Billing Tips and Tricks

[NinerNiner999]

So I was thinking that with all of the experience we have here on SDN, maybe we could get some advice and tips from some of the more senior, practicing EP's on how they increase their billing. Be it through documentation, added H&P, accurate procedures, etc, can some of you more experienced attendings clue us in to some of your tricks?

I'll start with a few that various attendings have told me along the way:

1) If the patient is involved in an altercation or MVC that had police involvement, include s/p MVC or s/p Assault in the diagnosis. This helps the coders recognize there is potentially a third party to collect from (insurance, state victims assistance, etc)

2) MD Venipuncture - $35

3) Dental procedures do not bill (we are not dentists). Use phrases such as acute maxillary infection for upper tooth pain, or manbiular inflammation for lower toothache.

4) Be liberal with psychiatric diagnoses (e.g. adjustment disorder, grief reaction) but be careful with your dispo vs. disorder.

5) There is a fine line between abscess drainage and open debridement, and that line is the length of your incision.

Please, keep em coming!

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[Apollyon]

The trauma things (MVC, fall, assault) have "E codes" (injury codes). That's built into ICD-9. There is also V22.2 (pregnant state, incidental) and V45.1 (renal dialysis status). The key with renal stuff is to code carefully, as the Medicare money is eaten up by the nephrologists, and, if you're not careful, you won't get paid. However, if the coders/your group pushes it, you can get paid (and Medicare/renal pays pretty well).

Stones - do NOT code "cholelithiasis" or "nephrolithiasis". Use "biliary colic" or "renal colic". Just having stones doesn't get paid - pain/morbidity from the stones does.

Infected stone? Pyelonephritis? 1. Urinary tract infection 2. Sepsis.

Laceration? Check. Abrasions, too? Separate code.

And don't forget your procedures! As Niner pointed out, even an IV counts. Also, it's not how many sutures, or if you glue or staple, but length, location, and complexity of the closure. Length is most important, then location.

 

[doctawife]

For the pediatricians in the hiz-house, cerumen removal will get ya $15.

Yes - the procedure we all do anyway gets it's own billing code. Very cool.

 

[EctopicFetus]

Great idea for a thread!. Lots of good knowledge here.

 

[EctopicFetus]

Anoscopy pays well, also a lac of 2.6 cm pays a lot more than one that is 2.5cm, lastly any facial repair is a complex repair, so i hear.

 

[c.bear]

For the pediatricians in the hiz-house, cerumen removal will get ya $15.

There really should be a code for complex cerumen removal or cerumen disimpaction. I removed impacted cerumen from an adult that should have qualified as a minor sugical procedure.

 

[Apollyon]

Anoscopy pays well, also a lac of 2.6 cm pays a lot more than one that is 2.5cm, lastly any facial repair is a complex repair, so i hear.

Apparently, I am the first person in 6 years to anoscope anyone in all the EDs in our health system. I just love it when some nurse or tech 10 years younger than me says "We don't do that here" or "I've never seen that done here". Yes, and? Get me the 'ass bullet'!

 

[spyderdoc]

Document a rhythm strip along with your ECG interp to add a few $$ to your reimbursement. Most ECGs actually come with a rhythm strip (the lead II running strip at the bottom...)

Jump at the chance to do ANY procedures that you can. Ingrown toenails, trephinating subungal hemtomas, etc...

Finger lac? Do a digital block to increase your reimbursement...For that matter, do blocks instead of local whenever possible (infraorbital for upper lips, mental for lower lips and chin)

On the PEA code, make sure to document your bilateral darts and pericardiocentesis if you do them....Big $$.

After securing the ETT after RSI, put the OG tube while you are standing at the head of the bed. An easy procedure that will get a few xtra $$...Make sure to document it...

Try to do your own splinting (instead of the tech) to increase the reimbursement. If you dont put the splint on, make sure to document a post-application exam...That will at least get you a couple of $$....

If you think a lac needs 2 layer closure, just do it....

