VA Hopeful Dr

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Not here. 99213 vs. 99214: Three tips for spotting the difference

A single acute (probably self-limited) problem with no lab review, imaging, or follow up just doesn't pass the smell test for 99214, regardless of prescription drug management, IMO.
I see that differently. New problem no work up and RX management hit the level 4 MDM.

If I'm prescribing antibiotics I clearly don't think it's self limited.
 
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I see that differently. New problem no work up and RX management hit the level 4 MDM.

If I'm prescribing antibiotics I clearly don't think it's self limited.

Our EHR will give me a 99214 for something like that based on my ROS and PE, but I'll manually downcode it to a 99213. My bell curve already skews waaaaaaay to the right, so I need to bill some 99213's just to keep the auditors off my ass. ;)
 

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Our EHR will give me a 99214 for something like that based on my ROS and PE, but I'll manually downcode it to a 99213. My bell curve already skews waaaaaaay to the right, so I need to bill some 99213's just to keep the auditors off my ass. ;)
Do you get those reports from insurers as well that you’re billing outside the average distribution for peers in your area? Lol.
 
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You suggest a level 2. If you were a doc that “fell under my review” (I’m the ‘lead’ at our office) I’d question your sanity. Please tell me you aren’t billing level 2s. Haha.

That would be akin to seeing you walk through the parking lot with a bad posture and I tell you to straighten up.
I’m billing 3’s. If you prescribe a medication that can’t be bought OTC, it’s a 3 (moderate). If u r taking care of 2+ chronic conditions, one requiring further management than refill (increase or decrease dose), plus follow up, etc then it’s a 4.

you should NOT be billing a 4 for a sinus infections esp since ~10 days is observation with symptomatic OTC tx and you can make an argument for an additional 10 days afterwards (I think this is the IDSA recommendations? Need to look it up again).
 
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Making 500+ K by seeing 45 patients a day is impossible unless ur doing a high volume, low accuracy medicine (crappy care that’s dangerous to patients) OR ur doing urgent care stuff and billing inappropriately (99214 for a sinus infection).
 
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1) Was testing done?
2) With a fever of 104 I’d argue unknown diagnosis with possible poor outcome leads to a 214 “seriousness.”
3) Were you paying out of pocket?

I always review my EOBs, but I never mind paying if there’s no concern. We all gotta eat.
As a resident I cared a lot more about the around $250 bill I had to pay. (It’s been over 3 years now so I can’t remember exact amount). If her normal pediatrician in the same health system had seen her it would have been billed a 99213 based on past experiences. That was the price after insurance (thankfully we have a much better insurance plan now!). The urgent care actually got in trouble for how many inappropriate 99214s they were doing. They tried to get all sinus infections and strep throats billed as those. And yes my kid’s fever I can see making it higher risk decision making.
 
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As a resident I cared a lot more about the around $250 bill I had to pay. (It’s been over 3 years now so I can’t remember exact amount). If her normal pediatrician in the same health system had seen her it would have been billed a 99213 based on past experiences. That was the price after insurance (thankfully we have a much better insurance plan now!). The urgent care actually got in trouble for how many inappropriate 99214s they were doing. They tried to get all sinus infections and strep throats billed as those. And yes my kid’s fever I can see making it higher risk decision making.
No the fever shouldn’t make it a higher risk. You can have a fever with a cold, strep, etc - it’s part of the picture. Three plus years ago, I think we were still using centor scores which listed fever as one of the metrics for scoring. The fever is part of the strep at that age. It was just BAD medicine and u had to unfortunately pay for that. That wasnt a high complexity case, 99214 case. Anyone who thinks it was doesn’t understand basic basic basic basic acute primary care medicine. This should have been a 99213. You got ripped off by someone who was doing bad medicine.
 

