Billing Question

[AttendingPod]

With the billing rules for this year, if you see a new diabetic patient for mycotic nails who has PAD and/or neuropathy, should it be a 99204 with 11720/11721 if you did an annual DM exam and nails?

I’m in a group and the other docs seem scared to use level 4’s which confuses me. I do some 4’s on other podiatry things but I’m confused where an annual DM exam would fall if they have DM with PAD for example. My rationale is the ADA guidelines put this person as a moderate risk for 2-3 month follow-up and they have 2 stable chronic illnesses (DM and PAD). I’ve been doing level 3’s in this scenario prior. I’m not sure why I’m hesitant.

Am I right? I don’t want to overbill or underbill, just get what I’m worth. Thanks!

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[HardRoadPaved]

With the billing rules for this year, if you see a new diabetic patient for mycotic nails who has PAD and/or neuropathy, should it be a 99204 with 11720/11721 if you did an annual DM exam and nails?

I’m in a group and the other docs seem scared to use level 4’s which confuses me. I do some 4’s on other podiatry things but I’m confused where an annual DM exam would fall if they have DM with PAD for example. My rationale is the ADA guidelines put this person as a moderate risk for 2-3 month follow-up and they have 2 stable chronic illnesses (DM and PAD). I’ve been doing level 3’s in this scenario prior. I’m not sure why I’m hesitant.

Am I right? I don’t want to overbill or underbill, just get what I’m worth. Thanks!

Rofl!!!!! Level 4!?!? What???? Boy dont let the RAC see that. There is no medical management or any diagnostic tests that you're doing to get you data points. Seeing long nails and going I'll cut them isn't difficult medical decision.

But at any rate there is no such thing as an annual dm exam anyway

Query: Annual Diabetic Foot Exams

Being a coder/biller for a number of podiatrists around the U.S., I am finding that some are still scheduling “annual diabetic foot exams” as a routine on all of their diabetic patients. They are then performing a full physical exam and trying to bill an E/M. Sometimes this coincides with callus or nail treatment, at which time they are wanting to add the -25 modifier. Of course, I am telling them that Medicare does not pay for an “annual diabetic foot exam” and that it is not a benefit and as such should be CASH.

Has anything changed? I would like to have a current conversation and guidance on this subject to present to these providers.

Tonia Silva, CPC, Administrator for Alanna Wargula, DPM, Lakeport, CA

Response: The answer is there is no such thing as an “annual diabetic foot exam” for reimbursement or coding. For a physician to bill it, it must be an E/M, evaluation and management service! Yes, they are diabetic on your evaluation but what are you managing for them from that E/M? If you are managing something, then bill an E/M. If not, it is considered a screening test which would be CASH.

David J. Freedman, DPM, CPC, Silver Spring, MD

 

[AttendingPod]

Rofl!!!!! Level 4!?!? What???? Boy dont let the RAC see that. There is no medical management or any diagnostic tests that you're doing to get you data points. Seeing long nails and going I'll cut them isn't difficult medical decision.

But at any rate there is no such thing as an annual dm exam anyway

Query: Annual Diabetic Foot Exams

Being a coder/biller for a number of podiatrists around the U.S., I am finding that some are still scheduling “annual diabetic foot exams” as a routine on all of their diabetic patients. They are then performing a full physical exam and trying to bill an E/M. Sometimes this coincides with callus or nail treatment, at which time they are wanting to add the -25 modifier. Of course, I am telling them that Medicare does not pay for an “annual diabetic foot exam” and that it is not a benefit and as such should be CASH.

Has anything changed? I would like to have a current conversation and guidance on this subject to present to these providers.

Tonia Silva, CPC, Administrator for Alanna Wargula, DPM, Lakeport, CA

Response: The answer is there is no such thing as an “annual diabetic foot exam” for reimbursement or coding. For a physician to bill it, it must be an E/M, evaluation and management service! Yes, they are diabetic on your evaluation but what are you managing for them from that E/M? If you are managing something, then bill an E/M. If not, it is considered a screening test which would be CASH.

David J. Freedman, DPM, CPC, Silver Spring, MD

I understand the annual diabetic foot exam being not billable that you performed it in itself but the education of PAD and neuropathy if they have those conditions are billable such as my example. Those are 2 chronic illnesses I’m helping to manage/educate and need to be monitored.

