code and there’s calculators everywhere, and most of the time, if you put a CPT code into Google, it’ll give you the RVU. So you say CPT code for… Now let’s see, 99283, which is an ER visit, and then we’ll do RVU for it, and the RVU for that is 1.75, so you can easily look this up and calculate it based off of what your normal CPT codes are. So the more procedures you do, the more codes you get, the more shots you give, the more RVUs you get, the more procedures you do, the more RVUs you get. When you do, for instance a toe nail removal is a pretty common Family Practice procedure.

0:49:00.7 Professor Walden: Yes.

0:49:02.8 John Canyon: You can do a digital block, it’ll separately for the digital block and then do the toe nail removal, so they’re two separate procedures in your note and then you get the toe nail and you get the digital block, so you get two things even though that’s probably in the best interest of the patient is doing a digital block in your toe nail. If you document the digital block in the toe nail removal instead of as a separate procedure, then you don’t get both, that make sense?

0:49:31.5 Professor Walden: Yes.

0:49:32.0 John Canyon: See… So, that’s how you understand what the… What the value is. And then you go back and you look up what the code is for it and you can get the RVU. So you can get about one RVU per digital block. And then you go back and you get that, plus you get your toe nail removal, plus you get your visit and it stacks up. So you get a 99213 plus a toe nail removal plus a digital block…

0:50:08.5 Professor Walden: Right.

0:50:08.9 John Canyon: Right. And other things you need to know, lacerations are built off of the length of the wound, so if it’s a two… You never document a 2.5 centimeter laceration, because a 2.5 centimeter laceration falls in the lower section. So you either document 2.4 or 2.6. 2.4 is lower level laceration repair, 2.6 is a higher level laceration repair. If you put one subcuticular stitch in, it’s a complex laceration. If you do abscess drainage and you pack the wound, it’s a complex incision and drainage. So those kinds of things make it easier to understand value, but you have to document it appropriately, then you have to build it appropriately. And you have to have a coder who’s coding appropriately. So we actually had a coder who was not coding our cerumen disimpactions with instrumentations, so we weren’t getting any value for it when we were RVU based.

0:51:03.6 John Canyon: So we had to go back and figure out what the problem was, and the problem is she had no clue what she was doing, ’cause she had come from cardiac coding so she didn’t understand how to code Family Practice, so she didn’t get it. And when you’re losing money on that, it makes a difference. I mean 64.64 RVUs is if you’re getting reimbursed 30 bucks per, that’s $20 you’re missing out on.

0:51:26.0 Professor Walden: Right.

0:51:27.1 John Canyon: You’re missing out on $20 for them just not knowing what they’re doing, you know. I don’t know about ya’ll, but you’re not getting paid.

0:51:33.4 Professor Walden: It adds up.

0:51:34.5 John Canyon: Yeah. It adds up. You do a hundred of those a year or 200 of those a year, that’s a car payment, right?

0:51:43.7 Professor Walden: Correct.

0:51:44.0 John Canyon: That’s how you figure it out. And if you go based off those metrics, you can actually translate this to any field in medicine. If you just understand what the CPT codes are, and then go look up what the RVUs are and then you can figure it out. And this doesn’t necessarily translate to… You don’t have to be RVU based to utilize the information either. You can be salaried and then you can ask for bonuses based off of… And you can re-negotiate your salary based off of this information. And that’s how you get the bigger salaries, you get people that get reimbursed well. The most I ever made in urgent care doing an RVU was 166.67 an hour.

0:52:28.6 Professor Walden: Wow.

0:52:29.1 John Canyon: Well, we were RVU based and we had to meet 27 RVUs a day before we got into bonus, which was 27 RVUs per for everything over. And this was in the previous method, so instead of a two and three being worth 1.3 RVUs, which would’ve been phenomenal, I’d have never left that place if it was like that, but it’s worth 1.97 RVUs. So, every 213 we saw… And for math’s sake we’ll say it was one. So we had to see 27 patients in order to get RVUs, that’s a lot of patients to see. But because we understood how to maximize our revenue generation we… And then we had a competing clinic, so there was… Where’s my click? There we go. So we had a competing clinic across town in the same organization, so we were able to look and see what their RVU generation was. Their RVU generation was 0.97… Sorry, one for math’s sake, one RVU per patient. So they had to see 27 patients in order to get a bonus, and they hated the contract.

0:53:28.2 Professor Walden: Right.

0:53:30.7 John Canyon: We were almost at two per. So we only had to see 18 patients to get the bonus. So our RVU generation was higher, so anything over 18 patients suddenly we’re making extra money, and if you see 60 patients a day…

0:53:51.0 Professor Walden: Right.

0:53:51.2 John Canyon: Then you get 60 minus 18… And we were daily RVU too, which made it even better. And it’s significantly better, which added massive amounts of income to that day. And the reason we did daily RVU was because it was urgent care, and you never know what you’re gonna get. So doing quarterly is harder to do in that kind of setting, ’cause you’re not in control over your schedule and that kind of stuff. Other things you can do to increase your RVUs, if you’re in a Family Practice or a controlled office type environment where you’re over your schedule, is leave acute visits open. So you have acute visit open in the morning and in the afternoon, you can fit somebody in do a five-minute acute visit, ’cause we all know the acute visits are significantly faster in Family Practice than doing a regular office visit. You can add another… One to two RVUs just for doing your sick visits.