We are finally getting our U/S machine within the month. I guess doing U/S guided procedures such as central lines, thora/para/pericardiocentsis will increase the reimbursement....

Document critical care time WHENEVER you can. It is one of the most under-used EM codes...

 

[NinerNiner999]

There really should be a code for complex cerumen removal or cerumen disimpaction. I removed impacted cerumen from an adult that should have qualified as a minor sugical procedure.

There is a code for adult cerumen disimpaction - I did one the other night.

Document critical care time WHENEVER you can. It is one of the most under-used EM codes...

And, if you have PA/Midlevel that is free for a few minutes, they can stand in the room for you and you might bill for more than the minimum time

 

[EctopicFetus]

There really should be a code for complex cerumen removal or cerumen disimpaction. I removed impacted cerumen from an adult that should have qualified as a minor sugical procedure.

How about Foreign body in ear. We had one guy come into Urgent Care with a Corn Kernel in one ear and a q tip cotton swab piece in the other. He was 21 and "normal"

 

[EctopicFetus]

Apparently, I am the first person in 6 years to anoscope anyone in all the EDs in our health system. I just love it when some nurse or tech 10 years younger than me says "We don't do that here" or "I've never seen that done here". Yes, and? Get me the 'ass bullet'!

Ive done 3 this yr. Interesting. I hear it pays well though.

 

[EctopicFetus]

There is a code for adult cerumen disimpaction - I did one the other night.

I think c.bear meant for "complex" removal rather than one code for all removals.

 

[diosa428]

Sorry, this is off topic, but aren't most EM docs on salary? So how does it benefit you to bill more? I'm only an MSI, so I don't quite understand these things yet...

 

[spyderdoc]

Sorry, this is off topic, but aren't most EM docs on salary? So how does it benefit you to bill more? I'm only an MSI, so I don't quite understand these things yet...

No. I am strictly FFS (fee for service). If I go a shift and don't see any patients, I don't get paid....Nice for me since there is no middle man taking my money. All I pay is minimal group overhead costs and malpractice (relatively cheap in CA)....

 

[Dr. Caveman]

Spyderdoc,

How does the pay work out in fee for service in comparison to salary groups in cal. I hear that group starting pay is in the 200's and more if you join a group with profit sharing, but way less if you join Kaiser or academic.

What happens to you when your shift is heavy with uninsured patients? Is there a group slush fund to compensate for treating patients that are unable to pay or is just chalked up as service day?

 

[The White Coat Investor]

Document a rhythm strip along with your ECG interp to add a few $$ to your reimbursement. Most ECGs actually come with a rhythm strip (the lead II running strip at the bottom...)

Jump at the chance to do ANY procedures that you can. Ingrown toenails, trephinating subungal hemtomas, etc...

Finger lac? Do a digital block to increase your reimbursement...For that matter, do blocks instead of local whenever possible (infraorbital for upper lips, mental for lower lips and chin)

...

My understanding is that digital blocks are now bundled in with the procedure code.

I also don't believe you can bill for rhythm strip interpretation AND ECG interpretation unless you can show that both were necessary. There is a little bit of tricky ground there that probably comes down to how you chart it and how aggressive your coders are.

 

[spyderdoc]

Spyderdoc,

How does the pay work out in fee for service in comparison to salary groups in cal. I hear that group starting pay is in the 200's and more if you join a group with profit sharing, but way less if you join Kaiser or academic.

What happens to you when your shift is heavy with uninsured patients? Is there a group slush fund to compensate for treating patients that are unable to pay or is just chalked up as service day?

Where I am, it is great. I easily make more than double what I made at Kaiser. However, I do see a LOT more patients than I did there during a shift (but I only do 12-14 8 hour shifts/month compared to 15-18 10 hour shifts at Kaiser). I think patient for patient, I make about the same, but more volume in FFS world is more $$. I figure, hey, why not bust my hump while I am at work and get rewarded for it....I really have nothing bad to say about the Kaiser system other than it does pay relatively low compared to the rest of the community. Even thought the yearly salary number may be somewhat comprable to the community, the salary is based on a 40 hour work week, so you do a lot of time for that salary. There are good benefits with a pension plan, so there is something to be said for that.

