Any tips to legally and easily bill Level 5?

[DrMDAware]

Any tips on how to legally and easily bill for a Level 5 for New and Established patients?

I imagine one could argue for “severe progression of a chronic disease” easily. That’s one category. We need to then look at the other two categories…

Category 1
I’m not sure if a simple ESI or MBB or whatever would count for a “major surgery” for the risk category. I’m also unsure if UDS would count for “invasive drug monitoring.”

Note: if it does then I can see how established patients getting a UDS or injection are seen as Level 5. If not then that leaves us with the next category.

Category 2
An easy way would be to send a note to the referring person or PCP and then interpret the MRI or X-ray.

But for “independent interrogation” of tests my interpretation that can only occur once. So it seems like it’s not difficult to get to Level 5 for a new patient. But what about Established patients?

I’m not looking to commit billing fraud. Just trying to figure out the shenanigans of billing. Thx

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[buddababa]

Level 5 is basically rare. Nothing we do warrants a level 5 unless you're in there for over an hour or they're in a fib with rvr and you're calling ems, etc

 

[RoloTomassi]

Either bill by time, and explain why it took so long, or higher complexity cases--SCS, kypho, stuff like that as long as you hit the criteria.

I don't think it's so much not being able to do it, but more doing it might draw attention to you and potentially trigger an audit.

 

[runfastnow]

Any tips on how to legally and easily bill for a Level 5 for New and Established patients?

I imagine one could argue for “severe progression of a chronic disease” easily. That’s one category. We need to then look at the other two categories…

Category 1
I’m not sure if a simple ESI or MBB or whatever would count for a “major surgery” for the risk category. I’m also unsure if UDS would count for “invasive drug monitoring.”

Note: if it does then I can see how established patients getting a UDS or injection are seen as Level 5. If not then that leaves us with the next category.

Category 2
An easy way would be to send a note to the referring person or PCP and then interpret the MRI or X-ray.

But for “independent interrogation” of tests my interpretation that can only occur once. So it seems like it’s not difficult to get to Level 5 for a new patient. But what about Established patients?

I’m not looking to commit billing fraud. Just trying to figure out the shenanigans of billing. Thx

It is maybe 1-2% of my billing? Which is in line with national averages per our EMR. Anything more than 5% would probably raise a few eyebrows unless you are in a cancer setting (or get a lot of referrals from oncology group).

Normally takes a combination of these things:
1. Concern for significant pathology: cauda equina, radic with severe weakness, cancer diagnosis on imaging (High Complexity) +
2. Independent review of imaging (Category 2/Moderate) AND discussion of case with surgeon (or other specialist) I am referring for further management (Category 3/High)
OR
3. 99215 - taking over 45 minutes to review data, speak with patient, write note. I maybe have two or three 99205 per year and basically people who walk in needing admission for cauda equina or undiagnosed obvious cancer.


From our EMR (ModMed):
"Category 3: Discussion of Management or Test Interpretation - Discussion of Management or Test Interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)"

Luckily by ortho surgeon partners are happy to answer phone or text in clinic and our primary neurosurgery team is the same. So if I have something that needs surgery I call/text conversation, document discussion, and can check off high complexity for the Data Review/Analyze section of the new billing rules.

Seems to be kosher by our internal billing people and per Zupko billing consulting service we used for education.

 

[DrMDAware]

Level 5 is basically rare. Nothing we do warrants a level 5 unless you're in there for over an hour or they're in a fib with rvr and you're calling ems, etc

I’d respectfully disagree. Maybe I am missing something, though. I could be wrong.

If the patient has the following don’t they get a level 5?
- severe progression of disease AND
- a note sent to the pcp AND images are interpreted

Maybe the severe progression of disease we don’t agree on?

 

[DrMDAware]

1. Concern for significant pathology: cauda equina, radic with severe weakness, cancer diagnosis on imaging (High Complexity) +

This is clear. Thank you. So severe progression is NOT “I can’t walk as far anymore” then.

It is maybe 1-2% of my billing? Which is in line with national averages per our EMR. Anything more than 5% would probably raise a few eyebrows unless you are in a cancer setting (or get a lot of referrals from oncology group)

These numbers are helpful. Thx.