0:54:47.2 Professor Walden: Right.

0:54:48.8 John Canyon: And what I did with Family Practice was I had two in the morning and three in the… I had four in the afternoon. So I started at 4:30 and had the rest of my day sick visits. So if I didn’t have any sick visits, I was done at 4:30. And then I also closed down the time before lunch, so we went to lunch at noon, so from 11:30 on was sick visits. So they could schedule me three 10-minute sick visits in the afternoon, I had three 10-minute sick visits. So I didn’t lose on that income. I didn’t lose on those RVUs in the Family Practice setting either. It’s just little tricks you can do to try and set your schedule up for success, and if you’re done then you go to lunch early. So nobody comes in that day you go to lunch early.

0:55:32.8 Professor Walden: Right. Right.

0:55:34.1 John Canyon: Nobody comes in that evening, you go home early which makes it a little bit easier and you still generate the required RVUs to meet your… Each salary, so…

0:55:41.3 Professor Walden: And you have not taken charting home because you…

0:55:43.6 John Canyon: Yes.

0:55:44.3 Professor Walden: Good.

0:55:45.1 John Canyon: Yes. That’s the key. Just understanding how to document so you don’t spend all your time at home. I’ve been doing this… Oh gosh, 2005… 16 years. In all my time, I’ve never documented at home. Not once.

0:56:02.8 Professor Walden: Same. Same.

0:56:03.5 John Canyon: Not once. I’ve stayed late probably, probably count on one hand the times I’ve stayed late documenting, and those are when we were in RVU production and had a bunch of people show up at the last second and we saw them all because if I’m RVU based and I’m in RVUs, I want every single one I can capture. So that makes a significant difference, but I can’t tell you any time that I’ve actually documented at home because you have to understand that time is value. So if you’re spending time at home doing that, you’re losing value. You just subtract your hourly rate every time from your salary every time you spend a minute at home doing anything.

0:56:41.8 Professor Walden: Exactly.

0:56:42.9 John Canyon: And that kills your salary. If you’re spending four hours a night doing RVUs, you take four hours of your salary off, so you only got paid four hours that day. That’s not worth anything. That’s no help.

0:56:54.5 Professor Walden: Right. Yup.

0:56:55.3 John Canyon: So anyways, alright, any other questions from anybody? Anybody in the… Any of the students have any questions before we…

0:57:02.6 Professor Walden: No, so that, I think they’re taking it all in. That happens.

0:57:08.1 John Canyon: It’s a lot, it’s a lot of information. It’s a lot of information real fast.

0:57:11.1 Professor Walden: Definitely. Yeah.

0:57:14.0 John Canyon: So it’s definitely something that if you understand it, and the other thing that I would recommend to everybody, and I never did this, but I recommend it for sure is take a coding course. You need to take a coding course, and this is something that from a, I don’t know if you have one available, if you don’t that’s just a, if you get one, let me know and I’ll refer everybody to it. This is something that from a perspective of understanding the job, you have to understand how to bill in order to bill effectively. There’s a code for being the first visit after a hospitalization, which gives beaucoup RVUs, and I can’t remember what it is ’cause it’s been… It’s funny Family Practice a long time, so I don’t know exactly how much but it’s been a while since I did Family Practice. I don’t remember that code specifically ’cause you don’t apply it in urgent care, but being the first visit after a hospitalization gives you more RVUs. It’s more than an initial visit so it’s very, very lucrative, but you have to know that and you have to know how to bill it, and if you don’t, you miss it.

0:58:21.5 John Canyon: Unfortunately, we just, it’s tricks of the trade that you have to learn and a coding course is exceptionally beneficial. I’d recommend to anybody who’s doing anything that you can justify your salary based off of your income, you need to do a coding course. Just makes your life a lot easier.

0:58:40.8 Professor Walden: Alright, that was wonderful. And good information, good information. So I’m gonna ask you, hang on, John. Just kinda hang out back stage for a second.

0:58:52.8 John Canyon: Sure, no problem.

0:58:54.2 Professor Walden: Alright, so fantastic. So if you miss that, you don’t want to. You’ll wanna go back and make your notes. I think one of the most important things that he said was determining your value. So now that you understand the numbers and RVUs and how it works and how they determine your salary, you can go back, renegotiate, understand how you are generating revenue and determine your salary. So this is super important. And it’s so rare. Again, RVUs. So, so rare that we talk about it, and it’s broken down for us in this lovely information, so consider yourselves lucky because you’re among the few that truly understand what’s happening, thanks to John. Alright guys, so as usual, I’m always respectful of your time and we are right on point, so high five to us and I will talk to you soon. So great information and be looking for the information from us ’cause you know we’ll have a kind of a tip sheet that he mentioned that we will post that are his words, so that you can have that and further your practice accordingly.

1:00:02.9 Professor Walden: Alright guys, we’ll talk to you soon. Bye.