Billing a lot of level 4 visits

[bloxxeeey]

I want to say most of my patients tend to be level 4s. I see maybe 8 patients a day and spend around 45 minutes with each. I meet nearly all of them through the time criteria. Is this common in our field? I feel like I heard most of my attendings when training never bill level 4 visits so it worries me quite a bit. My patients tend to come in with multiple complaints and because of my schedule I spend the time with them to address most which can take quite a while.

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[Adam Smasher]

This does make you an outlier. I'm pretty sure you don't need to break down what you spend so much time on, but for an added layer of security, you can explain that the patient had a complex history requiring, for example, a 15 min conversation and then another 15 min to counsel them and coordinate care and another 15 min to document your findings. I do find I can work through multi-complaint new patient visits (say DM + mycosis + heel pain) in less time, but we all work at our own speed.

Is it 8 new patients per day or 8 total patients per day?

 

[Feli]

Is there a question here?
If you meet the criteria, you can bill it. It is clearly defined.
A guy doing many complex wounds on sicko pts might have mostly 4s while I with mostly single-issue sports/derm stuff have mainly 3s.
In the long run, you are asking for an audit due to anomaly vs peers.

I think you do realize the e/m definitions standards changed a few years ago. Know them well.

...you are brand new outta residency, but 45min/pt is completely terrible and not sustainable in the the long run. I don't care if these are wheelchair pts with bilat ulcers for which you do the wraps and nearly all of the work yourself. You need to improve efficiency greatly, but that does take time. Train your staff (sucks if you're employed as that training's not technically your responsibility... but your assists undertrained IS your problem).

You need to develop your styles and your scripts (which is why mentor is useful). Still, when somebody comes back for a single issue (maybe gout first MPJ) and you don't change tx or order dx for anything other issue (you just show them foot XR again and refill Rx colchicine and talk diet), that can't justify a 99214. Just because you take 30mins to explain crystals and what joint fluid is and what Altra shoes are doesn't make it a 99214. Review the criteria.

Regardless, with ultra-low volume, even a VA/IHS would make you work a bit more. In PP, you will starve. In hospital/org employ, you will be below your peers and put your job in jeopardy sooner or later. Nobody wants you seeing 10 or 12/day when peers see 20 or 30 or even much more. Get significantly quicker, even if it just means you play on web or with notes between visits until your next one shows up and until you get more onto the schedule. Learn to delegate anything reasonable to trained MAs and other staff. Look up 48 laws of power, esp #7 and #11.

...This stuff should've largely been learned in pod school and definitely in residency, but it is often not:
You can't be spending so much time in rooms; it is a bad habit. It is not a virtue to be slow; it is simply inefficient. A doc's time/advice is to be considered valuable... not easily accessible and eary to obtain. A visit means greet+create basic rapport, exam, dx, explain tx, maybe 1min for questions... get gone. It's fine to acknowledge the pt, but if they know all about you, you're doing it way wrong. You want to find the harmony between being efficient with dx/plan - but not sloppy or rude. It is a real skill to be both efficient and warm during the encounter. Having social skills and trained staff is key.

Make no mistake: there are NO bonus points for hand-holding. It's a bad habit to be Dr. Best Friend in 99% of situations; it actually slows your development and neuters your income and drops your perceived value to staff, patients, everyone. Most of the "really nice" docs/nurses/whatever are acting that way to make up for being borderline incompetent. The competent ones are respectful... but they have other work to do. It is a professional service. Think of the most respected and profitable doctors you know: people know better than to waste their time. Worst, if you waste too much time in rooms, those patients may expect that later when you are busier and truly don't have the time. There is nothing wrong with a quick bit of personal convo, but that is during the intro or wrap up; the visit has a problem/goal you want to knock out fast and well. Try doing your f/u visits scheduled back a bit shorter to fill the schedule if the office/clinic doesn't have enough visits/patients. Welcome to podiatry; there are a whole lot of us! 👍

 

[bloxxeeey]

Is there a question here?
If you meet the criteria, you can bill it. It is clearly defined.
A guy doing many complex wounds on sicko pts might have mostly 4s while I with mostly single-issue sports/derm stuff have mainly 3s.
In the long run, you are asking for an audit due to anomaly vs peers.

I think you do realize the e/m definitions standards changed a few years ago. Know them well.

...you are brand new outta residency, but 45min/pt is completely terrible and not sustainable in the the long run. I don't care if these are wheelchair pts with bilat ulcers for which you do the wraps and nearly all of the work yourself. You need to improve efficiency greatly, but that does take time. Train your staff (sucks if you're employed as that training's not technically your responsibility... but your assists undertrained IS your problem).

You need to develop your styles and your scripts (which is why mentor is useful). Still, when somebody comes back for a single issue (maybe gout first MPJ) and you don't change tx or order dx for anything other issue (you just show them foot XR again and refill Rx colchicine and talk diet), that can't justify a 99214. Just because you take 30mins to explain crystals and what joint fluid is and what Altra shoes are doesn't make it a 99214. Review the criteria.

Regardless, with ultra-low volume, even a VA/IHS would make you work a bit more. In PP, you will starve. In hospital/org employ, you will be below your peers and put your job in jeopardy sooner or later. Nobody wants you seeing 10 or 12/day when peers see 20 or 30 or even much more. Get significantly quicker, even if it just means you play on web or with notes between visits until your next one shows up and until you get more onto the schedule. Learn to delegate anything reasonable to trained MAs and other staff. Look up 48 laws of power, esp #7 and #11.

...This stuff should've largely been learned in pod school and definitely in residency, but it is often not:
You can't be spending so much time in rooms; it is a bad habit. It is not a virtue to be slow; it is simply inefficient. A doc's time/advice is to be considered valuable... not easily accessible and eary to obtain. A visit means greet+create basic rapport, exam, dx, explain tx, maybe 1min for questions... get gone. It's fine to acknowledge the pt, but if they know all about you, you're doing it way wrong. You want to find the harmony between being efficient with dx/plan - but not sloppy or rude. It is a real skill to be both efficient and warm during the encounter. Having social skills and trained staff is key.

Make no mistake: there are NO bonus points for hand-holding. It's a bad habit to be Dr. Best Friend in 99% of situations; it actually slows your development and neuters your income and drops your perceived value to staff, patients, everyone. Most of the "really nice" docs/nurses/whatever are acting that way to make up for being borderline incompetent. The competent ones are respectful... but they have other work to do. It is a professional service. Think of the most respected and profitable doctors you know: people know better than to waste their time. Worst, if you waste too much time in rooms, those patients may expect that later when you are busier and truly don't have the time. There is nothing wrong with a quick bit of personal convo, but that is during the intro or wrap up; the visit has a problem/goal you want to knock out fast and well. Try doing your f/u visits scheduled back a bit shorter to fill the schedule if the office/clinic doesn't have enough visits/patients. Welcome to podiatry; there are a whole lot of us! 👍

That's fair I'm seeing new patients which take me 45 minutes which puts it into a level 4. Most follow-ups I have been seeing (not as many as I'm only 3 months into practice), are 15 minutes and certainly not level 4s. Great advice though.

