Compensation and reimbursement plans vary widely across the healthcare system. Collections-based, dollar per relative value unit (RVU) or salary plus incentive are three of the most commonly used plans. Regardless of the model, calculation of work RVUs is valuable as a tool for measuring productivity and in a growing number of circumstances, can be critical to determining the income that a provider receives.
Relative value units come in different varieties and contain different components. The total RVU (tRVU) includes the practice expense (PE), malpractice and physician (professional) component. The professional portion encompasses the physical and mental effort required to deliver appropriate care to a given patient. In the surgical specialties, this can generally be broken down as follows: 10% pre-operative care, 70% operative work and 20% post-operative care (1).
In the early 2000s Medicare began implementing the Multiple Procedure Payment Reduction (MPPR) guidelines which reduced payments for the PE portion of tRVUs. In instances where multiple procedures are performed as part of a surgical episode, the PE portion is typically incorporated into a reduced number of clinic visits or expenses than what would be generated if the procedures were performed as separate events. Therein lies the justification for MPPR. Hospitals, clinics and healthcare systems receive a reduced reimbursement but the provider delivering the care still performed each portion of the common procedural terminology (CPT) codes that were submitted for billing. When evaluating billing and coding reports, the -51 modifier indicates multiple procedures. In order to qualify for application of modifier -51 a CPT code must meet two criteria. First, it must be a secondary CPT code. When a surgical event is converted to CPT codes, the codes are rank ordered from highest to lowest based on the value of their RVUs.
The code with the greatest RVU value is termed the primary code while all Remaining codes are termed secondary codes. The secondary criteria for MPPR comes from the national physician fee schedule. This document is available online in MS Excel format. The fee schedule contains a column with heading ‘Mult Proc’. Within this column, the number indicating eligibility for modifier -51 is ‘2’. If a CPT code meets both of those criteria, the MPPR is applied and the payment is reduced but awarding of wRVUs should remain unchanged.
In most instances, billing and coding teams are not required to append modifier -51 to the claim as CMS and many private insurers will apply the MPPR internally. The majority of other modifiers are applied at the time of claim filing. It is imperative that healthcare providers are properly compensated for the work they provide. We shouldn’t accept a lack of involvement in the billing and coding process while simultaneously complaining about poor revenue with each passing quarter.
Billing management can create a lot of confusion often accompanied by a great deal of frustration. In residency, I had a rough familiarity with outpatient coding, fellowship was more of the same. Early on in my practice, my focus was on learning the correct verbiage to include in an operative report or worrying about my clinic note containing the right criteria to meet prior authorization needs. From there, I built up towards understanding quarterly profits and loss statements.
As each year passes, physicians across all specialties find themselves working harder for less and less. Orthopedics hasn’t been immune to this trend (2). No one that I know has ever asked for the moon but what most of us are asking for is clarity, honesty and fairness during the execution of an overly complicated medical billing and payment system. To be clear, I don’t approach this from the viewpoint of maximizing my own income. We all deserve to be paid fairly, sure, but delivering high quality and compassionate care costs money. Our practices need physical space, medical assistants, nurse navigators, surgery coordinators, athletic trainers, advanced practice providers, wound care supplies, imaging equipment, the list goes on. If we fail to take the time to maximize practice revenue, we’re failing our team and our patients.
Residency and fellowship are demanding times in our training process and our lives. Trainees often take on the mindset of “just get through this time and things will get easier”. Approaching a decade into practice and I’m not convinced that’s true. Demands quickly shift to building a practice, covering overhead, making the right clinical decision, passing oral boards, paying down educational debt, optimizing clinical outcomes and pleasing patients for good reviews. In my own experience, it wasn’t until about two years into practice that I began to feel more relaxed and confident with my clinical decision-making and surgical outcomes. It was at this point that I began to focus on other aspects of my practice like billing and finances.
It’s impossible to see into the future and we shouldn’t expect ourselves to make all the right decisions straight out of the gate. As general rule, I would encourage everyone to get a seat at the table with your hospital and practice administrators. Grab coffee or lunch, anything to get the conversation started and foster a collaborative work relationship. Invest the time in understanding an income statement and balance sheet, familiarize yourself with the top 25 CPT codes used in your practice. You don’t have to be overly neurotic but keep your own case log and have a general understanding of your OR and clinic volume. When you see something that doesn’t make sense, ask questions and when you don’t understand the answer, ask more questions. The world of medical billing and coding is confusing to say the least and guidelines change all the time. We all work hard and deserve to be compensated fairly for the service we provide and the liability we take on. As is true throughout life, there’s no better advocate for you than yourself. The more informed you are, the better.
REFERENCES
1) Wiskerchen, S. (2017). Work RVU compensation formulas and surgery modifiers: To discount RVUs or not. OrthopedicsToday.
2) Pereira DE, Hannon CP, Courtney PM, Rana AJ, Frisch NB. Trends in Orthopaedic Surgeon Compensation: A Com
