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.....

Fridays are Fun Days, Wolfram Alpha Fun!

I will skip writing about coding on Fridays and instead will focus on technology that will bring us closer to removing some of the layers of ineptitude in medicine and the business practice.

Wolfram Alpha is going to change how we understand coding and in fact if done properly, this computational system could put the Athena Health service which I mentioned wanting to charge me 10,000 USD for a set up. If done properly by placing the rejection claims on the internet where Wolfram Alpha could access it. 

Athena Health brags that they have 17,000 US physicians dumping into their database........What if the 700,000 physicians dump this information onto the Internet so that Wolfram Alpha can access it?

It may just so turn out that by writing apps around Wolfram Alpha, we may actually be able to replace the billing software systems as well. 

You see, the CPT code and ICD9/10 system were made for our benefit. Not to cost us money. It will only take a small matter of time before the inevitable has happened.

Wolfram Alpha is soon going to be Wolfram Beta, which will then be Wolfram.....

And we will have just put billions of dollars back in the pockets of doctors.

But it starts with you......joining us and putting this info online.......or at least blogging with us....

Want to join our blog? Email us at modifier25@gmail.com

Is it really a 99202?

Yesterday I mentioned the 99201 CPT E and M code. I said that it turns out most people over code the 99201 as a 99202. But I then thought, how would they know the difference and why would they over code.

Often overcoding is due to ignorance of what is required from each code. And frankly, to quote ex-president Clinton..........It depends on what the definition of Is, Is......

The same is true with words such as problem versus expanded problem.......

What does expanded problem mean? Expanded problem means that you took a problem relevant review of systems......my guess is that most of you do this, but often fail to document this. Review of Systems is super important here. In the 99201 you can get away without doing it in the HPI, but in the 99202 you cannot.

What is the 99202? A new patient which requires 3 components

1. An expanded problem focused history (Includes ROS)

2. An expanded problem focused exam

3. Straightforward medical decision making

So you may be asking yourself, "What is an expanded problem focused exam?"

A limited examination of the affected body area OR organ system affected AND other symptomatic or related organ systems

And now I hope you understand Straightforward Medical Decision Making......If not...

It is determined by:

1. The number of possible diagnoses if greater than 3 is usually complex....make sure you list differentials in your notes!!!

2. The amount of or complexity of medical records. labs, and other information that must be reviewed. Document ALL records reviewed in your notes.....

3. The risk of complications, morbidity and mortality associated with the problems, procedures and management options....

I hope you now see why cardiologists/surgeons/gastroenterologists get paid so much more than internists......EVERY SINGLE ONE OF THEIR CASES can be billed at higher levels of medical decision making.....

So, with that primer, let's see a 99202 in action.....

A 45 year old man is in with history and skin findings consistent with poison oak who is not responding to OTC treatment....

What is expected of you:

1. Preservice, review the medical history forms AND vital signs

2. Intraservice, Obtain the expanded problem history and physical, Formulate a diagnosis, formulate a treatment plan-Straight forward here-i.e. less than 3 differentials and simple treatment either way....Don't try and fudge this one...it is what it is....now reconcile your meds, write the Rx and test if you really need to...

3.  Document what you did, including listing dif Dx, care coordinate AND handle another treatment failure prn....

There, that wasn't so tough......Now how many of these do you see in a day....my guess is a whole lot more than you had thought about if you are new......if you are established, probably one to 2 a day at maximum.....

Want to Join us? Email me at modifier25@gmail.com so you can start blogging and learning codes too!

Welcome to my first Initiates!

I just received 3 emails from doctors looking to join the fray. They came from MedScape!

Welcome. Today I wanted to go over some simple things first. The Current Procedural Terminology Evaluation and Management Codes. These codes were introduced into the system in 1992 so they are only 17 years old. Yes that is correct, 17 years of insanity. Which is why the whole field has only gotten even more bloated lately.....

Prior to the E and M codes "visit" codes were used. Which obviously made a lot more sense to physicians who usually had their day scheduled as such with types of visits as comprehensive physicals and brief check ups.....

But, to dismantle the system we need to do it systematically. That is, by finding out what these codes mean and then applying them appropriately.

The next 5 days will be spent on the new patient E and M codes.

We start off the 9920x series with 99201. Office or outpatient visit for the new patient.

99201 requires 3 things.

1. A focused Problem History

2. A problem focused exam

3. Straight forward Medical Decision Making (This is the little bastard that gets us all)

As physicians, I think we need a good understanding and the best way to do that is with a clinical example of a 99201.....so here you go.

Initial visit for a 24 year old here for a refill of her acne cream.

These insurers are assuming you are doing the following things for this patient and it would be wise to document these as well as the mandatories.

1. Preservice-review the medical history form that the patient filled out while in the waiting room

2. Intraservice-Problem focused exam-in this case the skin, Formulate a treatment plan, discuss this with the patient. Also, discuss the need for preventative health maint....Reconcile medications and write an Rx as needed

3. Postservice-Complete the medical documentation, handle treatment failure if that happens, provide care coordination......

Pretty simple huh? How many people bill this one as a 99202???? I bet a ton of you do. But you will soon see that the cost of an audit is more than the extra few bucks you might get for jumping from a 1 to a 2.....

Want to Join our project? Email me at modifier25@gmail.com

OIG's work plan.

Have you ever wondered what Medicare was going to focus on and who medicare was going to focus on with their Auditing of Charts? Well know you can. Bookmark this site. This is the work plan for the office of Inspector General of the United States.

From the Site:

The OlG Work Plan sets forth various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The Work Plan includes projects planned in each of the Department's major entities: the Centers for Medicare & Medicaid Services; the public health agencies; and the Administrations for Children, Families, and Aging. Information is also provided on projects related to issues that cut across departmental programs, including State and local government use of Federal funds, as well as the functional areas of the Office of the Secretary. Some of the projects described in the Work Plan are statutorily required, such as the audit of the Department's financial statements, which is mandated by the Government Management Reform Act.

Here's the plan

• Place of Service Errors
  
• Evaluation and Management Services During Global Surgery Periods
  
• Medicare Practice Expenses Incurred by Selected Physician Specialties
  
• Services Performed by Clinical Social Workers
  
• Outpatient Physical Therapy Services Provided by Independent Therapists
• Medicare Payments for Colonoscopy Services
  
• Physicians’ Medicare Services Performed by Nonphysicians
  
• Appropriateness of Medicare Payments for Polysomnography
  
• Long-Distance Physician Claims Requiring a Face-to-Face Visit
• Geographic Areas With a High Density of Independent Diagnostic Testing Facilities
  
• Patterns Related to High Utilization of Ultrasound Services
• Medicare Payments for Chiropractic Services Billed With the Acute Treatment Modifier
  
• Physician Reassignment of Benefits
  
• Medicare Payments for Unlisted Procedure Codes
  
• Laboratory Test Unbundling by Clinical Laboratories
  
• Variation of Laboratory Pricing
  
• Clotting Factor Furnishing Fee
  
• Medicare Billings With Modifier GY
  

If you are doing any of these things or have any issues with this. Consider this blog post fair warning!

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!