12: Medical Billing with Complexity

Understanding RVUs and Medical Billing Basics

Beth Blimmer: Welcome back to Starting Strong, everyone! I'm Beth, and today we've got a topic that you can't really escape as a hospitalist—billing. Specifically, we're digging the basics of medical billing. I promise, this doesn’t have to be as intimidating as it sounds.

Mark Krause: Yeah, and—wait, if you haven't already, check out our other episode on RVUs to make this a bit easier. We’ve all been there. RVUs are Relative Value Units, and, honestly, think of them as this weird hospital currency. The value changes every year—like, one year your dollar buys a Coke, next year it buys you… half a Coke. That kind of vibe. Anyway, every patient encounter gets assigned a CPT code, and each code has a value in RVUs. For example is the admission code 99223, or the “level 3” initial admission, is one of the big ones for hospitalists.

Vicky Muller: Exactly, Mark. And that's where your paycheck comes from—billing RVUs to insurance, which then pays the hospital, and you get your cut depending on how many RVUs you’ve generated. There’s a target—like a productivity goal—where you’re expected to generate a certain number. And just to tie this to something practical, you can bill for RVUs in two major ways: Medical Decision Making, or MDM, and Total Time. Each way lets you show the complexity or, sometimes, just the sheer amount of work you did.

Beth Blimmer: Right, so if you’re billing by MDM, you’re focusing on the complexity in three main categories—the problems you addressed, the data you had to review or order, and the overall risk to the patient. If you bill by Total Time, you basically clock in every minute you spent on the case—chart review, examining, counseling, calling family, whatever. Both methods get you to an RVU number, but you have to pick one for that encounter.

Mark Krause: Okay, real talk—I have to share this. My first week as a hospitalist, I thought MDM was, like, “How sick is the patient?” I mean sure, that’s part of it, but I didn’t realize it’s so much about documentation, not just what happened. I remember writing “patient looks sick” and I thought, boom, level 3! Nope. It’s not just clinical complexity, it’s what you write down. Do not make early Mark's mistake, everybody.

Beth Blimmer: Mark, you’re not alone! We all have that moment—mine involved a progress note that could have doubled as a grocery list. But, that’s why we’re here. Stick with us and by the end, MDM won’t feel like some mystical hospital billing language. A few simple documentation strategies can reflect the actual work that is going on.

Decoding the Elements of Medical Decision Making

Vicky Muller: Let’s break down what actually goes into MDM, because the chart can look like a mess of boxes at first. There are three main elements: number and complexity of problems you addressed, amount and complexity of data you reviewed, and risk of complications or morbidity with your management. The “best two out of three” decide your billing level. So if two of them are high and one is low, congratulations you have a high billing!. It’s like hospitalist bingo, but for your paycheck.

Mark Krause: So, for problems addressed—think about your sickest patient, right? If you have a patient with a single self-limited problem, that’s low. Stable chronic illness, like hypertension on meds, is still low. But if they’ve got a new undiagnosed problem with an uncertain prognosis, or something like an acute illness with systemic symptoms, you’re in the moderate territory. If it’s organ failure, severe exacerbation, or anything life-threatening, that’s high--which is often where Hospitalists start their encounter with the patient.

Beth Blimmer: And when it comes to data, the process gets really particular. Maybe you review an outside note and order lab work or a diagnostic test, getting HPI or other history from an independent historian—think family at bedside, interpreting images or tests yourself or discussing management with another provider. For low complexity, you need any combo of the two and For moderate or higher billing, you need three from a wider array. The key here is to remember documenting you did these things--like what information was from the family member or your own interpretation of the chest x-ray, not just what the radiology read.

Vicky Muller: The third piece is management risk. So, low is like “hey, I prescribed Tylenol,” moderate is prescription drugs or a decision around surgery with some risk factors, and high is things like intensive drug monitoring, major surgery with risk, or even just deciding to ramp up or de-escalate hospital-level care. The tricky thing is matching an example to the right level. At a recent billing workshop, my group spent, I don’t know, fifteen minutes debating whether ordering a one-off infectious disease test counted enough to bump our data complexity from low to moderate. Spoiler: if it’s unique and documented, you can definitely make the case for moderate.

Vicky Muller: A simple rule that I use is any IV controlled substances such as opioids and benzos, or any medication that requires level or specific lab monitoring for toxicity. Easy ones are vancomycin or amphotericin but really most IV antibiotics do require monitoring. If the Infectious Disease doctor normally monitors metabolic panels a few times a week, then the medication has risk. It's important to differentiate: management risk is not the same as physician comfort level. You may feel just as comfortable ordering Zosyn as you do acetaminophen but the risk is different.