2. Independent review of imaging (Category 2/Moderate) AND discussion of case with surgeon (or other specialist) I am referring for further management (Category 3/High)

I may have misinterpreted this one. So if I just give a heads up to the PCP as an FYI then it does NOT count, right?

 

[runfastnow]

This is clear. Thank you. So severe progression is NOT “I can’t walk as far anymore” then.


These numbers are helpful. Thx.


I may have misinterpreted this one. So if I just give a heads up to the PCP as an FYI then it does NOT count, right?

I've interpreted and been told by billing people that discussion requires direct communication beyond just letter. I doubt an audit would go after phone records but I only count if I text/call doc and document a little blurb about the conversation - I suppose that could be with PCP I just never communicate with them directly.

I do see some sports patients though and use this check box when I talk with their high school or college athletic trainer.

 

[callmeanesthesia]

Personally rarely bill level 5. Sometimes for the most complex and significantly disabled patients, generally with notes from multiple prior specialists, a few years of imaging results of multiple adjacent body parts, EMG results, and prior procedure records.
Usually if I bill a level 5 I’m sending them to the ER, and calling the ER to give report, or I found some other major pathology like cancer and I’m calling their PCP to punt further management.

 

[deleted875186]

In most visits I will check PMP, look at some sort of radiology image, look at PCP referral note, or do independent radiology interpretation. Would easily be a level 5, but You need to get to level 5 with also “number or complexity of medical problems” or “risks or complications of therapy”, which as alluded to above seems to be only appropriate for perhaps urgent surgical referral for weakness, cauda equine, admission for pain control, etc.

For me, I will typically bill a 99215 or 205 if I reach it based off time, which can be easily done if you count prep time and charting time and you write a good note.

 

[Ducttape]

you basically should never be billing level 5. it should never be in your thought process to bill a level 5.

if you get audited, the ones they will focus on your billing and determine if you are billing fraudulently will be the level 5s.

think of billing as a bell shaped curve. the majority should be level 3s, then next most likely is level 4s, then level 2s. you probably should have as many level 1s as level 5s - ie almost never.



you need to talk to a coder/biller. if you are in a hospital system, you can ask to talk to them about your coding and billing.


fwiw, ESI is not major surgery or even moderate surgery (unless there are confounders such as anticoagulation). UDS is not invasive diagnostic study.

if ESI is major surgery, what "level" is CABG/thoracic aneurysm repair? in one case, the procedure (not even a true surgery per surgeons) is done as an outpatient in 10-15 min and dont even need sedation. in the other cases, there is probably 8% risk of death and an expected ICU stay of days, if not weeks...

 

[drrosenrosen]

The last level 5 I billed, which was the first one in as long as I can remember, was a patient who came in drenched in sweat and twitching, and I was trying to decide if she was withdrawing from opioids (new pt, had stopped her opioids two days prior), or having an MI. When MA told me she had to stop in the hallway on the way to exam room due to SOB, I called EMS and sent her to the ER, where she was diagnosed with NSTEMI. 99205.

In contrast to ducttape, though, I don't bill majority level 3s, but majority level 4s. I think that, as specialist consultants, it is really easy for us to hit the mark for 99204 for initial consultations. Opioid follow ups are easy to hit 99214, and new complaint/worsening symptoms/new med or procedure discussion is easy to get to 99214 as well. 99213s for me are "oh, great, your ESI worked well? OK, well I'll see you again in 3 months"

 

[buddababa]

The last level 5 I billed, which was the first one in as long as I can remember, was a patient who came in drenched in sweat and twitching, and I was trying to decide if she was withdrawing from opioids (new pt, had stopped her opioids two days prior), or having an MI. When MA told me she had to stop in the hallway on the way to exam room due to SOB, I called EMS and sent her to the ER, where she was diagnosed with NSTEMI. 99205.

In contrast to ducttape, though, I don't bill majority level 3s, but majority level 4s. I think that, as specialist consultants, it is really easy for us to hit the mark for 99204 for initial consultations. Opioid follow ups are easy to hit 99214, and new complaint/worsening symptoms/new med or procedure discussion is easy to get to 99214 as well. 99213s for me are "oh, great, your ESI worked well? OK, well I'll see you again in 3 months"

agree with this.