 

[Adam Smasher]

Most of the "really nice" docs/nurses/whatever are acting that way to make up for being borderline incompetent.

This reminds me of a medical school interview question I was asked a lifetime ago. "Would you rather have a doctor who was compassionate or one who was smart" and the gotcha answer they were looking for is "I want the compassionate doctor because that person can be trained to be smarter, whereas compassion cannot be taught to the smart doctor."

Of course being my autistic self, I answered that I didn't want either doctor, and flash forward now I grind toenails in exchange for money

 

[heybrother]

1. Do the right thing for people. Some people do need more time, but not everyone can have a lot of time.
2. Develop good habits. Use the time in your open schedule to work on coding, macros, order sets, reading.
3. Code appropriately, and then document appropriately to support it. Patchadamsfan said it really well (not a quote) - a visit isn't what you feel it is. Its what the coding guidelines state that it is.
4. Continue to work on relaying the right amount of information to the patient. How much information do you need to share about a therapy you aren't going to do. The answer is, it depends.
5. Billing on time should somewhat be a "consolation prize". Read the oncology forum. They are billing 3-4 99215s an hour on complexity.
6. Do not be afraid to tell a patient that they'll need to make a second appointment to discuss something. 5 trivial problems does not a 99215 make unless you hit time.
7. Sometimes the patient has a lot of problems, and sometimes the doctor gets to pick what problem gets addressed first.
8. We do stay in business though by offering more services. That's the nature of fee for service. So - if the patient who is there to discuss terbinafine also needs a subtalar joint injection - that's not necessarily bad business.

 

[Hybrocure]

How do you spend 45 mins with a standard podiatry patient? (Heel pain, nail fungus, etc). I can explain all the ins and outs and what to do in under 10 mins. I’d like to actually figure out how to extend that time; I honestly can handle most follow ups in under 5 minutes if I needed to. I’m not being facetious in asking that. Like are you doing full blown biomechanical exams and gait exams etc even if they’re there for an ingrown?

I’ve generally been of the mentality that time is precious not only to the doctors but to patients as well. For example, if I’m an inpatient in a hospital it makes more sense to want more face to face time with the doc. In an outpatient setting it’s more of an errand that needs to be ran in the mind of the patient as far as follow ups go.

Generally my time based level 4s tend to be chatters or random new patient trainwrecks

 

[Adam Smasher]

If Bloxxey does his own intake and is taking time to write really detailed notes, that ramps up the time. But Feli is right, this is very inefficient

 

[DYK343]

At 15 min I pretty much straight up walk out.
To be fair they get a 2 min warning.
I dont care about their grand daughters wedding. Or how great their bahama cruise was. Or about the new cat they adopted.
They get 15min and im onto the next. 99% of the time I know whats wrong in 2-3 min tops. Everything after that is me trying to be nice.

The #1 complaint is how long of a wait a patient has. Patients hate waiting.

 

[MicroPod]

I was spending 35-40 minutes per patient a couple of months ago (all new patients) but now I seem to be getting them done in about 20 minutes. Follow-ups are for the most part much quicker obviously. I need to train my MA to dress wounds and such still.

On a separate note (pun intended), my hospital recently rolled out using Dax (AI note writer in Epic). Really like it for new patients. Anyone else using AI for notes?

 

[DYK343]

I was spending 35-40 minutes per patient a couple of months ago (all new patients) but now I seem to be getting them done in about 20 minutes. Follow-ups are for the most part much quicker obviously. I need to train my MA to dress wounds and such still.

On a separate note (pun intended), my hospital recently rolled out using Dax (AI note writer in Epic). Really like it for new patients. Anyone else using AI for notes?

We were offered it but we have to pay for it. So far I dont think im busy enough to need it. With preset notes for bunion/hammertoe/plantar fasciitis/etc its about 45-60 seconds to write a note. Im not sure its necessary yet. I could see the benefit in some very high volume practices though. I kind of feel it would take just as long to review it as it would to dragon/type it.

 

[Feli]

...I’ve generally been of the mentality that time is precious not only to the doctors but to patients as well...

...The #1 complaint is how long of a wait a patient has. Patients hate waiting.

Yes, you have to run on time. That is always the top goal. If people wait too long, they are upset even if the visit is fairly good or fair priced. You sure don't create that on-time office with prolonged visits and spewing the textbook to every patient. I made that mistake a bit early (tried to over-educate every patient, present all treatment options). Hint: if you get "well, you're the doctor, you tell me what to do" more than once on a blue moon, then you are spending WAAAY too long. Figure it out. Shorten it up. Control the interaction.

I learned a bit of [good + effective] PP office in pod school, and I was fortunate to have a lot of rockstar PP attendings/owners/partners to learn from in my residency. Pgy1s did the resident clinic (fun and scientific and teaching-type, but a surgery-infused pod school clinic... understaffed and underbooked and MCA-heavy and just not real pod clinic).

For our pgy2 and pgy3s, it was semi-optional to do clinic as a after surgery. I went with my favorite ones pretty often, and it was well worth it. Many saw 40, 50, even 60+ visits daily in office and made very good income. They'd go in, greet, and get to business. Scripts are efficient. Effective handouts help. Good and competent staff running a system really, really helps. There was a bit of friendly chit-chat by the doc sometimes, but it was basically about giving the patient what they need and getting both pt and doc on with their day. The best advice I got was, "if they want to know more, they'll ask." This was from various different successful owner guys making $500k+ easily. My first two jobs out of residency were also with successful PPs that reinforced this even more. They worked hard, but they also worked very smart and ethically (though they shared knowledge, they shared little $$ with associates... never said they were StJude charity).

This is one of the big advantages of some pod schools over others imo: bigger cities, more arranged PPs, less students per clinic/patient.
Ditto for good residencies: it's more surgery, but it's also more good attendings and real PP offices to learn at. This is where most VAs and other pus bus residencies fail miserably.

If you want to really see max efficiency, think of a successful dental office with one or two DDS and maybe 6 or 8 or 10+ assistants. The doc(s) does quick exams, education as needed, and does the procedures. Assistants and support staff do most of the basic work. Doc does almost nothing that a lesser paid/skill employee could do. The people all get what they need, and revenue is high.

This reminds me of a medical school interview question I was asked a lifetime ago. "Would you rather have a doctor who was compassionate or one who was smart" and the gotcha answer they were looking for is "I want the compassionate doctor because that person can be trained to be smarter, whereas compassion cannot be taught to the smart doctor."

