Sitck with the Outpatient Codes, Please. 99211

Ok, Ok. I asked a read this week if they would rather have me review further inpatient or out patient codes. They begged me to stick with outpatient codes. So In response to that, no problem.

I figure I can walk you right through some outpatient cases which will help understand how your return patients match up. But first, let's talk a little about the established patient. This is defined as someone who has been seen by you or a physician in the same specialty in your group within the previous three years.There are five levels of care for this type of encounter which all require documentation of TWO out of THREE key components.

These are the absolute same components as you will see for most E and M visits.....

Yes, our lovely friends History, Physical and Medical Decision Making (MDM)

These components are broken down into several subgroups which in the end ultimately determine how much you get paid for Evaluation and Management codes.

The best part about established patients is that you do not have to meet such a high barrier to bill at the higher levels. Instead you only need 2 of 3 components to be at the highest level of your biling. Which is a heck of a lot nicer than the 99205 trainwrecks which require 3 of 3......

Let's talk about the simplest of these today. The 99211. The 99211 was designed as a quick 5 minute visit for follow up of one issue. In fact, this issue was not even thought to incur actual physician to patient face time.

This is a stable and acceptable BP check, done by nurse or PA. Let's look at it.

A 57 year old man comes to the office for a BP check. It is 120/80.....perfect. 

The patient has NO OTHER COMPLAINTS OR NEEDS at this time. I repeat, the patient has NO OTHER COMPLAINTS OR NEEDS at this time.

If he has ANYTHING ELSE....this code is not for him and he should be seen by an MD...... 

99211 equals one problem, no change in management or simple change in management. 

This visit does not require any hurdles. In fact the AMA considers this a 5 minute episode.....so If you have gone past 5 minutes, you need to look at other codes. In short, NO ONE REALLY CODES a 99211. In 2003 according to E/M University, 5% of all office visits were this code and the average reimbursement was 21 USD.

Take Home Point, If you've spent more than 5 minutes, you shouldn't use this code.

Want to join us? Want to put that 5 billion dollars the US spends on coders and billers back in your pockets? Email us at modifier25@gmail.com

Physicians Undercode out of Fear and Emotions.

This article is a must read. It turns out that Physicians often overcode Evaluation and Management codes. At least according to Medicare stats. Which is why you should pay attention when you read this article. The take home points???

1. “Some physicians will code every office visit as a 99212 just to stay under the radar and avoid a Medicare audit,” says Ginny Martin of Healthcare Consulting Associates of NW Ohio in Waterville. “However, coding everything the same can initiate an audit as well.”

2. Medicare data suggests that, for evaluation and management services, overcoding is far more common. Medicare providers overcode with the ubiquitous 99213

3. “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.”

4. For a 99214, the nature of the presenting problem(NPP) is usually of a moderate to high severity, in contrast to a 99211, where the NPP is usually minimal. Pinning down the NPP level is the key to accurate coding

5. Arrive at a tentative NPP as part of your differential diagnosis once they take a comprehensive history. We use 3 gen pedigree and extensive social history. Include a field for the NPP on your hard-copy encounter form or in your EMR

6. Use the whole ICD9 Code: “I’m stunned by how many doctors don't do that. A 250.00 means Type II diabetes that’s under control. What if it’s not under control? That’s 250.02.”

So to summarize, use the right code, be realistic with your encounters and make this PART OF YOUR CLINICAL PRACTICE. By using these, you begin to scrape away the magic of the billers and coders.....How do you do this? Keep reading, we'll get there.

If you are interested about joining us, then email modifier25@gmail.com to get access to this blog!

4 Billion Dollars. Out of Your Pockets.

Hello,

I am Steven Murphy M.D.

I am a physician who has a medical practice that just began accepting insurance. I take the best care of my patients possible, but I am not getting paid what I deserve for what I do. Why? I don't know squat about Insurance Billing. If you are like most doctors, I am certain you don't either. But here's the good news. I am doing a deep dive into Medical Coding and Insurance Billing.

If the average Medical Coder gets paid 40-50k per year and the American Academy of Professional Coders has a membership base of 75,000 then I estimate that we are AT LEAST spending 4 Billion dollars on medical coding each and every year. Who pays those people? Doctors pay them a percentage of each and every bit of the sweat of their labor.

Why? Because they can fill out some web forms and follow up on our payments for us? Is that really worth 4-8 percent of your work?

I know primary care physicians going out of business. I bet they could have used that 4-8 percent over the lifetime of their practice.

I am committed to removing this layer of expense. It is my purpose, It is my aim to have you, the physician, learn everything about coding. Why? So that we can put that 4 billion dollars back in YOUR POCKETS.....

Here's my strategy and I just learned it from a group called Athena Health. They actually gave me the impetus to do this. They have 17,000 physicians signed up. Those physicians dump all of their EOBs, Denials etc into this huge database.

When a physician who has signed up with them goes to submit a claim, Athena's database prescreens the claim, looking to see if it meets all the "rules" from insurers....it then sends the claim on to insurers.

Sounds great right? Well, they actually told me it would cost me 10,000 USD to get started and then they would take 4-8 percent of my revenues for what they did. I said to the salesman, so you are basically a medical coding and billing service.....He said yes.

So even with the bells and whistles all that these people do is act like leeches and suck our blood.

So here's my take. We create this blog, open it up to anyone who wants to post about denials or issues with insurance.....we cover each others' backs. We alert others to things insurers do. Heck, if we have enough users, we can even create our own "open source" Athena which is "Free" to all users and contributors.....

We create Athena's database, without having to shell out any money. Just a little time to rant and rave.......and save healthcare's most neglected professional......The Doctor.

If you are interested about joining us, then email modifier25@gmail.com to get access to this blog!