 

[cowboydoc]

@Ducttape Your advice is a bit dated. They eliminated the 99201 as of 1/1/2021.

@drrosenrosen is spot on. You shouldn't be looking to bill an -05. Mindful documentation to justify more -04/-14 visits than level 3s is how the game is played.

 

[DODOCSS]

14 with spattering of 1/3, 15, lone commie would diggres

 

[Ducttape]

cant remember the last time i tried to bill 99201.

same as the last time i tried to bill a 99205.



edit - fwiw, i have changed with time on i approach patients. in patients in extremis, before i spend too much time with them, i think about early transfer to a different location where they can get more optimal care - ie ER or Onc office. likewise, for those who i would have previously debated appropriate opioid use, nowadays i just say that we wont see eye to eye, that i cant offer that treatment, they will have to continue to search for that magical prescriber and move on, rather than get in to a heated discussion with the recalcitrant soon-to-be former client.

 

[cowboydoc]

cant remember the last time i tried to bill 99201.

same as the last time i tried to bill a 99205.



edit - fwiw, i have changed with time on i approach patients. in patients in extremis, before i spend too much time with them, i think about early transfer to a different location where they can get more optimal care - ie ER or Onc office. likewise, for those who i would have previously debated appropriate opioid use, nowadays i just say that we wont see eye to eye, that i cant offer that treatment, they will have to continue to search for that magical prescriber and move on, rather than get in to a heated discussion with the recalcitrant soon-to-be former client.

Sounds like good social instincts.

 

[Orin]

Data collated from link:

https://www.cms.gov/files/document/cy-2020-evaluation-and-management-em-codes-specialty.pdf?agree=yes&next=Accept

2020 EVALUATION AND MANAGEMENT CODES BY SPECIALTY

		ALLOWED SERVICES	ALLOWED CHARGES	PAYMENT AMOUNT
99201	Interventional Pain Management	168	7,435	5,241	0.14%
99202	Interventional Pain Management	1,886	135,967	99,413	1.57%
99203	Interventional Pain Management	35,008	3,681,170	2,675,467	29.13%
99204	Interventional Pain Management	74,093	12,105,039	8,806,401	61.64%
99205	Interventional Pain Management	9,044	1,908,457	1,403,084	7.52%
99211	Interventional Pain Management	14,115	322,817	237,961	1.05%
99212	Interventional Pain Management	37,048	1,602,241	1,156,518	2.75%
99213	Interventional Pain Management	665,002	49,309,554	35,577,776	49.34%
99214	Interventional Pain Management	611,775	66,917,486	48,462,032	45.39%
99215	Interventional Pain Management	19,895	2,947,828	2,160,920	1.48%

 

[IAmTheOne1]

I probably bill about 2-3% of the time with a 99215 - this is for a patient that for example: I review the chart (5 mins) Just got new MRIs and going over the results with patient (5 min), wants to proceed with SCS and I spend 10 mins discussing it, physical exam (5 min), discussing with the rep and my auth people (5 mins) and another 10-15 mins for documentation (I really try to write good notes). So the only time I ever bill 99215 is off of time and I document the time as >40 mins and I specifically document what I spent time doing.

For new consults, I actually bill 99205 about 75% of the time if not more as I very often will spend 10 mins reviewing referral notes, imaging. 35-40 mins directly with the patient (I confirm everything they write on the new patient packet directly with the patient) and 15-20 mins writing the note. Some might say I'm wasting time or need to be more efficient etc - which I don't believe is the case. In my experience, when I spend a lot of time with the patient on the first visit they are more likely to have trust and proceed with procedures. As with follow-ups, I document time-based billing very explicitly at the bottom of every note.

 

[clubdeac]

I probably bill about 2-3% of the time with a 99215 - this is for a patient that for example: I review the chart (5 mins) Just got new MRIs and going over the results with patient (5 min), wants to proceed with SCS and I spend 10 mins discussing it, physical exam (5 min), discussing with the rep and my auth people (5 mins) and another 10-15 mins for documentation (I really try to write good notes). So the only time I ever bill 99215 is off of time and I document the time as >40 mins and I specifically document what I spent time doing.