Of course being my autistic self, I answered that I didn't want either doctor, and flash forward now I grind toenails in exchange for money

Yeah, it's tale as old as time.
The majority of the hand-holding I see is at WCCs or nail farms (to make up for serial wound debrides and bandaging that are doing nothing ... and buttering pts up for HBO, which does nothing). For the nail jails, it is a way to glad hand the patients (because the service is nothing uncommon).

The basic visit construct of greet+create basic rapport, exam, dx, explain tx, maybe 1min for questions is always there.
The exam and dx and tx are the parts that must happen. It's a wasted visit otherwise. As we have a procedure-based specialty, there can usually be social convo (preferrably with doc during proced or with MA during rooming or wrap-up or DME), but it's quick and minimal... secondary to the real stuff the visit has to accomplish. I am always wary of health professionals who are more into the mushy social aspect than providing the service and efficiency.

 

[bloxxeeey]

If Bloxxey does his own intake and is taking time to write really detailed notes, that ramps up the time. But Feli is right, this is very inefficient

I'd say my other pod is non-surgical, he really only likes nails. I see more complicated stuff so my visits are as followed for example last Friday since I was off this week.

8 Patients
1: New Bilateral forefoot slam patient. Took a little while to discuss everything, procedures ex. Level4
2: New just recently diagnosed uncontrolled diabetic with neuropathy and leg wounds Level 4
3: New patient with wounds and gangrene. Needed revasc, vascular work-up. Level 4
4: New wound due to biomechanics abnormality. Had to modify his current orthotics. Level 4
5: New diabetic foot exam, patient had a skin graft that took but now has a contracture limiting his ankle ROM. Level 4
6.New diabetic foot exam with onycho. Level 3
7. New Patient needed ingrown toe nail removals bilateral with antibiotics due to the extent of cellulitis. Level 4
8. New patient needed ingrown toe nail removal and biopsy for a suspicious lesion. Level 4.

I don't know, what most of you would bill those as but I thought level 4 were justified for most.

 

[air bud]

Is there a question here?
If you meet the criteria, you can bill it. It is clearly defined.
A guy doing many complex wounds on sicko pts might have mostly 4s while I with mostly single-issue sports/derm stuff have mainly 3s.
In the long run, you are asking for an audit due to anomaly vs peers.

I think you do realize the e/m definitions standards changed a few years ago. Know them well.

...you are brand new outta residency, but 45min/pt is completely terrible and not sustainable in the the long run. I don't care if these are wheelchair pts with bilat ulcers for which you do the wraps and nearly all of the work yourself. You need to improve efficiency greatly, but that does take time. Train your staff (sucks if you're employed as that training's not technically your responsibility... but your assists undertrained IS your problem).

You need to develop your styles and your scripts (which is why mentor is useful). Still, when somebody comes back for a single issue (maybe gout first MPJ) and you don't change tx or order dx for anything other issue (you just show them foot XR again and refill Rx colchicine and talk diet), that can't justify a 99214. Just because you take 30mins to explain crystals and what joint fluid is and what Altra shoes are doesn't make it a 99214. Review the criteria.

Regardless, with ultra-low volume, even a VA/IHS would make you work a bit more. In PP, you will starve. In hospital/org employ, you will be below your peers and put your job in jeopardy sooner or later. Nobody wants you seeing 10 or 12/day when peers see 20 or 30 or even much more. Get significantly quicker, even if it just means you play on web or with notes between visits until your next one shows up and until you get more onto the schedule. Learn to delegate anything reasonable to trained MAs and other staff. Look up 48 laws of power, esp #7 and #11.

...This stuff should've largely been learned in pod school and definitely in residency, but it is often not:
You can't be spending so much time in rooms; it is a bad habit. It is not a virtue to be slow; it is simply inefficient. A doc's time/advice is to be considered valuable... not easily accessible and eary to obtain. A visit means greet+create basic rapport, exam, dx, explain tx, maybe 1min for questions... get gone. It's fine to acknowledge the pt, but if they know all about you, you're doing it way wrong. You want to find the harmony between being efficient with dx/plan - but not sloppy or rude. It is a real skill to be both efficient and warm during the encounter. Having social skills and trained staff is key.

Make no mistake: there are NO bonus points for hand-holding. It's a bad habit to be Dr. Best Friend in 99% of situations; it actually slows your development and neuters your income and drops your perceived value to staff, patients, everyone. Most of the "really nice" docs/nurses/whatever are acting that way to make up for being borderline incompetent. The competent ones are respectful... but they have other work to do. It is a professional service. Think of the most respected and profitable doctors you know: people know better than to waste their time. Worst, if you waste too much time in rooms, those patients may expect that later when you are busier and truly don't have the time. There is nothing wrong with a quick bit of personal convo, but that is during the intro or wrap up; the visit has a problem/goal you want to knock out fast and well. Try doing your f/u visits scheduled back a bit shorter to fill the schedule if the office/clinic doesn't have enough visits/patients. Welcome to podiatry; there are a whole lot of us! 👍

Sir, I have made a career of seeing 8 ish patients a day. And I have been handsomely rewarded....hell I am going to see zero patients over the 5 weeks and get paid 30,000 plus some quality metrics bonuses.

Don't give up on your dreams kids. I will eventually have to work...but that day is it today or tomorrow or even 8 or 10 weeks from now.

 

[air bud]

At 15 min I pretty much straight up walk out.
To be fair they get a 2 min warning.
I dont care about their grand daughters wedding. Or how great their bahama cruise was. Or about the new cat they adopted.
They get 15min and im onto the next. 99% of the time I know whats wrong in 2-3 min tops. Everything after that is me trying to be nice.

The #1 complaint is how long of a wait a patient has. Patients hate waiting.

Obviously you dont practice in a small enough town. You city doctors and your watches and schedules....round these parts the job is done when the job is done. Sometimes 3 in the afternoon sometimes 3 in the mornin.

 

[air bud]

We were offered it but we have to pay for it. So far I dont think im busy enough to need it. With preset notes for bunion/hammertoe/plantar fasciitis/etc its about 45-60 seconds to write a note. Im not sure its necessary yet. I could see the benefit in some very high volume practices though. I kind of feel it would take just as long to review it as it would to dragon/type it.

With dragon and phrases a PF note only takes that anyways.

 

[air bud]

Yes, you have to run on time. That is always the top goal. If people wait too long, they are upset even if the visit is fairly good or fair priced. You sure don't create that on-time office with prolonged visits and spewing the textbook to every patient. I made that mistake a bit early (tried to over-educate every patient, present all treatment options). Hint: if you get "well, you're the doctor, you tell me what to do" more than once on a blue moon, then you are spending WAAAY too long. Figure it out. Shorten it up. Control the interaction.

I learned a bit of [good + effective] PP office in pod school, and I was fortunate to have a lot of rockstar PP attendings/owners/partners to learn from in my residency. Pgy1s did the resident clinic (fun and scientific and teaching-type, but a surgery-infused pod school clinic... understaffed and underbooked and MCA-heavy and just not real pod clinic).

