Billing a lot of level 4 visits

[DYK343]

I've heard through the grapevine that a lot of payers are only paying H&P/consult notes for the first admission (hospitalist) and everyone else is considered a follow up.

Ex DFU infected. Hospitalist admits/H&P. DPM comes along and bills a new consult and its getting denied. Should be billed as a follow up even though its a new patient.

That sounded absurd to me but its what the grapevine talk said.

- - -

For ingrown most payers are not paying for procedure and E&M same day. I challenged this and they showed me medicare statements on billing these procedures with E&M attached and its not allowed (unless seperate identifiable issue not realted to ingrown nail procedure).

My argument was how can I perform a minor surgery without a focused H&P? But the history/exam/procedure/dressing is included in the measley 1.05 RVU partial/total nail avulsion when a 99203 is 1.6RVU.

Same with cortisone injections for plantar fasciitis. I take a pay cut to inject medication.

Makes no sense hence why I try to send every ingrown nail or small procedures possible to my private practice friends.

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[Hybrocure]

I've heard through the grapevine that a lot of payers are only paying H&P/consult notes for the first admission (hospitalist) and everyone else is considered a follow up.

Ex DFU infected. Hospitalist admits/H&P. DPM comes along and bills a new consult and its getting denied. Should be billed as a follow up even though its a new patient.

That sounded absurd to me but its what the grapevine talk said.

- - -

For ingrown most payers are not paying for procedure and E&M same day. I challenged this and they showed me medicare statements on billing these procedures with E&M attached and its not allowed (unless seperate identifiable issue not realted to ingrown nail procedure).

My argument was how can I perform a minor surgery without a focused H&P? But the history/exam/procedure/dressing is included in the measley 1.05 RVU partial/total nail avulsion when a 99203 is 1.6RVU.

Same with cortisone injections for plantar fasciitis. I take a pay cut to inject medication.

Makes no sense hence why I try to send every ingrown nail or small procedures possible to my private practice friends.

Injects pay poorly in PP too unless you can find a way to sneak another dx for an E&M in. They’re less than billing an office visit

 

[heybrother]

I reviewed my billing and have yet to be denied for an office visit + procedure this year by Novitas/Medicare. As I've pointed out elsewhere - you are paid in RVUs, but the hospital is paid in actual dollars and these procedural codes can actually be worth more in facility reimbursement than the E&M is if performed in a HOPD under OPPS. The hospital potentially gets a double win when they pay you on a minor procedure - you get fewer RVUs and the hospital potentially keeps the larger facility reimbursement pot. You can see this in the data I presented in another thread. A hospital 11042 is worth over $400 on Medicare. A 20610, which is not a perfect comparison, but I'm skeptical its truly dramatically worth more than a 20605/20600 etc is worth more than $300. If the hospital pays you on RVUs for that they pay you .. $50-53 x ~0.7? instead of paying you some variation of 1.3-1.6 x $50 against $200ish in collections. Obviously the hospital would make more money still if it was paid on both codes, but maybe Medicare is stricter on facility charges.

My argument was how can I perform a minor surgery without a focused H&P? But the history/exam/procedure/dressing is included in the measley 1.05 RVU partial/total nail avulsion when a 99203 is 1.6RVU.

 

[air bud]

I've heard through the grapevine that a lot of payers are only paying H&P/consult notes for the first admission (hospitalist) and everyone else is considered a follow up.

Ex DFU infected. Hospitalist admits/H&P. DPM comes along and bills a new consult and its getting denied. Should be billed as a follow up even though its a new patient.

That sounded absurd to me but its what the grapevine talk said.

- - -

For ingrown most payers are not paying for procedure and E&M same day. I challenged this and they showed me medicare statements on billing these procedures with E&M attached and its not allowed (unless seperate identifiable issue not realted to ingrown nail procedure).

My argument was how can I perform a minor surgery without a focused H&P? But the history/exam/procedure/dressing is included in the measley 1.05 RVU partial/total nail avulsion when a 99203 is 1.6RVU.

Same with cortisone injections for plantar fasciitis. I take a pay cut to inject medication.

Makes no sense hence why I try to send every ingrown nail or small procedures possible to my private practice friends.