For new consults, I actually bill 99205 about 75% of the time if not more as I very often will spend 10 mins reviewing referral notes, imaging. 35-40 mins directly with the patient (I confirm everything they write on the new patient packet directly with the patient) and 15-20 mins writing the note. Some might say I'm wasting time or need to be more efficient etc - which I don't believe is the case. In my experience, when I spend a lot of time with the patient on the first visit they are more likely to have trust and proceed with procedures. As with follow-ups, I document time-based billing very explicitly at the bottom of every note.

So if I'm understanding you correctly you spend about an hour total on each new patient? You must work at the VA or be salaried somewhere?

 

[MitchLevi]

For new consults, I actually bill 99205 about 75% of the time if not more as I very often will spend 10 mins reviewing referral notes, imaging. 35-40 mins directly with the patient (I confirm everything they write on the new patient packet directly with the patient) and 15-20 mins writing the note. Some might say I'm wasting time or need to be more efficient etc - which I don't believe is the case. In my experience, when I spend a lot of time with the patient on the first visit they are more likely to have trust and proceed with procedures. As with follow-ups, I document time-based billing very explicitly at the bottom of every note.

You're desperately inefficient if this is true, and your care isn't superior to your colleagues seeing 30 a day.

I don't mean that to be demeaning, so please don't take it that way.

Further, I'm not sure you can defend that time stamp by saying it took you 20 min to write a note. Not sure what could possibly take you 20 min TBH, and I've been told by multiple ppl that doesn't count towards time-based billing.

How long have you been in practice doing this?

I think I've had maybe 2 to 3 new visits at 99205 in 5 yrs. Virtually all new visits are 04 or 03. Same with 215 follow ups. I've prob had 3-4 in that time frame...Each of which was a work comp pt save one pt who was acutely suicidal 3 months ago.

 

[IAmTheOne1]

You're desperately inefficient if this is true, and your care isn't superior to your colleagues seeing 30 a day.

I don't mean that to be demeaning, so please don't take it that way.

Further, I'm not sure you can defend that time stamp by saying it took you 20 min to write a note. Not sure what could possibly take you 20 min TBH, and I've been told by multiple ppl that doesn't count towards time-based billing.

How long have you been in practice doing this?

I think I've had maybe 2 to 3 new visits at 99205 in 5 yrs. Virtually all new visits are 04 or 03. Same with 215 follow ups. I've prob had 3-4 in that time frame...Each of which was a work comp pt save one pt who was acutely suicidal 3 months ago.

Private practice.

Who are these people who told you documentation doesn’t count towards time-based billing?

I would say there are definite inefficiencies related to a very sub-par EMR that we have.

I’m not suggesting that my care is superior to those who are quicker. But I do find that spending more time on the first appt to build rapport goes a long way. I will often discuss some of their other non-pain related co-morbidities and give suggestions to follow up with their PCP or other specialists. I also spend a bit of time getting to know them as a person as well. I also don’t document in front of the patient during a consult, I try to have a conversation with them with eye contact.

I definitely realize this is far more than the vast majority of people spend. I’m sure someone will come on here bragging about how they see their consults in 7 minutes - I can do that too, I just prefer not to.

 

[RoloTomassi]

I've been told by multiple ppl that doesn't count towards time-based billing.

In the new guidelines, note writing definitely counts.

35-40 mins directly with the patient

That's learning their whole life story. But hey, your practice, your style.

 

[IAmTheOne1]

In the new guidelines, note writing definitely counts.

That's learning their whole life story. But hey, your practice, your style.

Exactly, again not suggesting this is the correct way, the better way, or that anyone else should be doing this.

 

[MitchLevi]

In the new guidelines, note writing definitely counts.

That's learning their whole life story. But hey, your practice, your style.

Time spent composing a note counts? The language always stated time was limited to "face to face time spent in direct patient care."

That changed?

Either way, my service couldn't survive if I didn't learn efficiency. Much more satisfying practice IMO

 

[Ducttape]

thats the language due to last year's changes. im a little suspicious of the typing of notes part, but the rest - reviewing charts (has to be the same day), reviewing images, contacting PCPs, communicating with others, etc.