 

[HardRoadPaved]

I understand the annual diabetic foot exam being not billable that you performed it in itself but the education of PAD and neuropathy if they have those conditions are billable such as my example. Those are 2 chronic illnesses I’m helping to manage/educate and need to be monitored.

Education can only qualify you for time in a visit. And what are you able to spend that much time on. Wear shoes and do a daily foot exam? Call me if something isnt right?

Visit needs conditions you're managing but you need data points or patient risk from your interventions.

But how you get risk of level 4 when they only need yearly followup is beyond me

 

[air bud]

Lol

 

[NobodyDPM]

As a Podiatrist, I would hesitate to bill a level 4 E&M code. Can you? If you are dealing with complex issues, perhaps, but I prefer to stay under the radar. I would certainly see a justification for a level 4 visit if the patient has a complex wound, or if they need complex procedures and have a complex medical history. YMMV.

Medicare allows for an annual E&M visit for patients that you see for "at risk" foot care, if nothing else has changed. Particularly, since MIPS became a thing. You should be adding additional information in your medical record annually if the patient is Diabetic or has Hypertension, to comply with MIPS, as well. It is easy to make sure you have all the bullets you need to properly code for this visit if you follow a MIPS template.

 

[NobodyDPM]

Education can only qualify you for time in a visit. And what are you able to spend that much time on. Wear shoes and do a daily foot exam? Call me if something isnt right?

Visit needs conditions you're managing but you need data points or patient risk from your interventions.

But how you get risk of level 4 when they only need yearly followup is beyond me

Do you do MIPS in your practice? Are you familiar with the process for complying with MIPS? If you do, you should be spending time to discuss all the medical issues related to complying with MIPS, documentation wise. Maybe not a level 4, but certainly enough to justify an annual E&M.

 

[619]

I know this has been debated in the past but we are in 2021 and with the new changes to e/m services since 01/201, I believe it is time to revisit this conversation and see what y'all doing.

Just to ask you guys/gals on this forum, a patient comes in every 3 months for nails and callus. Patient is diabetic (controlled or uncontrolled) with PVD, neuropathy, high blood pressure, high cholesterol etc and sure throw in even end stage kidney disease with history of previous amputation. My question is do y'all add in a 99213/99212 together with the nails and callus or not at every visit.

You can add your reason; why or why not. Let's have a meaningful debate. This will help everyone especially new grads who are in their first year of practice.

 

[AttendingPod]

I appreciate the information. I have a few thoughts below.

- With the new coding this year, you should be doing at least some level 4’s in general. It is much easier to hit requirements now vs before. APMA members can watch webinars about it right now with examples through the coding section
- Educating someone on a condition is not just billable through time spent. No such rule exists. There is 2 routes for billing, not just one.

I’m not sure what’s funny about the scenario I posted. Everyone bills differently and from the few docs I asked in person, answers are all over the place and most do not reference current guidelines which are time spent or MDM.

My question is in particular for the nail pt who is at risk patient with diabetes and PAD and possibly neuropathy as well. If I made a case for a level 4, it does hit number and complexity of problem addressed by definition: 2 chronic stable illnesses. If I label them as moderate risk based off of what American diabetes association is suggesting about my patient, that’s enough for level 4. Plus, this pt would follow every 3 months for nails (with nail code only) so I am deeming them needing closer monitoring. My concern is that I am technically not managing their diabetes so can this count? Or does it count because I am helping educating and monitor their neuropathy and/or PAD due to diabetes? It’s simple for podiatry conditions such as bunions and hammertoes but that is where my concern is. Any input is appreciated. Thanks!

 

[PeaJay]

As a Podiatrist, I would hesitate to bill a level 4 E&M code. Can you? If you are dealing with complex issues, perhaps, but I prefer to stay under the radar. I would certainly see a justification for a level 4 visit if the patient has a complex wound, or if they need complex procedures and have a complex medical history. YMMV.

Medicare allows for an annual E&M visit for patients that you see for "at risk" foot care, if nothing else has changed. Particularly, since MIPS became a thing. You should be adding additional information in your medical record annually if the patient is Diabetic or has Hypertension, to comply with MIPS, as well. It is easy to make sure you have all the bullets you need to properly code for this visit if you follow a MIPS template.

