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

RACs and RUCs and 99204s, Oh My!!!

Today is the next installment in the New Patient Office Visit Series.

We will be covering the 99204 CPT code. In 2003 it was selected 30% of the time for the new patient encounter.....which means just about 65% of patients fit into the 99203 or 99204 zone. My guess is that by the time we are done, you will be using 99204 much more than not.

So what is a 99204?

99204 requires these 3 components

1. A "Comprehensive" History

2. A "Comprehensive" Examination

3. Medical Decision Making of "Moderate" Complexity

Once again the definition of Moderate and Comprehensive are key here.

Moderate Complexity Decision Making is often audited and requires:

A. Multiple Diagnoses or Management Options. AMA doesn't list the exact number here but E and M University has a good wrap up 

The take home is that new problems with additional work up gets a maximum of 4 problem points. If it is a new problem with no further work up it is 3 points.

You can feel pretty confident  billing 99204 here if you have 3 points here AND

B. Amount and/or complexity of data reviewed has to be moderate as well. 

In this case you would need 3 data points reviewed. Ordering clinical lab tests counts as 1 point. So does ordering a radiology test, the same with EKG.

Discussing the results with a physician gives you a measly one point as well. But independent review of the specimen, image or tracing gives you 2 points......

So if you looked at the film, document that you looked at the film....or EKG.....

Review and summation of Old Records ALSO gives you 2 points.......

You can consider yourself getting warm here if you have 3 data points here AND 3 problem points.......

C. Moderate Risk of Complications, Morbidity or Mortality.....Well, what does that mean?

You can turn to the "Table of Risk!"

This basically indicates that you have one thing of 3 categories......

Category A-Presenting Problems

One or more chronic illnesses with mild exacerbation

Two or more stable chronic illnesses (HTN and Hyperlipidemia)

One Undiagnosed New problem

Acute Illness with Systemic Symptoms

Category B-Diagnostic Procedures

Stress Test or Fetal Stress test

Diagnostic Endoscopies

Deep Needle or Incisional Biopsies

Cardiac Cath

Fluid removal from Body Cavity

Category C-Management Options Selected

Minor surgery

Elective Major Surgery

Prescribing Medicines

IV fluids

Closed treatment of a fracture

So, you need one of each category to qualify Risk as a moderate data point

Listen, this system is complicated here.....My gut tells me that you should not count on using Risk as 1 of your 2 required points to qualify MDM as moderate complexity.

My take home on MDM is-Always review your own data, Always review old records, 

Always document new problems and demonstrate your work up of them......If you do these things you will likely qualify for moderate MDM

Now that's over, let's look at a Comprehensive Exam

Comprehensive is defined as 

1. "A general multisystem examination"

2. " A complete examination of a single organ system"

Organ systems are:

Eyes

Each Extremity, I repeat EACH Extremity

Ear, Nose,Throat and Mouth

Eyes

CV

Respiratory

GI

GU

Musculoskeletal

Skin

Neurologic

Psychiatric

Heme/Lymph

If you set up a template of your exam as such, you will do well in documenting these events. The take home here is that to be complete you would need 2 bullets for each of the 9 systems.......Ah silly coders, they have to be so precise in defining complete.....do they really know what complete means?

I go over bullets and the exam in prior posts 

This is a gimmee here. Anyone would do this for a new patient......Anyone......Count Complete physical as one of the 2 Categories filled

Lastly,

Complete History. This bugger is considered the Highest Level of History. Which means often people try but fail at performing this.

This history includes:

1. Chief Complaint

2. "Extended" HPI

3. Review of systems related to the problems in the HPI PLUS all other systems

4. COMPLETE Family, Social and Past Medical and Past Surgical History

I will go through each in detail, but suffice to say.....you should be doing these things for ALL new patients if you want to code a 99204.....I actually do this for ALL of my new patients....I will explain why shortly...

The big question here is likely to be What is a COMPLETE PM/PS/Soc/FamHx (PFSHx)......One thing it isn't is NonContributory.......It is at a minimum-Parents, Siblings AND Children! I do grandparents too!

This includes Medicines and Allergies! I repeat, this includes medicines and allergies....

I plan on covering this in another post, but just keep these tips in mind.

Is the patient married? Are they employed? Have they had education? Do they have exposures? Sex? Drugs? Rock and Roll? 

Remember, nearly all outpatient codes require some elements of this here. So it is just good sense to do this at EVERY encounter.....

And most importantly, the PFSHx can be taken by another person, OR EVEN a Form......

What does this look like in real time? 

Initial visit for a 59 year old woman with HTN, Obesity, OA. She has a complaint of palpitations with some occasional dizziness. Her PMSFHx includes TAHBSO for DUB 15 years ago. She has not been seen for 5 years.

If this new patient is also here for a complete physical exam....there is something I need to share with you.....it is called Modifer 25....the name of this blog! 

Want to learn coding and billing? Want to put 5 billion back in your pockets? Join us....email us at modifier25@gmail.com

Middle of the Road 99203

According to EM University, in 2003 this code accounted for 39% of all documented office visits in 2003. I wonder why we don't have any further data on this. Wouldn't it be fantastic if we could see who was coding what and how often? Imagine if we could have a website that would present this information to physicians yearly and then match it against your rates? Well, there are some pay services that allow this for subscribers of their service....

I think you know how I feel about someone taking your data, compiling it with others AND THEN SELLING IT BACK TO YOU!

Frankly, that is just bull......I think it should either be outlawed OR we should be given FREE ACCESS to this.

It is after all, OUR DATA.

So with that little rant out. Let me tell you about a 99203

A 99203 is also called a Level 3 New Office Visit. What is it?

This office visit requires 3 key components

1. A Detailed History

2. A Detailed Examination

3. Medical Decision making of LOW complexity

Why do I point out Low complexity? Because, I think we may actually be coding too much of these and may instead need to be coding more 99204s and 99202s....

Let's examine what the definition of "Detailed" is.

"Detailed History"-Requires a Chief Complaint (CC), "extended" HPI, problem pertinent Review of Systems (ROS) which is "extended" tp incude a limited review of:

A. Family History

B. Social History

C. Past Medical History 

All directly related to patient's problem.....

2. Detailed Examination-Requires an "Extended" examination of the affected body area or organ system AND other symptomatic or related organ systems.....

"Extended Examination"- requires 12 data points/bullets.

If you want to learn more about bullets you can see it here.

3. Lastly, Medical Decision Making of "LOW COMPLEXITY"

Which requires

1. Limited number of Diagnoses or Management Options

2. Limited amount of data to review

3. Low complexity of data to review

4. Disease with low morbidity or mortality

So the question remains...."What does this look like?"

Initial offive visit for a 67 year old woman with hypertension, new to the area. She has had no problems with her BP while on a diuretic and home bp monitoring. She brings in her log.

You are expected to do the same things that you would for a 99202

So why do I think we are using this code too much? Here's the question.....would you do such a thorough History or Physical in a patient with well controlled HTN?

Probably not, which would then bump you down to a 99202. 

But what about well controlled diabetes? The mortality and morbidity is higher and you would do more work.....thus a 99204, which I will cover tomorrow......

You see, by choosing middle of the road, we may be coding wrong......

Want to join us? Email us at modifier25@gmail.com You can learn the system and be better at coding too. This may save you 80-100k per year.....

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!