 

[deleted875186]

thats the language due to last year's changes. im a little suspicious of the typing of notes part, but the rest - reviewing charts (has to be the same day), reviewing images, contacting PCPs, communicating with others, etc.

My understanding is time spent charting after the visit on the same day counts.

 

[RoloTomassi]

Time spent composing a note counts? The language always stated time was limited to "face to face time spent in direct patient care."

That changed?

Either way, my service couldn't survive if I didn't learn efficiency. Much more satisfying practice IMO

Yes, now it's:
preparing for the visit (such as reviewing tests); getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family, or caregiver; and care coordination

 

[bedrock]

sounds like someone missed their calling and should have gone into internal medicine.

 

[MitchLevi]

Yes, now it's:
preparing for the visit (such as reviewing tests); getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family, or caregiver; and care coordination

I'm glad they changed it.

Unfortunately that does nothing for me in 90% of encounters.

 

[Orin]

To be clear, time spent by any qualified healthcare professional on the day of the encounter counts.

This is one of those scenarios where if you had a CSW or an athletic trainer/dietician/etc on your staff, they could spend 15 minutes with each patient after you did your 10 minutes to get you to a 25 minute visit with minimal extra stress and likely better outcomes.

 

[powermd]

Yes, now it's:
preparing for the visit (such as reviewing tests); getting or reviewing a history that was separately obtained; performing the exam; counseling and providing education to the patient, family, or caregiver; ordering medicines, tests, or procedures; communicating with other healthcare professionals; documenting information in the medical record; interpreting results and sharing that information with the patient, family, or caregiver; and care coordination

Outstanding. I just created a macro based on this.

 

[clubdeac]

sounds like someone missed their calling and should have gone into internal medicine.

you mean psychiatry

 

[epidural man]

Personally, I feel all Chronic pain patients are Level 5. That is why most rotators can’t stand the field. They are a complicated group of patients.

 

[epidural man]

…., and your care isn't superior to your colleagues seeing 30 a day.

.

I disagree.

I mean I don’t know, but I bet it makes a difference.

 

[Agast]

 

[GlowInTheDark]

View attachment 358673

We really should be able to bill a combo of time and emotional damage suffered

 

[Ducttape]

View attachment 358673

by this measure, i got hit by a convoy yesterday.

 

[Welcome123]

Any tips on how to legally and easily bill for a Level 5 for New and Established patients?

I imagine one could argue for “severe progression of a chronic disease” easily. That’s one category. We need to then look at the other two categories…

Category 1
I’m not sure if a simple ESI or MBB or whatever would count for a “major surgery” for the risk category. I’m also unsure if UDS would count for “invasive drug monitoring.”

Note: if it does then I can see how established patients getting a UDS or injection are seen as Level 5. If not then that leaves us with the next category.

Category 2
An easy way would be to send a note to the referring person or PCP and then interpret the MRI or X-ray.

But for “independent interrogation” of tests my interpretation that can only occur once. So it seems like it’s not difficult to get to Level 5 for a new patient. But what about Established patients?

I’m not looking to commit billing fraud. Just trying to figure out the shenanigans of billing. Thx

Ordering a discogram would be a level 5

 

[Welcome123]

you basically should never be billing level 5. it should never be in your thought process to bill a level 5.

if you get audited, the ones they will focus on your billing and determine if you are billing fraudulently will be the level 5s.

think of billing as a bell shaped curve. the majority should be level 3s, then next most likely is level 4s, then level 2s. you probably should have as many level 1s as level 5s - ie almost never.



you need to talk to a coder/biller. if you are in a hospital system, you can ask to talk to them about your coding and billing.


fwiw, ESI is not major surgery or even moderate surgery (unless there are confounders such as anticoagulation). UDS is not invasive diagnostic study.

if ESI is major surgery, what "level" is CABG/thoracic aneurysm repair? in one case, the procedure (not even a true surgery per surgeons) is done as an outpatient in 10-15 min and dont even need sedation. in the other cases, there is probably 8% risk of death and an expected ICU stay of days, if not weeks...