I routinely bill level four visits and if you are doing an appropriate work-you should too.

Assessment of multiple chronic complaints with an acute finding. Ordering foot/ankle films with independent interpretations. Maybe throw in a lab. Discuss surgery, add assessment of medical history for optimization prior to surgery including assessment of thrombosis risk with appropriate prescription management. This is easily a level 4, all day everyday.

 

[AttendingPod]

I know this has been debated in the past but we are in 2021 and with the new changes to e/m services since 01/201, I believe it is time to revisit this conversation and see what y'all doing.

Just to ask you guys/gals on this forum, a patient comes in every 3 months for nails and callus. Patient is diabetic (controlled or uncontrolled) with PVD, neuropathy, high blood pressure, high cholesterol etc and sure throw in even end stage kidney disease with history of previous amputation. My question is do y'all add in a 99213/99212 together with the nails and callus or not at every visit.

You can add your reason; why or why not. Let's have a meaningful debate. This will help everyone especially new grads who are in their first year of practice.

Personally, I would bill for the nails and calluses every 3 month and once a year, I will bill for the diabetic foot exam. In this situation the person is at risk with PAD and possibly neuropathy, I’d educate them on these issues and evaluate them for these issues. I’d also make recommendations as needed. I would be billing for educating/monitoring/giving recs on these conditions, not for the DM exam in itself. This is billable and would reference the importance of this in my note. I’d do this once a year unless pt has acute change occur. All other visits just get nail and callus codes.

 

[dtrack22]

I appreciate the information. I have a few thoughts below.

- With the new coding this year, you should be doing at least some level 4’s in general. It is much easier to hit requirements now vs before. APMA members can watch webinars about it right now with examples through the coding section
- Educating someone on a condition is not just billable through time spent. No such rule exists. There is 2 routes for billing, not just one.

I’m not sure what’s funny about the scenario I posted. Everyone bills differently and from the few docs I asked in person, answers are all over the place and most do not reference current guidelines which are time spent or MDM.

My question is in particular for the nail pt who is at risk patient with diabetes and PAD and possibly neuropathy as well. If I made a case for a level 4, it does hit number and complexity of problem addressed by definition: 2 chronic stable illnesses. If I label them as moderate risk based off of what American diabetes association is suggesting about my patient, that’s enough for level 4. Plus, this pt would follow every 3 months for nails (with nail code only) so I am deeming them needing closer monitoring. My concern is that I am technically not managing their diabetes so can this count? Or does it count because I am helping educating and monitor their neuropathy and/or PAD due to diabetes? It’s simple for podiatry conditions such as bunions and hammertoes but that is where my concern is. Any input is appreciated. Thanks!

Nothing in any of your posts support Moderate complexity for a DM foot care patient.

I bill e/m for new patient nails and use the qualifying diagnosis (PAD or Neuropathy) as the e/m. But subsequent visits are just scheduled procedures and should be billed as such (CPT only). Unless there is a new problem you are actually addressing. Sometimes that is the case. But not often. They are there for their free pedicure and nothing else…

 

[NobodyDPM]

My question is in particular for the nail pt who is at risk patient with diabetes and PAD and possibly neuropathy as well. If I made a case for a level 4, it does hit number and complexity of problem addressed by definition: 2 chronic stable illnesses. If I label them as moderate risk based off of what American diabetes association is suggesting about my patient, that’s enough for level 4. Plus, this pt would follow every 3 months for nails (with nail code only) so I am deeming them needing closer monitoring. My concern is that I am technically not managing their diabetes so can this count? Or does it count because I am helping educating and monitor their neuropathy and/or PAD due to diabetes? It’s simple for podiatry conditions such as bunions and hammertoes but that is where my concern is. Any input is appreciated. Thanks!

You are providing a service/procedure (nail care) with no change in diagnosis or complexity of decision making, therefore an E&M visit is not warranted, but once a year to re-evaluate and to comply with MIPS.

Regardless if you are educating them about the issues involved, again, you are not providing anything else but the same service you provided last time.

If they come to you because their neuropathy has progressed and they need further assistance with this issue, like it is not causing pain for example, since there is now a new diagnosis of pain, and if you then start them on a med to manage their pain, this would definitely be cause for an E&M code.

 

[NobodyDPM]

I routinely bill level four visits and if you are doing an appropriate work-you should too.