Mark Krause: Yeah—it all comes back to documentation. You could be doing a super complex case but if you just write “plan: monitor,” you’re not going to get those higher RVUs. The chart wants detail: what did you review, who did you talk to, what’s your plan for risk mitigation?

Beth Blimmer: And don’t forget, the “best two out of three” rule is your friend. You don’t have to hit high on all three elements. If you document moderate in, say, data and risk, but your problems are low, you can still bill at the moderate level. That flexibility makes a big difference when your cases are complicated in some ways but not all.

Applying MDM to Real Practice Cases

Beth Blimmer: Okay, so let’s actually apply this to some sample cases. First up: let’s say you have a patient in for a pneumonia admission. The problem’s moderate—acute illness with systemic symptoms. If you do a thorough review of labs and consult family in addition to ordering a CXR, you can get to moderate in the data category too. The risk? If you’re starting prescription drug management with some more mild antibiotics, again, that supports moderate. So, two outta three and you’re at moderate MDM.

Vicky Muller: And if you want to get to high—for example, say you’re admitting the same patient but they have severe sepsis—that’s higher in the problems category as the risk to bodily damage is higher. For data, you are ordering more labs, perhaps rechecking lactic acid. Maybe in addition to family providing some HPI you also reach out to their PCP to confirm medication lists or get additional history. You read the chest x-ray and clearly document your interpretation as "concerning for right lower lobe consolidation, official read pending".

Mark Krause: Even if you start basic community acquired pneumonia coverage you may not be starting high risk medications but that's okay. That’s why “best two out of three” is gold. You don’t need to hit high everywhere, and honestly, nobody does. I’ve seen cases where the problem was only moderate, but by documenting three different data sources—like a nurse’s note, a unique lab, and a discussion with the nephrologist—we were able to bill higher. So, if you’re thinking, “how can I ethically bill at a higher level,” always look to the work you are likely already doing. Billing rewards good behaviors that we often learn in training--looking at unique data sources, talking to reliable historians, and actually speaking directly to colleagues or outside docs.

Beth Blimmer: I’ll add in a quick story—I once had a case that felt stuck at moderate because the patient’s risk was borderline. But then I realized I’d actually spent 10 minutes talking to cardiology on the phone. As soon as I documented that discussion in my note—who I talked to and why—the final billing went up to high complexity. It made a real difference in RVUs and also just reflected how much work happened behind the scenes. Billing can actually reflect better patient care.

Vicky Muller: Yeah, and reviewing your notes for these little details is key. When you practice, keep running through—problems, data, risk, which are your “power two”? Then document the heck out of 'em!

Documentation Best Practices for Accurate Billing

Vicky Muller: Let’s spend our last chunk on what really makes or breaks your billing—documentation. This is where you prove your MDM to the coders. It’s not enough to know the patient was complex; you have to make it clear for anyone reviewing the chart.

Mark Krause: Absolutely. Stating specifics is what matters—not just “spoke with a consultant.” Go for “Discussed with Dr. Smith in GI regarding uncontrolled bleeding and possible escalation to endoscopy.” If you’re reviewing labs, say which labs. If you use an independent historian, identify them and why. It sounds tedious, but those details are the difference between low and moderate—or moderate and high—billing.

Beth Blimmer: And you don’t have to write a novel to do this. Templates and checklists are your best friends. Have a note structure that prompts you to include everything billing wants—like prompts for specialist discussions, tests ordered, or “was an outside note reviewed?” That way, you miss less. I like to end my notes with a section on risk stratification—literally spelling out, “risk is moderate due to prescription drugs” or whatever fits the case.

Vicky Muller: And don’t forget to review your notes compared to the billing chart regularly—actually cross-check your documentation against what a coder would look for. That’s how you make sure you’re not missing opportunities for proper reimbursement. Going back over your cases, especially trickier ones, trains your brain to spot those billable details.

Mark Krause: One last tip from me: try to review your own documentation—maybe once a week or after a particularly busy shift. Flip through a chart or two, run them against the MDM sheet, and see if you actually documented what you did. It’s kind of like re-watching game tape as an athlete, you know?

Beth Blimmer: That wraps us for today! Thanks for listening, everyone—this stuff really can make your practice (and paycheck) so much stronger. We hope you feel a little less mystified by RVUs and MDM. Vicky, Mark, thanks for sharing your wisdom and occasional embarrassing moments with us!

Vicky Muller: Always happy to, Beth! And if anyone has billing wins or horror stories they want us to talk about next time, send them in. Billing doesn’t have to be scary—let’s figure it out together.

Mark Krause: Yeah, and keep those questions coming—next episode, we’ll keep building on this foundation. Until then, take care and happy documenting!

Beth Blimmer: Bye everyone!

Mark Krause: See ya!

Vicky Muller: Bye guys!