Most physicians will not code correctly. The bulk of my follow ups are a level 4. For example.
2 stable problems on follow up (back pain, knee pain) + prescription med (gabapentin)= level 4
• 1 or more chronic illnesses with severe exacerbation,progression, or side effects of treatment; prescription medication + discogram= level 5
Billing these codes is not vague or ambiguous and can easily be confirmed on coding guidelines

https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf

 

[MD87]

What is everyone’s thoughts on “prescription” drug management with regards to Tylenol? Does telling someone to take 1g Tylenol TID, do not exceed 3g daily etc count? Technically, Tylenol can be prescribed but obviously is also available OTC.

 

[RoloTomassi]

What is everyone’s thoughts on “prescription” drug management with regards to Tylenol? Does telling someone to take 1g Tylenol TID, do not exceed 3g daily etc count? Technically, Tylenol can be prescribed but obviously is also available OTC.

I think it counts if your note states you actually prescribed/increased/decreased/stopped it. I always use generic name, e.g. prescribed naproxen 500 mg BID #30 sounds more legit than take a couple Aleve.

 

[Laryngospasm]

If you are managing the patients usage it counts. You can kill yourself with tylenol or ibuprofen.. this is valid medical advice and while common knowledge to many you may save someone elses life. Document it, count and dont feel bad about it. I cant count how many times someone has told me they are taking 1000mg ibuprofen 5x a day or 3 extra strength Tylenol 4 or 5 times per day.

 

[lobelsteve]

What is everyone’s thoughts on “prescription” drug management with regards to Tylenol? Does telling someone to take 1g Tylenol TID, do not exceed 3g daily etc count? Technically, Tylenol can be prescribed but obviously is also available OTC.

After 2 weeks risk goes up over 2400mg per day.
Limit to 1000mg bid if it works for them. I recommend Skittles, same clinical effect, taste better. But no antipyretic effect.

 

[MitchLevi]

The only role for Tylenol in my practice is that it occasionally decreases the amount of Motrin or Aleve they take. Agree with Steve on 1g BID.

 

[deleted875186]

The only role for Tylenol in my practice is that it occasionally decreases the amount of Motrin or Aleve they take. Agree with Steve on 1g BID.

I disagree. Tylenol is not helpful for younger patients, but I have a lot of older patients that tell me it’s helps.

 

[MD87]

After 2 weeks risk goes up over 2400mg per day.
Limit to 1000mg bid if it works for them. I recommend Skittles, same clinical effect, taste better. But no antipyretic effect.

Risk goes up by how much? Can you provide paper? Thanks.

 

[lobelsteve]

Paracetamol: not as safe as we thought? A systematic literature review of observational studies - PubMed

Given the observational nature of the data, channelling bias may have had an important impact. However, the dose-response seen for most endpoints suggests a considerable degree of paracetamol toxicity especially at the upper end of standard analgesic doses.

pubmed.ncbi.nlm.nih.gov

Start here. I can look to see where the 2400mg numbers come from tomorrow. It was in 2005-06.

 

[deleted875186]

Paracetamol: not as safe as we thought? A systematic literature review of observational studies - PubMed

Given the observational nature of the data, channelling bias may have had an important impact. However, the dose-response seen for most endpoints suggests a considerable degree of paracetamol toxicity especially at the upper end of standard analgesic doses.

pubmed.ncbi.nlm.nih.gov

Start here. I can look to see where the 2400mg numbers come from tomorrow. It was in 2005-06.

Excuse my ignorance, but what is the mechanism of GI bleed, cardiovascular event, or kidney injury with Tylenol, or is this just a meta analysis of a bunch of random observational studies?

 

[callmeanesthesia]

Excuse my ignorance, but what is the mechanism of GI bleed, cardiovascular event, or kidney injury with Tylenol, or is this just a meta analysis of a bunch of random observational studies?

Must be the patients who are alternating Tylenol and ibuprofen.

 

[MitchLevi]

I disagree. Tylenol is not helpful for younger patients, but I have a lot of older patients that tell me it’s helps.

Fair. I see it too, but the other 80% of elderly pts who use it say otherwise.