Dental assistants and hygienists get paid a crap load more than you are paying MAs...you get what you pay for. So comparing a well run pod practice to a dental practice doesn't really work.

For our pgy2 and pgy3s, it was semi-optional to do clinic as a after surgery. I went with my favorite ones pretty often, and it was well worth it. Many saw 40, 50, even 60+ visits daily in office and made very good income. They'd go in, greet, and get to business. Scripts are efficient. Effective handouts help. Good and competent staff running a system really, really helps. There was a bit of friendly chit-chat by the doc sometimes, but it was basically about giving the patient what they need and getting both pt and doc on with their day. The best advice I got was, "if they want to know more, they'll ask." This was from various different successful owner guys making $500k+ easily. My first two jobs out of residency were also with successful PPs that reinforced this even more. They worked hard, but they also worked very smart and ethically (though they shared knowledge, they shared little $$ with associates... never said they were StJude charity).

This is one of the big advantages of some pod schools over others imo: bigger cities, more arranged PPs, less students per clinic/patient.
Ditto for good residencies: it's more surgery, but it's also more good attendings and real PP offices to learn at. This is where most VAs and other pus bus residencies fail miserably.

If you want to really see max efficiency, think of a successful dental office with one or two DDS and maybe 6 or 8 or 10+ assistants. The doc(s) does quick exams, education as needed, and does the procedures. Assistants and support staff do most of the basic work. Doc does almost nothing that a lesser paid/skill employee could do. The people all get what they need, and revenue is high.


Yeah, it's tale as old as time.
The majority of the hand-holding I see is at WCCs or nail farms (to make up for serial wound debrides and bandaging that are doing nothing ... and buttering pts up for HBO, which does nothing). For the nail jails, it is a way to glad hand the patients (because the service is nothing uncommon).

The basic visit construct of greet+create basic rapport, exam, dx, explain tx, maybe 1min for questions is always there.
The exam and dx and tx are the parts that must happen. It's a wasted visit otherwise. As we have a procedure-based specialty, there can usually be social convo (preferrably with doc during proced or with MA during rooming or wrap-up or DME), but it's quick and minimal... secondary to the real stuff the visit has to accomplish. I am always wary of health professionals who are more into the mushy social aspect than providing the service and efficiency.

 

[heybrother]

I'd say my other pod is non-surgical, he really only likes nails. I see more complicated stuff so my visits are as followed for example last Friday since I was off this week.

8 Patients
1: New Bilateral forefoot slam patient. Took a little while to discuss everything, procedures ex. Level4
2: New just recently diagnosed uncontrolled diabetic with neuropathy and leg wounds Level 4
3: New patient with wounds and gangrene. Needed revasc, vascular work-up. Level 4
4: New wound due to biomechanics abnormality. Had to modify his current orthotics. Level 4
5: New diabetic foot exam, patient had a skin graft that took but now has a contracture limiting his ankle ROM. Level 4
6.New diabetic foot exam with onycho. Level 3
7. New Patient needed ingrown toe nail removals bilateral with antibiotics due to the extent of cellulitis. Level 4
8. New patient needed ingrown toe nail removal and biopsy for a suspicious lesion. Level 4.

I don't know, what most of you would bill those as but I thought level 4 were justified for most.

I know you already billed these on time, but I would encourage you to look at each visit on complexity and ask yourself - how would I write the note to support that these are level 4s even if they only take 15-20 minutes. In the future, that's the time you're going to have for many of them.

1. You have the surgery column but your note likely needs to spell out the exacerbation of the chronic condition and ideally it would be great to included chronic diagnoses. A bunion can be chronic ("after a year") but degenerative arthritis or rheumatoid arthritis is presumably chronic.
2. If you didn't prescribe something, then your note needs to justify what part of your management justifies this being a level 4. I don't think its unreasonable to call a discussion about wounds in an uncontrolled diabetic a 4, but you presumably aren't operating. Did you spell out their social determinants of health in the note?
4. What is the overlying chronic diagnosis leading to them forming a wound?
5. Are you going to operate?
7. You are not the only person on this forum billing ingrown toenails as 4 and I did not see the infection, but if an auditor was standing in front of you with the E&M table I think a lot of people would have trouble justifying their 4 coding for ingrown toenails.
8. I didn't say it for the others but I'm curious how your time based billing intersects with your procedures. I'm personally skeptical we're meant to include the time it takes to perform procedures within the time that's used for E&M visits. I don't currently have a resource for this.

 

[pod squad]

8. I didn't say it for the others but I'm curious how your time based billing intersects with your procedures. I'm personally skeptical we're meant to include the time it takes to perform procedures within the time that's used for E&M visits. I don't currently have a resource for this.

My understanding is that procedure time is not supposed to be included in E&M time calculations. The -25 modifier is supposed to be for a significant, separately identifiable issue. I think a strict biller would tell us that the 'workup' is included in the payment for the procedure code. This is especially true for follow up E&Ms (even more so for RFC). New patients, I think it's definitely more justifiable to bill E&M + procedure code. If you have an established patient that presents with an ingrown nail without infection, no abx required, that should probably just be the 11730/50 if you're going by the book.

Here's a reference article from the AMA (not from the APMA so you know it's legit 😉
www.ama-assn.org/system/files/regulatory-myths-doc-coding-em.pdf

 

[GreenHousePub]

4,5,7,8 most likely would be level 3s.

Probably would trigger an audit. None of these patients should take longer than 10 minutes.

Schedule all 8 patients in the first two hours and go home early.

 

[Feli]

I'd say my other pod is non-surgical, he really only likes nails. I see more complicated stuff so my visits are as followed for example last Friday since I was off this week.

8 Patients
1: New Bilateral forefoot slam patient. Took a little while to discuss everything, procedures ex. Level4
2: New just recently diagnosed uncontrolled diabetic with neuropathy and leg wounds Level 4
3: New patient with wounds and gangrene. Needed revasc, vascular work-up. Level 4
4: New wound due to biomechanics abnormality. Had to modify his current orthotics. Level 4
5: New diabetic foot exam, patient had a skin graft that took but now has a contracture limiting his ankle ROM. Level 4
6.New diabetic foot exam with onycho. Level 3
7. New Patient needed ingrown toe nail removals bilateral with antibiotics due to the extent of cellulitis. Level 4
8. New patient needed ingrown toe nail removal and biopsy for a suspicious lesion. Level 4.

I don't know, what most of you would bill those as but I thought level 4 were justified for most.