VA Hopeful Dr

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99214 isn't high complexity
No the fever shouldn’t make it a higher risk. You can have a fever with a cold, strep, etc - it’s part of the picture. Three plus years ago, I think we were still using centor scores which listed fever as one of the metrics for scoring. The fever is part of the strep at that age. It was just BAD medicine and u had to unfortunately pay for that. That wasnt a high complexity case, 99214 case. Anyone who thinks it was doesn’t understand basic basic basic basic acute primary care medicine. This should have been a 99213. You got ripped off by someone who was doing bad medicine.
 
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I’m billing 3’s. If you prescribe a medication that can’t be bought OTC, it’s a 3 (moderate). If u r taking care of 2+ chronic conditions, one requiring further management than refill (increase or decrease dose), plus follow up, etc then it’s a 4.

you should NOT be billing a 4 for a sinus infections esp since ~10 days is observation with symptomatic OTC tx and you can make an argument for an additional 10 days afterwards (I think this is the IDSA recommendations? Need to look it up again).

My dude/ dudette, you are literally leaving money/ RVU points on the table for no good reason except because of how it “feels” not and objectively at the way it is calculated. Could you argue that a strep throat left untreated could lead to endocarditis or Rheumatic fever? Reasonably yes. I’m not sure how you are calculating your MDM between problem/data/risk but take a look here:

 
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My dude/ dudette, you are literally leaving money/ RVU points on the table for no good reason except because of how it “feels” not and objectively at the way it is calculated. Could you argue that a strep throat left untreated could lead to endocarditis or Rheumatic fever? Reasonably yes. I’m not sure how you are calculating your MDM between problem/data/risk but take a look here:

I’m a dude. And yes, apparently this is why I’m not ballin

I’ve literally been billing 99213’s for these things based on it taking me 5 minutes (including the swab). I never actively think about a long term PSGN, sepsis, scarlet fever, endocarditis, myocarditis as complications because it’s engrained in my head and feels like “duh this can happen, let’s treat it”. I guess u guys r right, technically MDM supports 99214. Just feels strange my detailed MSK H&P with X-ray followed by diagnostic msk ultrasound with possible ultrasound guided injections Followed by a referral to PT and a 4-6 week follow up is equivalent coding to a strep throat (minus the additional billing codes for diagnostic US, etc).
 
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I’m a dude. And yes, apparently this is why I’m not ballin

I’ve literally been billing 99213’s for these things based on it taking me 5 minutes (including the swab). I never actively think about a long term PSGN, sepsis, scarlet fever, endocarditis, myocarditis as complications because it’s engrained in my head and feels like “duh this can happen, let’s treat it”. I guess u guys r right, technically MDM supports 99214. Just feels strange my detailed MSK H&P with X-ray followed by diagnostic msk ultrasound with possible ultrasound guided injections Followed by a referral to PT and a 4-6 week follow up is equivalent coding to a strep throat (minus the additional billing codes for diagnostic US, etc).

Coming from PM&R, your last sentence rings true. It's pretty much impossible for private practice outpatient PM&R physicians to be "ballers" practicing good medicine with how care is reimbursed. This is also why despite liking outpatient MSK the most, I don't currently practice in that setting/subfield.
 
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VA Hopeful Dr

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I’m a dude. And yes, apparently this is why I’m not ballin

I’ve literally been billing 99213’s for these things based on it taking me 5 minutes (including the swab). I never actively think about a long term PSGN, sepsis, scarlet fever, endocarditis, myocarditis as complications because it’s engrained in my head and feels like “duh this can happen, let’s treat it”. I guess u guys r right, technically MDM supports 99214. Just feels strange my detailed MSK H&P with X-ray followed by diagnostic msk ultrasound with possible ultrasound guided injections Followed by a referral to PT and a 4-6 week follow up is equivalent coding to a strep throat (minus the additional billing codes for diagnostic US, etc).
It is strange, but that's American medical billing for you.
 
