How Much Does A Central Line Pay In RVUs?

I placed a central line (a big IV) into the subclavian vein. It's used in critically ill patients with poor IV access to give medications very quickly and to help guide therapies.  It looped up on itself.  I've never had that happen. Nor do I know why it happened. Stenosis perhaps? Another first for Happy. To fix it, you can withdraw and re advance blindly, or have a radiologist manipulate it under a fluoroscope.

Now, let me give you a little lesson on how much I get paid for putting this special little line in. It takes, on average, about 15-20 minutes to consent the patient, dress, prep and suture the line. 15-20 minutes from start to finish. How much does Medicare pay me for my efforts? I refer you to my explanation of relative value unit.  In this post I explain the formula for how physicians get paid:
To calculate the payment for every physician service, the components of the fee schedule (physician work, practice expense, and malpractice RVUs) are adjusted by a geographic practice cost index (GPCI). Payments are converted to dollar amounts through the application of the conversion factor which is updated annually(this is what the SGR or sustainable growth rate affects). The general formula for calculating the fee schedule amount is: Payment = [(RVU work x GPCI work) + (RVU Practice expense x GPCI Practice expense) + (RVU malpractice x GPCI malpractice) x Conversion Factor. The conversion factor for 2007 is $37.8975; the same as in 2006.
Medicare, through the RUC, recommends an RVU value for every possible physician encounter.  Every encounter has a CPT® code, which the AMA also owns.  In the purest sense for creating relative values, you strip out the malpractice component and you strip out the physician expense component and you get the actual value that Medicare, through the RUC, applies to all physician encounters. The physician work RVU value.

They are trying to make an apples to apples comparison across every possible specialty and encouter. They are trying to set a relative value for a total knee replacement, as it compares to a mid level office visit by your primary care doctor.  I feel these numbers are flawed and are destroying access to primary care in this country. How do I know that? Because the numbers don't lie. Let me walk you through the example of my central line and its relative value unit (RVU) as it compares to my hospital follow up encounters, which make up 50% of my hospitalist charges.

Here's how it works. I show up to do a central line. the CPT® code is 36556 (reference the CPT 2013 Standard Edition from the AMA for definitive authority). I mark this code on my billing sheet and turn it into my billing company. So how much do I get paid? The RUC has determined that the physician component for a 36556 is worth 2.5 RVUs. Now remember, this takes me about 15-20 minutes to do. One RVU is currently worth about $38 . This value changes from year to year and is defined by law.  Here is an explanation of the value of one RVU.  So, do the math. 2.5 RVUs is worth $95. This is a pure payment of physician effort. It strips out malpractice and expense to the physician for supplies, nursing, syringes sterile equipment.

 For 15-20 minutes of work, that works out to $285-$380/ hour. That's what the RUC believes the physician expertise and training and knowledge is worth for putting these things in. How does this compare with my hospital follow up encounters?  I have an updated resource detailing the year to year changes in RVU values for common hospitalist codes, including central lines.  You can find the most update information on central line RVUs here.  As of 2013 the work RVUs remain 2.5 and the total RVUs are 3.61.

A level one hospital follow up visit, CPT® code 99231 is assigned a physician work component RVU value of 0.76 RVUs. The AMA, in their definition of this CPT® code, states this encounter should take 15 minutes. That works out to $29 (0.76 *$38) for 15 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $116 an hour.

A level two hospital follow up visit, CPT® code 99232 is assigned a physician work component RVU value of 1.39 RVUs. The AMA, in their definition of this CPT® code states this encounter should take 25 minutes. That works out to $53 (1.39*$38) for 25 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $127/hour

A level three hospital follow up visit, CPT® code 99233 is assigned a physician work component RVU value of 2.0 RVUs. The AMA, in their definition of this CPT® code states this encounter should take 35 minutes. That works out to $76 (2.0*$38) for 35 minutes of work. That's what the RUC believes this encounter is worth, purely from a physician effort, experience and training. That works out to $130/hour.

Do you see the problem here? I have placed hundreds of central lines. Most specialists never place central lines. Gastroenterologists, orthopaedic surgeons, dermatologists, even most cardiologists do not place central lines. Yet many hospitalists do. Many critical care specialists do. Many community family practice docs do. The issue has nothing to do with the length of training. Which brings me back to the original point. If it's not related to length of training and expertise, why is it worth 2-3 times more in assigned value to the physician effort than are my hospital follow up cognitive encounters.  That's why every medical student is going into specialties that are high in procedural volume. 

You can see much more in my free lectures on hospitalist coding.


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5 Outbursts:

  1. So you're overpaid for the lines, and you screwed it up?

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  2. "I've never had that happen. Nor do I know why it happened. Stenosis perhaps? "

    Most likely the tip of the catheter caught the azygous vein osteum (a normal variant) and prolapsed on itself.

    That'll be $250, please...

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  3. procedures have higher reimbursement because the immediate risk/complications are higher. What happens if you cause a pneumothorax or a subclavian artery injery or create a pseudoaneurysm. I have seen all these complications... as I'm sure you have as well.

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  4. I'm an average "Joe" that stumbled upon your blog post. I just wanted to commend you for your honesty. Doctors like yourself are the last hope our health-care system has for solvency. It's all about getting back to the basics... a specialist's time is worth "x"... that doesn't matter if a person is mowing a yard or putting in a central line. Thank you for pointing out how flawed the AMA is.

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  5. I doubt you are getting a line in in 15 minutes. It takes around 5 minutes to consent a patient, about 5 minutes to gather supplies/ultrasound/nurse to help, and about 5 minutes to review the XR, interpret the CVP, document, etc. Beyond this, it probably takes a fast person about 15 minutes from prep to tegaderm. I have timed myself, and I am fast. It is very hard to do a sterile ultrasound guided upper line in less than 30 minutes. If you time yourself from when you decide to place the line until the time you are are throwing your gloves in the trash it will be at lesast 30 minutes. So that's about 200 per hour. the current work RVU is $40. In the ED you can see 2-2.5 level 4-5 patients in an hour which works out to be $250-400 per hour. 2 central lines in a hour would be incredibly fast, unless they are just crash groin lines. I don't think the physician service for a central line should be less than $100. This is a proceudre that requires signfigant risk or morbidity, mortality, and malpractice. It requires a signifigant amount of experience and skill. It takes $50 just to get the oil changed in my truck, and that takes about a half an hour. So I dont' think $100 to use a needle to find a vien directly next to my lung and then shove a piece of plastic up to my atrium then read a chest x ray that says there are no signifigant coimplications is to much. If i was a patient, I weould want the person placing the line to make at least 100 for that.

    Also, there are more people who perform cognitive services than their are proceduralists. In general, lest training is reqiured to perform primarily cognitive services. Supply and demand.

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