@GreenHousePub is correct above... the #1 pt is also almost certainly not a 99204 imo.

pt1 is just one issue (forefoot deformity of bunion/hammertoes/meta). All you do new visit is order and/or discuss XR, give pads, re-appoint, document conservative care now and in past. If they are someone else's long term post op that is stable, definitely not a lvl 4 for simply pads or XR or orthotics. PS, don't do bilat elective surgery (do one side, let it fully heal, then the other). PPS, don't board surgery first visit unless it's trauma or infection stuff... boarding elective first visit looks terrible for ABFAS, for malpractice, you don't get to know pt (crazy? follows recs? compliant?), and you are flushing money and pt trust away also.
2 is a level 4, sure.
3 is level 4, sure
4 is level 3 barring something crazy time-consuming (bunch of old surgery and imaging, PMH stuff, etc).
5 is level 4, maybe... did you make a significant plan for contracture?
6 is level 3, as you said.. possibly level 4 if XR deformity or Rx shoes or something
7 is absolutely level 3 (cellulitis). Nail procedure doesn't justify time, and you knew you needed procedure and abx about 15 seconds into your exam, ya? Shocker: 11730/50 visits are highly scrutinized/audited by payers (because they are high fraud rates by DPMs!). Even if ingrown pt were ESRD DM wheelchair or something, very unlikely to justify 99204 without serious other stuff (labs? XR? admit? Rx shoes?). As said, don't count procedure time in ANY setting - or XR/ultra time if they're done in office (otherwise nearly any proced besides injects on f/u pts would be lvl 4).
8 absolutely level 3 (it's just one issue, one complaint... and fyi, do one procedure at new visit and the other at f/u).

Be really careful trying to consider procedure pts as automatically being higher level e/m since you're in room awhile...
The procedure pts are typically NOT high level; most were just quick easy decision to do the procedure (or DME or imaging). The true higher level e/m are more often NOT procedure pts... just interpreting imaging, labs, Rx meds or PT or DME or whatever, make decisions based on Rx/PT/rad/lab/DME etc results, extended HPI or plan, much past records to review, admit pt or send to ER, just out of hospital, planning + edu for surgery, etc. Again, read e/m guidelines. But yeah, you occasionally have both (high level issues/decisions... plus wound debride or inject or DME or wrap or etc).

From AMA (and 100 other sources):
"Do not count time spent on the following:
• Performance of other services that are reported separately ..." (procedures are obviously reported separately, XR and u/s and DME are also if your office has them)

...This is really too bad you didn't glean most of this stuff in school, in residency, or from your current PP owner. At least you are asking and not "teaching" like PodiatryCrazy does, lol. Learn it soon, and start getting faster. You can bill on time with 8pts/day if you like and say you spend a ton of time with pts and/or notes, but that still makes you an outlier to peer docs in the area. You should soon have 15-20+ per day where that's basically impossible to have any more than the occasional 50min new pt or 35min f/u pt.

.... a visit isn't what you feel it is. Its what the coding guidelines state that it is. ...

^^^Precisely.

 

[Adam Smasher]

I'd say my other pod is non-surgical, he really only likes nails. I see more complicated stuff so my visits are as followed for example last Friday since I was off this week.

8 Patients
1: New Bilateral forefoot slam patient. Took a little while to discuss everything, procedures ex. Level4
2: New just recently diagnosed uncontrolled diabetic with neuropathy and leg wounds Level 4
3: New patient with wounds and gangrene. Needed revasc, vascular work-up. Level 4
4: New wound due to biomechanics abnormality. Had to modify his current orthotics. Level 4
5: New diabetic foot exam, patient had a skin graft that took but now has a contracture limiting his ankle ROM. Level 4
6.New diabetic foot exam with onycho. Level 3
7. New Patient needed ingrown toe nail removals bilateral with antibiotics due to the extent of cellulitis. Level 4
8. New patient needed ingrown toe nail removal and biopsy for a suspicious lesion. Level 4.

I don't know, what most of you would bill those as but I thought level 4 were justified for most.

A lot of this should take less than 45 min. Modifying orthotics only feels like it takes 45min, normally it's a 10 min job. And maybe you know this already, but just because you spend 45 min taking out the ingrown doesn't mean you can bill for 45min worth of e/m time. The time you spend on the procedure doesn’t count.

If you're going to spend 45 min just counseling and advising these patients, might as well make it a full 60 min so they can get CME credit for your lecture 😉

 

[Ruralpod]

Oh, it has been some time since posting on SDN, but hey, why not try to keep these old things called forums alive

I'm hospital based so take it for what it's worth. I find that it is MUCH easier to reach level 4s since the E/M changes a few years ago now. Typically, I find my old level 3 is now a level 4.

Each visit you must think of what level of complexity it meets and go from there.

Procedure times can NOT be added into an E/M time, this includes associated workup/discussion for said procedure. If you are hospital based, an established level 5 (40 minutes or more) is worth more than an new level 4 (45 minutes or more) from an RVU perspective

8 Patients
1: New Bilateral forefoot slam patient. Took a little while to discuss everything, procedures ex. Level4
2: New just recently diagnosed uncontrolled diabetic with neuropathy and leg wounds Level 4
3: New patient with wounds and gangrene. Needed revasc, vascular work-up. Level 4
4: New wound due to biomechanics abnormality. Had to modify his current orthotics. Level 4
5: New diabetic foot exam, patient had a skin graft that took but now has a contracture limiting his ankle ROM. Level 4
6.New diabetic foot exam with onycho. Level 3
7. New Patient needed ingrown toe nail removals bilateral with antibiotics due to the extent of cellulitis. Level 4
8. New patient needed ingrown toe nail removal and biopsy for a suspicious lesion. Level 4.

This is my line of reasoning on each but without more information for each, we are all just speculating
1. independent eval of XR and decision for major surgical intervention. Also, these patients should be stating problems for greater than 1 year with bunion, hammertoe and then worsening if you are taking them to surgery, indicating chronic issue with progression - level 4 all day
2. you could say acute injury with leg wounds complicated by DM and neuropathy but I would find that to be a stretch. I would likely do a level 3 unless patient reports chronic (greater than 1 year) neuropathy symptoms and worsening. Then you would either need to have medication management with gabapentin or identify labs/notes 3 or more. Not hard if you think PCP if they referred, endocrine, and a Ha1C or CMP or BMP if you are going to prescribe meds
3. acute new issue with with uncertain prognosis as you will not know level of amp from gangrene pending workup. You still need to then either discuss with another provider which can be easier for some compared to others depending on your work setup, or I would have an XR review with independent eval on this to ensure no gas proximal, level 4 all day long. If you send to hospital, then level 5 as gangrene poses threat to bodily function with proximal amp and decision regarding hospitalization
4. level 3 unless you got updated xrays and independent review, discussed major surgery for off loading wound
5. I don't know about you, but my diabetic foot exam is pretty standard foot exam unless I am pulling out a monofilament for whatever odd reason. You should be able to take 2 seconds to tell if a diabetic has a potential high risk foot. If they came in for a diabetic foot exam and you noted on exam decreased ROM and graft, these are incidental findings from your physical exam (you don't get points for PE), not a patient concern, so do not count for E/M points unless patient brings up issues with them
6. onycho - if patient states it is greater than 1 year and worsening or more toes affected, this would be chronic issue with progression and then med management, making this a level 4. If they state it was there 2 months, 8 months or less - level 3, just how it goes with E/M criteria
7. As commented above, grey area with this. Abx alone is not a level 4, if you are reviewing other issues, labs, etc. it may reach to a level 4 vs a level 3
8. All procedures have an inherent E/M component worked into them, whether we like it or not. From above, level 3 and then whatever procedure code for ingrown and biopsy. Strict billers may even say no E/M at all if you doing a biopsy and a ingrown code already

By no means am I a billing guru. I just work a lot

 

[HardRoadPaved]

6. onycho - if patient states it is greater than 1 year and worsening or more toes affected, this would be chronic issue with progression and then med management, making this a level 4. If they state it was there 2 months, 8 months or less - level 3, just how it goes with E/M criteria

I'm sure the insurance company is gonna love seeing b35.1 next to 99204.