Assessment of multiple chronic complaints with an acute finding. Ordering foot/ankle films with independent interpretations. Maybe throw in a lab. Discuss surgery, add assessment of medical history for optimization prior to surgery including assessment of thrombosis risk with appropriate prescription management. This is easily a level 4, all day everyday.

When I did a Medicare symposium with CMS years ago, I asked this exact question. And they category said that this would not qualify for a level 4 E&M code. See below.

What does "prescription management" mean? So if they are at risk for a DVT, you are managing a blood thinner for them? What is the purpose if "throwing in a lab" and are you going to manage if there is an abnormality past just turfing them to their PCP or a specialist? This is exactly the issue. You are managing a very specific issue related to the foot and ankle and nothing else. Or are you?

 

[king22]

When I did a Medicare symposium with CMS years ago, I asked this exact question. And they category said that this would not qualify for a level 4 E&M code. See below.

What does "prescription management" mean? So if they are at risk for a DVT, you are managing a blood thinner for them? What is the purpose if "throwing in a lab" and are you going to manage if there is an abnormality past just turfing them to their PCP or a specialist? This is exactly the issue. You are managing a very specific issue related to the foot and ankle and nothing else. Or are you?

I'm not sure we can go by what CMS said years ago in regards to E&M level coding; it was completely revamped this year.

Most podiatrists should be hitting level 4s frequently if they are coding right.

 

[king22]

everyone should have a copy of this document in their office https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

This is what determines the level of service you can bill for

 

[dtrack22]

Most podiatrists should be hitting level 4s frequently if they are coding right.

Yes, you should. But not for the visit that the OP keeps describing. There is almost nothing about a DM foot exam visit where you cut some toenails that would be considered moderate complexity.

 

[air bud]

I know this has been debated in the past but we are in 2021 and with the new changes to e/m services since 01/201, I believe it is time to revisit this conversation and see what y'all doing.

Just to ask you guys/gals on this forum, a patient comes in every 3 months for nails and callus. Patient is diabetic (controlled or uncontrolled) with PVD, neuropathy, high blood pressure, high cholesterol etc and sure throw in even end stage kidney disease with history of previous amputation. My question is do y'all add in a 99213/99212 together with the nails and callus or not at every visit.

You can add your reason; why or why not. Let's have a meaningful debate. This will help everyone especially new grads who are in their first year of practice.

why on earth would there be an E an M code based on this scenario?

 

[air bud]

As a Podiatrist, I would hesitate to bill a level 4 E&M code. Can you? If you are dealing with complex issues, perhaps, but I prefer to stay under the radar. I would certainly see a justification for a level 4 visit if the patient has a complex wound, or if they need complex procedures and have a complex medical history. YMMV.

Medicare allows for an annual E&M visit for patients that you see for "at risk" foot care, if nothing else has changed. Particularly, since MIPS became a thing. You should be adding additional information in your medical record annually if the patient is Diabetic or has Hypertension, to comply with MIPS, as well. It is easy to make sure you have all the bullets you need to properly code for this visit if you follow a MIPS template.

lol I guess we now know why you have been audited....for UNDERcoding

 

[air bud]

since we are talking about diabetics...level 4s all day. As I have discussed before, I prescribe a lot of gabapentin and have been very happy with results. Diabetic neuropathic with paresthesias placed on/not placed on but talked about gabapentin - level 4. Also the follow up if you are titrating dosage

- Category 1 - chronic unstable condition - ie not at ideal level. Improving but still paresthesias at night and you add 300mg more? yup not stable
- Category 3 - medication management - always remember you do not need to place the patient on medication - if you legit talk about it inclduing risks benefits compications etc and they decide they don't want to? too bad that is medication management. document document document.

 

[HardRoadPaved]

Most podiatrists should be hitting level 4s frequently if they are coding right.

Arent the majority of podiatry issues carry risk that is straightforward to low? A wound based practice, sure.

But typical PP stuff---moderate to severe morbidity for flat feet that ache at the gym losing covid weight? heel pain? wart? ingrown toenail? bunion? (and assuming its not some 2 min talk about saying yes you can get surgery for it but they are there for some basic recommendations). Remember no data point for order and review of an x-ray or u/s you read in house. so aside from documenting time how can you get there on these visits?

physical therapy, basic prefab DME items, NSAIDs, an injection, orthotics, minor office procedures like nails and warts are not getting you to moderate to severe in the treatment category.