I have talked about this before. I've had some people say that yes only the admitting hospitalist is truly the initial visit and then any specialist even if it's the first time seeing them is a subsequent encounter. But then at the coding course they said that was not the case. So I've still not getting a good understanding

 

[DYK343]

I reviewed my billing and have yet to be denied for an office visit + procedure this year by Novitas/Medicare. As I've pointed out elsewhere - you are paid in RVUs, but the hospital is paid in actual dollars and these procedural codes can actually be worth more in facility reimbursement than the E&M is if performed in a HOPD under OPPS. The hospital potentially gets a double win when they pay you on a minor procedure - you get fewer RVUs and the hospital potentially keeps the larger facility reimbursement pot. You can see this in the data I presented in another thread. A hospital 11042 is worth over $400 on Medicare. A 20610, which is not a perfect comparison, but I'm skeptical its truly dramatically worth more than a 20605/20600 etc is worth more than $300. If the hospital pays you on RVUs for that they pay you .. $50-53 x ~0.7? instead of paying you some variation of 1.3-1.6 x $50 against $200ish in collections. Obviously the hospital would make more money still if it was paid on both codes, but maybe Medicare is stricter on facility charges.

"The description of CPT codes 11730, 11732, and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT codes 11730, 11732, or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border."

This is from the medicare website which my billers read as "all services" includes the E&M. They claim E&M gets denied 100% of the time.

 

[DYK343]

So I've still not getting a good understanding

In reality we all have opinions, our billers have opinions, and no one really knows except the auditor who probably is also running off opinions.

 

[heybrother]

"The description of CPT codes 11730, 11732, and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT codes 11730, 11732, or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border."

This is from the medicare website which my billers read as "all services" includes the E&M. They claim E&M gets denied 100% of the time.

Maybe it does for you, but it doesn't for me ie. denials. I'll throw something else to you - at my clinic - I care more than anyone else about how and when we get paid. I'm the only person truly reviewing the reimbursement. To me - its life. I either get paid, change how I'm coding/practicing, or die. You have a high school graduate who literally could be changing your coding behind your back telling you how it is. My residency faculty had coders telling them things and when they finally got the actual data - it turned out the coders were botching the coding and causing the claims to not be paid. It was true that nothing was being paid, but it wasn't because of some sort of real rule. It was because of stupid billing by the coders, and there was a very real question of fraud because many of the insurances were owned by the hospital. The hospital had motivation not to pay.

And I don't believe that is what that text is meant to mean, but again - the only opinions that matter in your case are your coding masters. To me that text means - don't unbundle. The nail surgery code encompasses all components of the procedure ie. there isn't a separate code for cutting or curetting or debridement. There isn't a separate I&D code for releasing pus. The nail surgery code represents the entirety of the service performed "on that nail". I'm well aware that procedures include a measure of E&M decision making reimbursement that in no where compensates people for the level of E&M that went into it, but ultimately that becomes a 25 modifier question. Here's how I know your coder is full of **** though - nothing is 100% of the time in coding. Every insurance has slight nuances and differences in behavior.

 

[DYK343]

You have a high school graduate who literally could be changing your coding behind your back telling you how it is.

Yes, yes I do have this.

I think they have to take some sort of coding courses beyond a high school diploma.

But yes, I am not in control of my billing and I unfortunately never will be as long as I am hospital employed at this position. Its in my contract that I sign over my billing rights. I can attest/argue and they do listen. But ultimately they have the last say.

And I don't believe that is what that text is meant to mean, but again - the only opinions that matter in your case are your coding masters.

See my comment directly above this. In my opinion its nothing but opinions.

Even the billing course experts argue and pick things apart.

No one really knows. Language is written vague.

All I know for truth is if I want a 99203 I have to send them home and come back another day for a procedure - which I never do because it feels wrong.

 

[dtrack22]

This is from the medicare website which my billers read as "all services" includes the E&M. They claim E&M gets denied 100% of the time.

To be fair, we have established that your billers are re-tarded

I think you should have @heybrother send you a receipt of payment from Medicare showing e/m and minor procedure being paid on the same DOS. Then forward it to your billers and ask them to explain.

I would disagree with your billers, not only based on the language of the CMS link you posted, where “services” is only ever used to describe additional procedural codes on the same digit vs different digits (there is zero mention of e/m). But also based on your previous comment…when you ultimately decide to do an unscheduled or unplanned procedure, how is the e/m component included in the CPT code, when the CPT code has a lower RVU than the e/m alone?

 

[Feli]

"The description of CPT codes 11730, 11732, and 11750 indicates partial or complete avulsion or excision of a nail plate. When CPT codes 11730, 11732, or 11750 is reported, it represents all services performed on that nail for that date of service (DOS). When lateral and medial sides of a nail are involved, do not report a separate code for each border."

This is from the medicare website which my billers read as "all services" includes the E&M. They claim E&M gets denied 100% of the time.

People with ingrown nails also have cellulitis, HAV, DM, tinea, any number of other treatable issues. That's all I'd say.
"all services performed on that nail for that date of service"

I've never had issues with the e/m (initial visit).... 25 mod on e/m, TX mod on ingrown obviously.
The 2nd ingrown that day or any other wound, wart, inject, etc will obviously be 50% reduction like any sx/proc codes.