 

[Ruralpod]

I'm sure the insurance company is gonna love seeing b35.1 next to 99204.

They should take it up with AMA and CMS. We win some, we lose some with criteria. Regardless, it is there and we need to follow it. You either meet criteria or not for levels of visits. I don't see anywhere where certain ICD codes are excluded?

 

[Adam Smasher]

A note on chronic problems. Either it's gone on for a year OR you expect it to last longer than a year. So if a bunion has been aching for 6 months it's probably still going to be achy next summer, and it still counts as chronic. Tinea pedis is cited as a specific example of a self-limiting problem.

Here's your Level 4 dermatophytosis visit:
-Order pas, pcr, plus hepatic panel
-prescribe terbinafine/jublia.

(No I don't do that really, at least one of you is going to take me literally)

 

[Adam Smasher]

Another random thought:
Sometimes it's not worth the time you spend embellishing your chart for some of these patients. In the example of the gangrene toe, yeah it's a no brainer level 4. You know at a glance. Exacerbation of chronic problem + decision for surgery/hospitalization.

In the diabetic with the contracted ankle, however, it depends on your decision making, but I'm probably managing it conservatively. I'm sure I could get away with embellishing the note to upcode the encounter, but that gets me an extra $30-50 from the fee schedules I'm on. May as well pick up another nailcare visit. Lobsters know not to swim up for food when there's plenty to feed off the bottom.

 

[MicroPod]

Does the time an MA/nurse spend going over meds, history and getting vitals count towards the time and/or complexity of the visit?

 

[Adam Smasher]

Does the time an MA/nurse spend going over meds, history and getting vitals count towards the time and/or complexity of the visit?

Nope, gotta be a QHP "qualified health professional"

 

[msion]

I will say a level 4 is deserved where it's deserved. Don't complicate things. Level 4 visits means level 4 in either diagnoses, data, or risks. Those three components contribute to the overall medical decision making and hopefully together they land in the Moderate category to quality for a level 4.

Diagnoses: I gave up on the diagnoses part. Lots of podiatry problems just won't qualify, and spending the time figuring out how many problem, chronic vs. acute, acute on chronic, long-term management is just too much for me.

Data: A bit easier to understand. Review notes, labs, x-rays/MRI. Order new labs/imaging. Referral to other services. Discuss treatment. Meeting least 1 out of the 3 categories shouldn't be too hard, unless you are doing nails all day.

Risks: Lately the social determinants of health have been a big one to boost this category. Majority of my diabetic ulcer (or podiatry in general) patients will have some of these issues. Use the Z-codes. Build a good template. I attached this one from CMS and I have been using and documenting these Z codes.

 

[Feli]

They should take it up with AMA and CMS. We win some, we lose some with criteria. Regardless, it is there and we need to follow it. You either meet criteria or not for levels of visits. I don't see anywhere where certain ICD codes are excluded?

It's not that it is excluded, but certain ICD and CPTs get hit really hard and trigger audits (11730 and wound "grafts" right now for MCR, for example). You can thank colleagues for that.

If you're hospital-based, it's not really your problem. For most DPMs (like the OP), it's wise not to hit too hard on the buttons that are already half-broken. We are using a limited playbook, and it's just not hard to find patterns and crack down on them.

Does the time an MA/nurse spend going over meds, history and getting vitals count towards the time and/or complexity of the visit?

Man, that'd be the dream. Lol

 

[podwho]

I would download the AMA guidelines for coding and read it carefully. If you meet the criteria then bill it. If your seeing 90% level 4 thats OKAY. Very uncommon in podiatry but theres no real problem if its legit.

Will you increase your chance of being audited? YES. If its legit then you will pass. Who cares. If you are not sure then be cautious and do level 3. There are other procedures/codes you would obv be billing in your example that will pay you well and cover the 30$ difference from medicare, or god forbid a trash uhc contract of 10$.

Also time to preform any procedure doesn't count towards your e/m billing time. infected ingrown nails are not level 4 in healthy pts basically ever.

Heres some free data - podiatry on avg - 20-25% level 4. You can adjust based on your patient population and region. National avg is 40-45% level 4 for all doctors.

 

[deleted1162946]

I’m a new attending. Starting to see 20+ a couple months in. I get in and get out. Can’t imagine spending 45 mins on a patient. I’ll probably get up to 40 patients or so a day and that would be impossible. I bill mainly level 3’s. Have done maybe one or two four’s so far. One 5 that I sent to the hospital. On my nail avulsion follow ups I do 2’s, but I’m sure that can be a 3

 

[Feli]

I’m a new attending. Starting to see 20+ a couple months in. I get in and get out. Can’t imagine spending 45 mins on a patient. I’ll probably get up to 40 patients or so a day and that would be impossible. I bill mainly level 3’s. Have done maybe one or two four’s so far. One 5 that I sent to the hospital. On my nail avulsion follow ups I do 2’s, but I’m sure that can be a 3

You will do fine with mostly level 3s AND a lot of procedures.... and DME/otc if you get credit for those. That is really where you should be in most PP/collections setups... people come in with typically single issue/injury and you fix it fast, prn them fairly quick to make room for more. In non-hospital/wound DPM setups, the trying to do more typing and templating for questionable 4s is typically better spent just seeing more and doing more procedures (and XR and u/s and basic vasc tests your office may have as appropriate).

Nothing wrong with rare level 2s (easy f/u that is all better... or even new pt that basically has straightforward dx that wants no tx and basically nothing wrong - or pt who came to wrong type of doc with knee pain, varicose, various out of scope complaint, etc). Similarly, you can do procedure CPT only for f/u for verruca, wounds, RFC, etc where there is no status or plan change whatsoever... skip e/m there, at least sometimes.