 

[HardRoadPaved]

is do y'all add in a 99213/99212 together with the nails and callus or not at every visit.

You can add your reason; why or why not. Let's have a meaningful debate. This will help everyone especially new grads who are in their first year of practice.

There really is no debate. If you are 'separate and identifiable' from the procedure then ok. but adding a tinea pedis cream when cutting toenails, nope.... NGS uploaded a video on this:

 

[king22]

why you have been audited....for UNDERco

Arent the majority of podiatry issues carry risk that is straightforward to low? A wound based practice, sure.

But typical PP stuff---moderate to severe morbidity for flat feet that ache at the gym losing covid weight? heel pain? wart? ingrown toenail? bunion? (and assuming its not some 2 min talk about saying yes you can get surgery for it but they are there for some basic recommendations). Remember no data point for order and review of an x-ray or u/s you read in house. so aside from documenting time how can you get there on these visits?

physical therapy, basic prefab DME items, NSAIDs, an injection, orthotics, minor office procedures like nails and warts are not getting you to moderate to severe in the treatment category.

Go review the document I posted. There are many ways to reach a level 4. For example, I had a patient the other day come in from urgent care because of a "sprain". I reviewed the Xrays the patient brought with them and noticed a small fracture at the head of the 2nd metatsrsal. I put the patient in a walking boot and Rx NSAIDS. That's a level 4- independent interpretation of xray + Rx.

There really is no debate. If you are 'separate and identifiable' from the procedure then ok. but adding a tinea pedis cream when cutting toenails, nope.... NGS uploaded a video on this:

Watch the video carefully. They mention "previously prescribed " cream. If you Rx a medication thats a different story

 

[air bud]

Great example of proper use of office visit and closed management code. If someone comes to your office from ER with some met fx, the diagnosis is made and can only bill one or the other.

 

[air bud]

Go review the document I posted. There are many ways to reach a level 4. For example, I had a patient the other day come in from urgent care because of a "sprain". I reviewed the Xrays the patient brought with them and noticed a small fracture at the head of the 2nd metatsrsal. I put the patient in a walking boot and Rx NSAIDS. That's a level 4- independent interpretation of xray + Rx.

Watch the video carefully. They mention "previously prescribed " cream. If you Rx a medication thats a different story

Great example of proper use of office visit and closed management code. If someone comes to your from ER with some met fx, the diagnosis is made and can only bill one or the other.

 

[HardRoadPaved]

Go review the document I posted. There are many ways to reach a level 4. For example, I had a patient the other day come in from urgent care because of a "sprain". I reviewed the Xrays the patient brought with them and noticed a small fracture at the head of the 2nd metatsrsal. I put the patient in a walking boot and Rx NSAIDS. That's a level 4- independent interpretation of xray + Rx.

Watch the video carefully. They mention "previously prescribed " cream. If you Rx a medication thats a different story

For those interested in the breakdown need 2 of the three elements:

Number and complexity
• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or • 2 or more stable chronic illnesses; or • 1 undiagnosed new problem with uncertain prognosis; or • 1 acute illness with systemic symptoms; or • 1 acute complicated injury

Miss here--- Not an acute complicated injury or this having "uncertain prognosis". Its a small chip fx.

Amount and/or Complexity of Data to be Reviewed and Analyzed
Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or 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)\

Category 2- you get this one


Risk of Complications and/or Morbidity or Mortality of Patient Management
Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health

This one is a toss-up and need good documentation to push the level 4. some general rant of NSAID side effects is sufficient.

E/M FAQ -- What constitutes prescription drug management?

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.

 

[heybrother]

A few random thoughts

(a) The system is still a little silly. ie. a sprain/mild metatarsal fracture (without diabetes) is an acute uncomplicated injury, but if the x-ray was done elsewhere then you get "column 2" credit and bam - you are on your way to a level 4 even though the problem is at its heart a level 3.

(b) and yet, I can't fault ya'll because nothing was stupider in the past than a patient showing up with 2 MRI to a new patient visit. Its an acknowledgement of just how unpredictable and wild the amount of info a patient can bring to a new visit can be.