But yeah, if you do 99203 to L60.0 and then 11750 to L60.0, that'd typically be a denial.
There is a good chance they are coding it that way - even if you like icd to cpts in the emr, they may "adjust" it.

 

[MicroPod]

For noninfected/not currently painful ingrowns I have been scheduling them on a Friday so the patient has a couple of days to rest after anyways. That way I get the e/m and the procedure on different days too.

 

[619]

Makes no sense hence why I try to send every ingrown nail or small procedures possible to my private practice friends.

I want to be your private practice friend. Your loss is my gain.

As mentioned above, the hospital gets way more money in facility fees so don't need to be bother about getting paid for e/m.

The primary goal of insurance companies is to maximize profit. Simple as that. And the two major ways to maximum profit is to increase patient premiums which they do every year without missing a beat and the second way is less payout by simply denying or delaying payments.

 

[Homo sapien]

I want to be your private practice friend. Your loss is my gain.

As mentioned above, the hospital gets way more money in facility fees so don't need to be bother about getting paid for e/m.

The primary goal of insurance companies is to maximize profit. Simple as that. And the two major ways to maximum profit is to increase patient premiums which they do every year without missing a beat and the second way is less payout by simply denying or delaying payments.

Me too. I can befriend you!

 

[DYK343]

To be fair, we have established that your billers are re-tarded

True statement

when you ultimately decide to do an unscheduled or unplanned procedure, how is the e/m component included in the CPT code, when the CPT code has a lower RVU than the e/m alone?

This has been my argument all along. I spend 10-15 minutes with my standard plantar fasciitis talk. Then at end if they want an injection I lose money. I go from 1.6 to 0.75rvu. Makes no sense to take extra risk.

Injects pay poorly in PP too unless you can find a way to sneak another dx for an E&M in. They’re less than billing an office visit

For noninfected/not currently painful ingrowns I have been scheduling them on a Friday so the patient has a couple of days to rest after anyways. That way I get the e/m and the procedure on different days too.

Sounds like I am not the only one having these problems. Perhaps different MACs have different rules?

Airbud mentioned to me not too long ago that I&D to bone post op care is billable at a wound center (no where else) for follow up despite the 90 day global. Apparently some on here may be getting away with that. I messaged our head biller as this was news to me and they said that may be true in some MACs but not mine.

 

[deleted1162946]

Billing is one huge game. quite annoying. Either see 40 patients a day and bill ineffectively or bill effectively and see 30.

And by effectively I still mean legally/correct. Just knowledgeable

 

[deleted1162946]

Can someone explain the purpose of setting a higher fee schedule? Will insurance pay more? My job has changed our fees to a really high fee schedule and curious if I’ll actually get paid more or not. Or if the insurance will still reimburse the same

 

[Feli]

Can someone explain the purpose of setting a higher fee schedule? Will insurance pay more? My job has changed our fees to a really high fee schedule and curious if I’ll actually get paid more or not. Or if the insurance will still reimburse the same

Most places just do 2x or 3x medicare rates.
If you set them much higher, expect ppl to flip out about their EOBs in mail/portal.

You want to set at least a bit above highest payers that you see.

Work comp usually has a fee schedule from the state you work in (higher than MCR or most payers - but still barely worth it due to paperwork and delay pays).

Most private insurances will negotiate a raise on e/m or proc - or both - every year or two (if you ask)... sometimes 6mo for startup. Never hurts to ask.

 

[heybrother]

Can someone explain the purpose of setting a higher fee schedule? Will insurance pay more? My job has changed our fees to a really high fee schedule and curious if I’ll actually get paid more or not. Or if the insurance will still reimburse the same

The impact will be close to zero. Self-pay patients will get higher bills or potentially be scared off if they ask for a quote ahead of time.

I fiddle with fee schedules for maybe 2-3 reasons.

1. I realize we are charging less than an insurance will pay for an individual service
2. To increase the price of self-pay nails/calluses
3. To try and find balance in self-pay services for things like office visits vs injections.

When I joined my practice the price of a 99203 was $130 which hilariously was less than a few insurances would pay. But what really stood out to me was that people would pay the $130 and then decline all other services and want to talk your ear off. They would essentially try to buy themselves an hour of your time for $20 than Medicare would pay. The solution - control the encounter and increase the price. You don't want to do anything. Fine. I'll still get paid. I'm mostly of the opinion you should always be satisfied with reimbursement from a self-pay patient. Its the only time in medicine where you set the price.