Try less nail avulsions and more matrix... with 97597 when appropriate on matrix f/u visits (minority of them, but still sometimes legit and needed). For nail proced f/u, I often do 99212 if healed well and prn them, or 99213 if I need abx or some other complaint/edu. -730 avulsions are really only for PVD folks or kids or ppl who've had nail injury or some first-time ingrown that may have just minor injured or cut it wrong. If they have bona fide ingrown with any hx ingrown or any type of thick/curved/wide nail, they are usually better served -750 matrix imo and exp.

You could probably do more level 4 for pts with multiple issues (usually 3+ complaints you do more than lip service to), visits with appropriate CPT quals of the more complicated workup (order/discuss rad if you don't have it in office, order/discuss adv imaging, order/discuss labs, Rx DME not in office, order PT/refer/etc), visits for ppl with decision for surgery, etc... but you'll get the hang of it if you read the CPT and AMA stuff. I did the same thing: under-coding out of training for a year or two until I got the hang of it (but e/m definitions were also different back then where 4s were harder and 5s were basically impossible for podiatry). It helps to make your templates geared to hit quals, esp if you are going to do more 4s than peers (but again, you'd honestly rather just see more pts and do more proc/DME, for PP type).

...For most podiatry, you basically want a bell curve of sorts (adjusted for your pt mix complexity):
~5% level 2
~55% level 3
~40% level 4
<1% level 5

 

[deleted1162946]

...For most podiatry, you basically want a bell curve of sorts (adjusted for your pt mix complexity):
~5% level 2
~55% level 3
~40% level 4
<1% level 5

I’m under billing by far then.

 

[deleted1162946]

If you guys have a patient with let’s say a trauma induced nail issue. Maybe it’s barely hanging on. You use no local anesthetic and rip it off with a hemostat… are you billing for a total nail avulsion & office visit or just an office visit?

 

[Homo sapien]

If you guys have a patient with let’s say a trauma induced nail issue. Maybe it’s barely hanging on. You use no local anesthetic and rip it off with a hemostat… are you billing for a total nail avulsion & office visit or just an office visit?

Office visit. You didn't do a whole procedure

 

[Homo sapien]

Office visit. You didn't do a whole procedure

If I yoink it like that I just wrap it up and tell them to go. Now if there's nail bed lacerations or something I bill that, still not full nail procedure. I don't bill the full Monty unless I do the full Monty

 

[heybrother]

If you guys have a patient with let’s say a trauma induced nail issue. Maybe it’s barely hanging on. You use no local anesthetic and rip it off with a hemostat… are you billing for a total nail avulsion & office visit or just an office visit?

Insert meme - "NO MERCY".

The Washingtonpost had a KFF article about hospital employed physicians billing varieties of excision/incision type codes for procedures that questionably hit code definition. Patients seeing facility physicians were getting 10120s and such to the tune of hundreds of dollars for pulling superficial splinters out of fingers with a small forcep without numbing. The code description says "INCISION" but the hospitals were telling patients who argued and fought back that "you can make an incision with forceps".

 

[Homo sapien]

Insert meme - "NO MERCY".

The Washingtonpost had a KFF article about hospital employed physicians billing varieties of excision/incision type codes for procedures that questionably hit code definition. Patients seeing facility physicians were getting 10120s and such to the tune of hundreds of dollars for pulling superficial splinters out of fingers with a small forcep without numbing. The code description says "INCISION" but the hospitals were telling patients who argued and fought back that "you can make an incision with forceps".

That's so juvenile.

Maybe call me a bitch but I don't love money so much that I'd be doing that

 

[heybrother]

That's so juvenile.

Maybe call me a bitch but I don't love money so much that I'd be doing that

The harder people hit the codes the more the value will fall. I've told this story before, but one of the APMA coding guys presented that podiatrists were using a shave lesion (a biopsy code) code on calluses. Whoever thought of it shared it and then podiatrists hit it hundreds or thousands of times and it got so much use it showed up on CMS radar and caused a dermatology freak-out because "its their code". When the CPT is submitted it also shows what diagnosis code it was tagged two and this was supposed to presumably tag to skin cancer or real pathology, not L84.

 

[MicroPod]

On my dermatology rotation as a resident, I felt like sometimes the attending would just pick a few random spots and biopsy them knowing full well they were benign as benign can get lol.

 

[Feli]

If you guys have a patient with let’s say a trauma induced nail issue. Maybe it’s barely hanging on. You use no local anesthetic and rip it off with a hemostat… are you billing for a total nail avulsion & office visit or just an office visit?

I would go the other way and say 11730 + e/m absolutely. It doesn't matter if the nail you avulse is 100% or 80 or 50 or 10% attached. If it was so easy, the patient would have done it themself. There is also nowhere that says this code requires anesthesia, and if you do a procedure, then you should code for it... and hopefully get paid for it.

If there is significant nail bed wound you debride and cleanse, you could also bill a wound debride code instead (but either that or avulsion of nail, whichever is more appropriate... not both). If it's a digit fracture with the nail injury, you can bill the 28490 or etc as appropriate (will create a 90d global).

If you just trim a toenail with onycholysis, then no, that's obviously not an avulsion (sorry to the toolboxes who bill 11721+11730+11755 for trimming nails and sending a few clips to the "path lab" their group owns).

...One thing I will say is that it's not noble or wise to not bill what you do. It's masochism. Dont do it.
This is a bigtime new grad mistake. It's very common... part ignorance and part fear. Correct it asap.
(and yes, I made this mistake early in my career... undercoding, being "nice," doing no charge visits if minor f/u or pain had resolved and prn them, etc... it took a few bosses calling me out on it and me wising up over yeeeears to get better. I wish I'd have learned sooner!)

This is podiatry. Our codes are already reimbursed pretty low. Our RVU pays for hospital pods are low relative to any other surgeons.
This is a business. Our education is expensive. Our ROI is very bad on average. This is not Jerry's Kids telethon. Treat all comers about the same.
There is nothing wrong with getting paid for what you do. Code it correctly. If you are not sure, simply read the code books.
If you think you are "giving" to the patients, you are actually then stealing from your group, boss, yourself, facility, etc. Don't do that. It's fine to be kind if you are an owner/partner (give free OTC or forgive/reduce a balance for ppl who are obviously truly struggling), but don't be a doormat overall... don't be scared to code what you reasonably do and code what people needed. You are not some saint. You have no idea who goes to Hawaii 3x per year or has 30mil in accounts... yet same people might complain of their $15 coinsurance on callus care or the $5 bunion pad. No idea.

Here's a mind blower: you already do take literal zeroes on some visits, some patients don't pay their bill, some patients give fake or expired insurance, and you're paid very low on MCA etc. It is a personal call to charge less/no codes on complications that are not normal after a surgery. Regardless, any of those are actually negatives for the encounter when you count your $0 gained yet staff/supplies/time. That is your "charity" if you want to look at it that way... and you are doing that "giving" whether you want to or not. This is not 2nd grade where we still believe in weakness being kind and poverty being virtuous and heaven being real, is it? If it is still 2nd grade, then the "noble" pods not coding what they do and playing favorites would go to hell for stealing from the office/hospital. And fyi, even if you do tithe or like to give or do that stuff, you can do it MUCH better once you're out of debt. 🙂

Of note: For procedures that might normally use local anesthesia where you just use nothing or proximal cryo spray or whatever (maybe biopsy, ingrown, FB, aspirate ganglion, flexor, etc), simply add or edit your template a bit to say "anesthesia was not necessary due to neuropathy/nature of the injury/pt request/etc."