(c) additionally, there's something to be said for the idea that it really shouldn't matter what the diagnosis is if I have to write a prescription. We've already had a thread about what is onychomycosis ie. nature of the problem and yet I get referrals from other doctors who won't prescribe terbinafine because its dangerous and they'd feel more comfortable with me doing it. If its dangerous to prescribe or requires special care - why are we still doing columns. The defining trait of the visit is that I apparently wrote a dangerous prescription. Give me my level 4 already.

(d) Always keep in mind that the majority of this system applies to family medicine, internal medicine, medical subspecialties etc. Writing prescriptions for hypertensive, hypothyroid, diabetics is their bread and butter. The whole point of the system jokingly was so that they could continue to bill 99214s for many of their patients without feeling like they had to kill themselves battling out HPI and PE points.

(e) We should all be very grateful that they didn't attempt to further breakdown and diversify prescription management. The old system you may recall literally differentiated OTC verse prescription medications. If they had somehow defined acute and chronic prescriptions or something like that my 14 day meloxicam prescription probably wouldn't have passed muster.

 

[NobodyDPM]

lol I guess we now know why you have been audited....for UNDERcoding

LMAO...you do you, brother. Have you ever been audited? If you are coding a lot a Level 4s, I wonder how you'd do. Report back eventually.

 

[NobodyDPM]

It seems that this is the CMS document for the "new" rules. Not that much has changed to me.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

[king22]

For those interested in the breakdown need 2 of the three elements:

Number and complexity
• 1 or more chronic illnesses with exacerbation, progression, or side effects of treatment; or • 2 or more stable chronic illnesses; or • 1 undiagnosed new problem with uncertain prognosis; or • 1 acute illness with systemic symptoms; or • 1 acute complicated injury

Miss here--- Not an acute complicated injury or this having "uncertain prognosis". Its a small chip fx.

Amount and/or Complexity of Data to be Reviewed and Analyzed
Moderate (Must meet the requirements of at least 1 out of 3 categories) Category 1: Tests, documents, or independent historian(s) • Any combination of 3 from the following: • Review of prior external note(s) from each unique source*; • Review of the result(s) of each unique test*; • Ordering of each unique test*; • Assessment requiring an independent historian(s) or Category 2: Independent interpretation of tests • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported); or 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)\

Category 2- you get this one


Risk of Complications and/or Morbidity or Mortality of Patient Management
Moderate risk of morbidity from additional diagnostic testing or treatment Examples only: • Prescription drug management • Decision regarding minor surgery with identified patient or procedure risk factors • Decision regarding elective major surgery without identified patient or procedure risk factors • Diagnosis or treatment significantly limited by social determinants of health

This one is a toss-up and need good documentation to push the level 4. some general rant of NSAID side effects is sufficient.

E/M FAQ -- What constitutes prescription drug management?

Q. During an evaluation and management visit, what constitutes "prescription drug management?"
A. "Prescription drug management" is based on documented evidence that the provider has evaluated the patient's medications as part of a service. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.

I believe I unquestionably get that 3rd column. I Rx ibu 800mg TID, instructed patient take for one week than transition to PRN. I always give my NSAID talk (don't mix with advil, motion, alleve etc. You can take Tylenol for added analgesia etc). I also had to review the patients current medication to make sure there were no interactions

 

[king22]

It seems that this is the CMS document for the "new" rules. Not that much has changed to me.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

A lot has changed. You no longer need to meet the systems requirement which was the biggest limiting factor when it came to level 4 and 5 visits for a podiatrist.

 

[NobodyDPM]

A lot has changed. You no longer need to meet the systems requirement which was the biggest limiting factor when it came to level 4 and 5 visits for a podiatrist.

I would love to read about these changes. I was unable to find that information on a Google search. Do you have a link where I can read more about this? Thanks.

 

[HardRoadPaved]

Here is a medicare video on "prescription drug management" --- "Your records show the problem you are addressing and your drug must treat the patient's problem. you can also detail your thought on even their choice not to take the medicine"

 

[air bud]

Arent the majority of podiatry issues carry risk that is straightforward to low? A wound based practice, sure.