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Coming from PM&R, your last sentence rings true. It's pretty much impossible for private practice outpatient PM&R physicians to be "ballers" practicing good medicine with how care is reimbursed. This is also why despite liking outpatient MSK the most, I don't currently practice in that setting/subfield.
That’s unfortunate to hear. This many years out of residency and I had no clue that this is why I didn’t see outpatient PM&R practices (I think amongst sports medicine, we all agree PM&R knows MSK better than any field with the exception of ortho). This whole billing system is just ridiculous.
 
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Eight of them though?

I have friends with that many. They're not unusually high earners, either. They're doing fine.

My friends with multiple exes, OTOH, bitch about money all the time. Most of them are high earners.

Part of it's probably lifestyle-related, granted. The guys with big families tend to live within their means. The multiply-divorced guys don't.
 
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Well if they were high earners, would the ex still get more than the eight kids?
Gotta compare apples to apples.

Dunno. The monetary stuff is anecdotal, to be sure, but there's nothing crazy about having a big family, assuming you can take care of them. You aren't obligated to buy every kid a car at 16, send them to private school, or pay their college tuition, nor should you sacrifice your retirement no matter how many kids you have.
 
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chocomorsel

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Dunno. Then monetary stuff is anecdotal, to be sure, but there's nothing crazy about having a big family, assuming you can take care of them. You aren't obligated to buy every kid a car at 16, send them to private school, or pay their college tuition, nor should you sacrifice your retirement no matter how many kids you have.
I am talking about what the judge is going to order you to pay for child support versus alimony. No one says you have to buy your wife extravagant crap either.
Ok. I think we both can agree that it highly unlikely for alimony to outweigh child support for eight children. Hell I don't think it should outweigh child support for even one child. I mean, who's more incapable of taking care of themselves. A grown woman/man or a child.
 
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I am talking about what the judge is going to order you to pay for child support versus alimony. No one says you have to buy your wife extravagant crap either.
Ok. I think we both can agree that it highly unlikely for alimony to outweigh child support for eight children. Hell I don't think it should outweigh child support for even one child. I mean, who's more incapable of taking care of themselves. A grown woman/man or a child.
Now you’re talking about someone getting divorced who also has lots of kids. I was speaking to the original comparison of multiple kids vs. multiple exes.
 

chocomorsel

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Now you’re talking about someone getting divorced who also has lots of kids. I was speaking to the original comparison of multiple kids vs. multiple exes.
Well then, clearly we are speaking two different languages. Since you addressed the poster who talked about eight kids and claimed they are cheaper than ex wives, I thought you were talking literally. The same scenario the he was talking of. If that man got divorced.
And to be a high income earner, get divorced and taken to the cleaners, be stupid enough to do it again, well that is on you. What is the upside of marriage in that situation? Why not just live in sin?
 
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Well then, clearly we are speaking two different languages. Since you addressed the poster who talked about eight kids and claimed they are cheaper than ex wives, I thought you were talking literally. The same scenario the he was talking of. If that man got divorced.
And to be a high income earner, get divorced and taken to the cleaners, be stupid enough to do it again, well that is on you. What is the upside of marriage in that situation? Why not just live in sin?
*** grabs popcorn ***
 

chocomorsel

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*** grabs popcorn ***
This must be a rather dull forum if this is all it takes for y'all to grab some popcorn.
You should come over to the anesthesia forum if you want to see some mudslinging. And I don't think the person I was addressing is in that repeatedly divorced situation. He/she was speaking of friends. But y'all would know better than me.
 
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Well then, clearly we are speaking two different languages. Since you addressed the poster who talked about eight kids and claimed they are cheaper than ex wives, I thought you were talking literally. The same scenario the he was talking of. If that man got divorced.
And to be a high income earner, get divorced and taken to the cleaners, be stupid enough to do it again, well that is on you. What is the upside of marriage in that situation? Why not just live in sin?

I'm going to assume that's a rhetorical question.
 
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It is strange, but that's American medical billing for you.

 

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