 

[deleted1162946]

I would go the other way and say 11730 + e/m absolutely. It doesn't matter if the nail you avulse is 100% or 80 or 50 or 10% attached. If it was so easy, the patient would have done it themself. There is also nowhere that says this code requires anesthesia, and if you do a procedure, then you should code for it... and hopefully get paid for it.

If there is significant nail bed wound you debride and cleanse, you could also bill a wound debride code instead (but either that or avulsion of nail, whichever is more appropriate... not both). If it's a digit fracture with the nail injury, you can bill the 28490 or etc as appropriate (will create a 90d global).

If you just trim a toenail with onycholysis, then no, that's obviously not an avulsion (sorry to the toolboxes who bill 11721+11730+11755 for trimming nails and sending a few clips to the "path lab" their group owns).

...One thing I will say is that it's not noble or wise to not bill what you do. It's masochism. Dont do it.
This is a bigtime new grad mistake. It's very common... part ignorance and part fear. Correct it asap.
(and yes, I made this mistake early in my career... undercoding, being "nice," doing no charge visits if minor f/u or pain had resolved and prn them, etc... it took a few bosses calling me out on it and me wising up over yeeeears to get better. I wish I'd have learned sooner!)

This is podiatry. Our codes are already reimbursed pretty low. Our RVU pays for hospital pods are low relative to any other surgeons.
This is a business. Our education is expensive. Our ROI is very bad on average. This is not Jerry's Kids telethon. Treat all comers about the same.
There is nothing wrong with getting paid for what you do. Code it correctly. If you are not sure, simply read the code books.
If you think you are "giving" to the patients, you are actually then stealing from your group, boss, yourself, facility, etc. Don't do that. It's fine to be kind if you are an owner/partner (give free OTC or forgive/reduce a balance for ppl who are obviously truly struggling), but don't be a doormat overall... don't be scared to code what you reasonably do and code what people needed. You are not some saint. You have no idea who goes to Hawaii 3x per year or has 30mil in accounts... yet same people might complain of their $15 coinsurance on callus care or the $5 bunion pad. No idea.

Here's a mind blower: you already do take literal zeroes on some visits, some patients don't pay their bill, some patients give fake or expired insurance, and you're paid very low on MCA etc. It is a personal call to charge less/no codes on complications that are not normal after a surgery. Regardless, any of those are actually negatives for the encounter when you count your $0 gained yet staff/supplies/time. That is your "charity" if you want to look at it that way... and you are doing that "giving" whether you want to or not. This is not 2nd grade where we still believe in heaven and weakness and poverty and , is it? If it is still 2nd grade, then the pods not coding what they do and playing favorites would go to hell for stealing from the office/hospital. And fyi, even if you do tithe or like to give or do that stuff, you can do it MUCH better once you're out of debt. 🙂

Of note: For procedures that might normally use local anesthesia where you just use nothing or proximal cryo spray or whatever (maybe biopsy, ingrown, FB, aspirate ganglion, flexor, etc), simply add or edit your template a bit to say "anesthesia was not necessary due to neuropathy/nature of the injury/pt request/etc."

Great thanks. This is what I’ve figured too because I’m literally avulsing the nail so why am I not billing for it? Thanks feli

 

[msion]

This is podiatry. Our codes are already reimbursed pretty low. Our RVU pays for hospital pods are low relative to any other surgeons.
This is a business. Our education is expensive. Our ROI is very bad on average. This is not Jerry's Kids telethon. Treat all comers about the same.
There is nothing wrong with getting paid for what you do. Code it correctly. If you are not sure, simply read the code books.
If you think you are "giving" to the patients, you are actually then stealing from your group, boss, yourself, facility, etc. Don't do that. It's fine to be kind if you are an owner/partner (give free OTC or forgive/reduce a balance for ppl who are obviously truly struggling), but don't be a doormat overall... don't be scared to code what you reasonably do and code what people needed. You are not some saint. You have no idea who goes to Hawaii 3x per year or has 30mil in accounts... yet same people might complain of their $15 coinsurance on callus care or the $5 bunion pad. No idea.

This hits home. Patient have expectations that medical treatments are expensive. People think a bunion surgery will cost over $10k, and any procedure will be over $500. Bill what you did. No good deeds go unpunished. When I started out I charge peanuts for cash pay patients. Gradually I learned if they can't afford my fee then they are not my target demographic.

Other specialities are not cheap and they bill this way. I recently went to dermatology to check on a mole. No procedure, just an office visit. Billed insurance $550 for E&M and dermotoscopy, my insurance paid out $360.

 

[deleted1162946]

Anyone have any answers for these:

Why are my 99253’s getting denied on patients I do surgery for? It says it’s in the global in the denial. The 99253 was my decision to take the patient to surgery. Makes no sense. I had to evaluate the patient, review mri, etc to determine they need surgery.

My 11730’s rarely ever get paid with office visits. Is there anything to do different? You clearly need an office visit to determine that the nail avulsion is necessary so just add a 25 modifier to the office visit right? Well.. never gets paid.

 

[SubungualDebris]

Anyone have any answers for these:

Why are my 99253’s getting denied on patients I do surgery for? It says it’s in the global in the denial. The 99253 was my decision to take the patient to surgery. Makes no sense. I had to evaluate the patient, review mri, etc to determine they need surgery.

My 11730’s rarely ever get paid with office visits. Is there anything to do different? You clearly need an office visit to determine that the nail avulsion is necessary so just add a 25 modifier to the office visit right? Well.. never gets paid.

Use 99221-99223 series for inpatient consults (initial evaluation) and 99231-99233 for subsequent visits. Medicare and many private insurers have discontinued using and paying for consult codes. This should solve your issue.

 

[deleted1162946]

Use 99221-99223 series for inpatient consults (initial evaluation) and 99231-99233 for subsequent visits. Medicare and many private insurers have discontinued using and paying for consult codes. This should solve your issue.

those are the codes I’m using actually. I misspoke. I guess they just don’t want to pay it.

 

[SubungualDebris]

those are the codes I’m using actually. I misspoke. I guess they just don’t want to pay it.

Are you appending a 57 modifier (decision for surgery) onto the consult CPT code? It protects the E&M code when you initially evaluate the patient.

 

[josebiwasabi]

The global period actually includes the day before the surgery so if you don't put the -57 modifier on an inpatient consult that occurs the day before or day of surgery it falls into the global period.