But typical PP stuff---moderate to severe morbidity for flat feet that ache at the gym losing covid weight? heel pain? wart? ingrown toenail? bunion? (and assuming its not some 2 min talk about saying yes you can get surgery for it but they are there for some basic recommendations). Remember no data point for order and review of an x-ray or u/s you read in house. so aside from documenting time how can you get there on these visits?

physical therapy, basic prefab DME items, NSAIDs, an injection, orthotics, minor office procedures like nails and warts are not getting you to moderate to severe in the treatment category.

Yes that is one Point. 2 if you are in a MSG and not billing for the xray.

Billing is not a subjective thing. It is objective. Well category one gets subjective if you aren't not realistic about things ...
But you read the referring docs note? One point. You look at previous x-rays they being with them? 2 points. You order a CT? One point. You need to operate on someone but concern for PVD and you talk to vascular to have them review a previous Doppler? One point.
Look at the chart. Bill appropriately.


Edit - ok risk management is now subjective. In your professional opinion is this low moderate severe. No more "minor surgery (10 day global) with risk factors = moderate"

 

[dtrack22]

I believe I unquestionably get that 3rd column. I Rx ibu 800mg TID, instructed patient take for one week than transition to PRN. I always give my NSAID talk (don't mix with advil, motion, alleve etc. You can take Tylenol for added analgesia etc). I also had to review the patients current medication to make sure there were no interactions

you “prescribed” a commercially available OTC medication. That’s not considered moderate risk. That’s a level 3 visit…

That’s like writing an Rx for urea cream (at any %) and calling it prescription drug management

 

[HardRoadPaved]

you “prescribed” a commercially available OTC medication. That’s not considered moderate risk. That’s a level 3 visit…

That’s like writing an Rx for urea cream (at any %) and calling it prescription drug management

silly you... that's why you send it to a compounding pharmacy!

 

[ldsrmdude]

Billing is not a subjective thing. It is objective.

I think this is the biggest thing that helped me when I was first starting, understanding that it’s essentially an objective process. I had attendings during residency billing based on how much work they felt like they did on each patient. It’s much easier to understand it objectively and I think once you look at it objectively, you get past the fear of billing level 4 (or 5) visits.

 

[king22]

I would love to read about these changes. I was unable to find that information on a Google search. Do you have a link where I can read more about this? Thanks.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

 

[king22]

you “prescribed” a commercially available OTC medication. That’s not considered moderate risk. That’s a level 3 visit…

That’s like writing an Rx for urea cream (at any %) and calling it prescription drug management

Ibuprofen 800mg is not otc.

 

[heybrother]

Its interesting - the old MDM tables spelled out OTC vs prescription. There's less description in the new though perhaps they felt the word "prescription" was information enough. 800 mg pills are prescription only though patients can obviously duplicate that dose with sufficient OTC pills.

Wiki - MDM Help

If a provider gives 800mg ibuprofen would this be a low or moderate MDM. I feel a low since you can get this otc. Provider wants to see this in written can you please help me. Thank you.

www.aapc.com

(see specifically the last post)

Some coders specifically discussed this in 2017 though again - how relevant is it now and what authority do these people have. The most interesting thing though to me from it (because hell - you can switch your ibuprofen prescribing to meloxicam or diclofenac and be kosher again) is that this person wants to see your text saying the prescription was for management. I've seen other players saying prescription management means you reviewed all of the patients medications.

 

[king22]

Its interesting - the old MDM tables spelled out OTC vs prescription. There's less description in the new though perhaps they felt the word "prescription" was information enough. 800 mg pills are prescription only though patients can obviously duplicate that dose with sufficient OTC pills.

Wiki - MDM Help

If a provider gives 800mg ibuprofen would this be a low or moderate MDM. I feel a low since you can get this otc. Provider wants to see this in written can you please help me. Thank you.

www.aapc.com

(see specifically the last post)

Some coders specifically discussed this in 2017 though again - how relevant is it now and what authority do these people have. The most interesting thing though to me from it (because hell - you can switch your ibuprofen prescribing to meloxicam or diclofenac and be kosher again) is that this person wants to see your text saying the prescription was for management. I've seen other players saying prescription management means you reviewed all of the patients medications.

Definitely a giant "grey" area

 

[PeaJay]

When I did a Medicare symposium with CMS years ago, I asked this exact question. And they category said that this would not qualify for a level 4 E&M code. See below.

