Primary Care Procedures

[HikingDO]

There's only two procedures that I've found that I will do as a PCP that are quick and worth the time for the RVUs that they generate. Joint injections and OMT (If you're a DO, but I know an MD colleague who also does OMT). The rest, toenails, biopsies, etc., seem to take too much time for the amount of RVUs that they produce vs just seeing another UTI or two..

[Zaphod]

Your success is great, but dont think the incentive is driving that, its the patients and their willingness to go along, etc...there are majorities of the population that simply will not change their behavior. I mean most people in america that are "sick" are so not because they dont listen to the doctor but because they dont listen to anyone about anything and eat and do whatever they feel regardless.

Reminds me of when online folks say its doctors fault people are overweight and all you need to do is teach them nutrition, bugger off with that, everyone has a basic and mostly realistic food health schema, what they dont have is will power or long term thinking enough to care.

[beagler]

Fee for service is all about money. Pay more for doing more regardless of outcomes. Sicker patient: do more, see them more, get paid more. Encourages “oh well non compliant nothing I can do... will see them next chf admit cha-ching.” The incentive drives what our system looks like.

Turn a chronic sick patient into well compensated and your reward is nil. I have no repeat chf patients now due to doing whatever it takes to get them compliant. I didn’t think this was possible, but I have proven myself wrong. Why am I doing this? Because I’m now paid in part to keep these high risk patients out of the hospital.

I’d rather be incentivized to reduce preventable hospitalizations and ED use. This is happening now and many of us have measureably bent the cost curve. This is coming sooner than you may expect because the current system is unsustainable—ask any employer or ask Medicare trust fund.

It is more smartly measured than old fashioned capitation. Patient satisfaction scores, quality measures, measurement of ed and inpatient use, and open access to specialists are now present. We have to actually provide better value care not just denial of care.

[Lordosis]

Right now medicine is fee for service. During our career it is going to morph to a rate per patient variable on certain metrics. Basically you want as many patients as possible and to do as little for them as possible.
if it were all about the money...

[beagler]

Joint injections and skin biopsies. Depending on where you practice, there might be a specialist shortage.

In the very near future, health systems and primary care will be graded on total cost of care. Things you do are much cheaper than a specialist visit and associated tests, procedures and follow ups. If you avoided an MRI and an "elective" arthroscopy more power to you.

[Zaphod]

Find out what you're treating or going to see a lot of and learn those things. Easily this would be things like biopsies for skin cancer, dysplastic nevi, etc....I wouldnt waste much time with cryo, it pays almost nothing, and you neither get a confirmed diagnosis nor know whether or not you've actually definitively treated something. Lose-lose. Learn how to do full thickness/punch biopsies and throw a stitch. It is much appreciated by the end clinicians. These do not pay terribly but Im a surgeon and this is super easy to me so ymmv.

I have literally done hundreds of wRVUs in a couple days of clinic with minor procedures, but those will be much more involved than what you'd do most places, though could be done in more rural areas. No reason you couldnt work up to fully excising and layer closing all the easy stuff.

[Lordosis]

The amount any procedure bills will depend on your contracts. The only one you know for certain (assuming you know where you’re going to be practicing) is Medicare rates. See the final 2020 PFS from CMS and the files they provide online to see the list of every CPT and RVU.

I imagine I lose more then gain with procedures due to ^^^this.
Yes if some one is in for their regular follow up doing a knee injection is quick and easy but when I consider all the procedures it is more of a time suck.
A nexplanon literally takes 3 minutes. The 5 follow up phone calls about the patient being unhappy with the way it altered their bleeding patterns (That I specifically warned them about) Takes a lot longer.

[8arclay]

If this is something you plan to integrate into your practice with any regularity, it would behoove you to set up the infrastructure of the office to accommodate this. For instance, train staff on how to set up/prep a joint injection. So you see the patient, agree to a procedure. You go see the next patient while staff gets consent/prep setup. Then you can come in and quickly perform the procedure once ready.

If you get the logistics sorted it shouldnt be an issue. If it becomes the bottleneck in your schedule, you may be better off skipping them

[HandFellow]

I agree and disagree with the above statements.
Agreed: If you want to learn about the business side of medicine, talk to your current attendings. Learn which procedures they do and how they perform them. If you aren't efficient with these extra things, you will end up revenue neutral. Only do procedures that you are comfortable with.
Disagreed: Not all procedures are time consuming. An injection literally takes me 1 more minute. But I have a good system in place and do a ton of injections. These increase my revenue significantly. Talk to your staff and doctors and try to figure out the best way to implement procedures into your practice

[jacoavlu]

Agree with ENT Doc. Most procedures you would think of doing in the office probably don’t pay that well as far as the pro fee goes. Think, in the neighborhood of $50 on medicare patients. You’re probably better off focusing on efficiency in seeing patients and getting your charts done.

[ENT Doc]

The amount any procedure bills will depend on your contracts. The only one you know for certain (assuming you know where you’re going to be practicing) is Medicare rates. See the final 2020 PFS from CMS and the files they provide online to see the list of every CPT and RVU.

[ENT Doc]

Something people forget about these procedures is that they think about the absolute benefit rather than the marginal benefit. Sure you can do a joint injection or a skin biopsy. But I’ll bet you that in the time it took you to explain the procedure, do the consent, prep, drape, do procedure, clean up, etc. that you could have seen a follow up or new patient that would have taken in just as much income. Agree with others re: doing what makes you happy and that gives you a fulfilling practice experience for you and your patients.

[relentlessrook18]

Thanks for the answers. I feel like some people may have taken the way I wrote my question wrong. I didn’t go into medicine for the money. I absolutely did not pick my specialty for the money. My residency doesn’t really talk about reimbursement much other than basic billing codes. I think it’s pretty disappointing that doctors do not talk about money more than what I’ve experienced. I think getting out of debt more quickly will allow you to enjoy your career much more. At least for me, I feel like that. But on a side note, I would never do something just to make an extra dollar on a patient if it wasn’t indicated. I mean, I’ve gotta sleep at night... I was just curious to how procedures billed and which ones would also be fun to learn.

[Lordosis]

Having the ability to do several procedures can really help your patients. It is nice to be able to put in a mirena or nexplanon and not have to refer to gyn. Same with joint injections and Ortho. Breaks up the day a little too. Better then fiddling with blood pressure meds all day. But unless you have a ton of partners sending folk your way you will not get to many procedures out of a typical primary care panel.
i wouldn't do it for the money. Do it to broaden your skills and help your patients.

[ACN]

Talk to your attendings and ask them about reimbursements and the business side of medicine. Only perform procedures you are comfortable with and that benefit your patient. Don't do injections because it pays off your loans if you don't really know what medications to injection or what the indications are.

But...to answer your question

You can also lookup CPT codes for the procedures you are interested in and get the RVU number.

For example: "Joint Injection" is 20610 - Asp/Inj of Major Joint.

• Then you go to https://www.aapc.com/practice-manage...alculator.aspx. This gives you 0.79 RVU. Then you need to know how much insurance or your contract pays per RVU.
• Or you can see Medicare reimbursement here: https://www.cms.gov/apps/physician-f...-criteria.aspx
• It reimburses about $45-70
• So you need to do 12k injections to pay off $300k in loans (assuming 50% overhead)