What does "prescription management" mean? So if they are at risk for a DVT, you are managing a blood thinner for them? What is the purpose if "throwing in a lab" and are you going to manage if there is an abnormality past just turfing them to their PCP or a specialist? This is exactly the issue. You are managing a very specific issue related to the foot and ankle and nothing else. Or are you?

Am I managing the blood thinner? Yes ASA, lovenox, or apixaban.

Throwing in a lab… typically random glucose or a1c for management of peri-operative risk. Possible kidney labs or liver depending on history. Often a full infection work-up as the hospitalist/ED leaves management to our team including antibiotics etc.

I tend to assess my patient prior to turfing to pcp.

I frankly look at the entire person/history. I do not salivate at a juicy bunion and turf the rest to pcp

 

[NobodyDPM]

Am I managing the blood thinner? Yes ASA, lovenox, or apixaban.

Throwing in a lab… typically random glucose or a1c for management of peri-operative risk. Possible kidney labs or liver depending on history. Often a full infection work-up as the hospitalist/ED leaves management to our team including antibiotics etc.

I tend to assess my patient prior to turfing to pcp.

I frankly look at the entire person/history. I do not salivate at a juicy bunion and turf the rest to pcp

Bolded mine.

As do I, but managing complex medical issues stemming from multi system disease is a job better left to the particular specialist needed. The more eyes on the patient, the better. Especially those complex patients, who also tend to be rather non-compliant.

I also get labs and possibly EKGs and Chest X-Rays on patient that need them, but if an issue comes up on those, I ASSESS them, but don't MANAGE them. I know many Podiatrist that wanted to be heroes that way and got burned very badly with it when it hit the fan. And by sending your patients out to other physicians for management, you are also creating a referral base. Win/win.

 

[NobodyDPM]

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Thank you!

 

[dtrack22]

Ibuprofen 800mg is not otc.

It’s an OTC medication that any patient can replicate by purchasing ibuprofen at any store in the country…

We all know that isn’t what “prescription management” means when it comes to moderate risk and moderate complexity. But the chance you ever get audited is low (unless you’re that one person above who’s been audited multiple times lol) so keep on using ibuprofen as your justification for moderate risk 🙄

 

[air bud]

Also don't forget that talking to another specialist is a data point in middle category. Doesn't have to be all labs and x-rays. Obtain info from secondary person due to poor historian....labs/xray/read notes/....discuss with another provider. I talk to ID and vascular all the time. It helps build my codes

Also the idea of managing more than aspirin is crazy to me. But that is not where my training focused.

 

[HardRoadPaved]

Just write for a cox-2 inhibitor if you want an Rx NSAID. Pretty well tolerated by most.

 

[PeaJay]

Bolded mine.

As do I, but managing complex medical issues stemming from multi system disease is a job better left to the particular specialist needed. The more eyes on the patient, the better. Especially those complex patients, who also tend to be rather non-compliant.

I also get labs and possibly EKGs and Chest X-Rays on patient that need them, but if an issue comes up on those, I ASSESS them, but don't MANAGE them. I know many Podiatrist that wanted to be heroes that way and got burned very badly with it when it hit the fan. And by sending your patients out to other physicians for management, you are also creating a referral base. Win/win.

I definitely agree that I do not necessarily manage the complex health issues. It is however prudent to monitor and refer when appropriate. I am in a large msg and my internal med colleagues encourage patients to be sent with an idea of what I would like addressed. A blanket of “optimization” is not often met with enthusiasm.

As for ekg/cxr I do not even dabble in that. Most up to date standards do not encourage blanket ordering of those. Similar can be said about not being a hero with those.

With all being said I do get an PCP H&P for my patients. I do however check under “rocks” to check if they are an appropriate surgical candidate instead of letting the PCP cancel the case.

 

[PeaJay]

Also the idea of managing more than aspirin is crazy to me. But that is not where my training focused.

You can manage other dvt ppx, I believe in you. No monitoring for lovenox or apixaban.

 

[NobodyDPM]

I've had the time to review the document linked by @king22 and I must admit, I learned a great deal. Thank you for putting that link up. Very much appreciated. It certainly seems that billing a level 4 should be much more common than I think it is at this point. The only caveat is to make sure your medical records justify it.

One of the reasons I like to browse (and participate at times) these types of forums is because I understand that I don't know it all, and also that things change. Sometimes to the point that it is virtually impossible to keep up! Thanks again.