I am lucky in that my wife is a doc at Kaiser, so she gets all of our health and dental benefits, including those for our son....

Yep, all the "self pay" patients are pretty much charity work. We have no slush fund....California has a Maddy fund that gives us a small check each year for the self-pay patients, but it really is not much $$. We have a pretty good payor mix in general, so we still do really well.

We have a great billing company, so all I do is the chart, and the billing company handles the rest. I don't know what really goes on behind the scenes as far as coding and collections go. I just get a check every month....

 

[NinerNiner999]

Even if you are on salary or fixed hourly pay, collecting more can mean a great deal more income for you, especially if you are in a small-medium sized democratic group with profit sharing. If each physician collects just $10 more per patient, and the group sees 100k patients per year, there is suddenly an extra $1,000,000 to divide amongst the group.

Granted, this won't do much for you if you work for those megagroups, but it will increase your RVU's and give you an extra layer of job security...

 

[EctopicFetus]

This might be a real dumb question, but where does the money go in academics? Is it that it goes to the research arm and paying those salaries for AA's, PhDs etc? This is my assumption. We see a lot of patients in my residency, not a ton of attendings etc.

Just curious.

 

[Dr. Caveman]

Where I am, it is great. I easily make more than double what I made at Kaiser. However, I do see a LOT more patients than I did there during a shift (but I only do 12-14 8 hour shifts/month compared to 15-18 10 hour shifts at Kaiser). I think patient for patient, I make about the same, but more volume in FFS world is more $$. I figure, hey, why not bust my hump while I am at work and get rewarded for it....I really have nothing bad to say about the Kaiser system other than it does pay relatively low compared to the rest of the community. Even thought the yearly salary number may be somewhat comprable to the community, the salary is based on a 40 hour work week, so you do a lot of time for that salary. There are good benefits with a pension plan, so there is something to be said for that.

I am lucky in that my wife is a doc at Kaiser, so she gets all of our health and dental benefits, including those for our son....

Yep, all the "self pay" patients are pretty much charity work. We have no slush fund....California has a Maddy fund that gives us a small check each year for the self-pay patients, but it really is not much $$. We have a pretty good payor mix in general, so we still do really well.

We have a great billing company, so all I do is the chart, and the billing company handles the rest. I don't know what really goes on behind the scenes as far as coding and collections go. I just get a check every month....

Thanks for the reply that helps alot.... I have one more question about salaries in general. Are the online stats on 200k a year in Cali accurate (for say 12 10 hour shifts a month)? I'm not in medicine for the money...but I would like to pay down my 300k debt sooner rather than later or at least prepare myself for a long long payback if the other end of 120k with Kaiser is a more accurate salary estimate

 

[Apollyon]

Sorry, this is off topic, but aren't most EM docs on salary? So how does it benefit you to bill more? I'm only an MSI, so I don't quite understand these things yet...

Thanks for the reply that helps alot.... I have one more question about salaries in general. Are the online stats on 200k a year in Cali accurate (for say 12 10 hour shifts a month)? I'm not in medicine for the money...but I would like to pay down my 300k debt sooner rather than later or at least prepare myself for a long long payback if the other end of 120k with Kaiser is a more accurate salary estimate

There are TONS of threads on this - this thread was going on a nice line. The off-topic/derailing posts would be MUCH better served in their own thread.

 

[bulgethetwine]

There are TONS of threads on this - this thread was going on a nice line. The off-topic/derailing posts would be MUCH better served in their own thread.

Yeah, agreed, let's not get de-railed here, this was (is) a GREAT thread. I say more more 'ass bullet' billing details!

What pays more - putting someone on a PCA or repetitive pain control dosing? And I heard that the difference between a level 5 vs. level 4 billing (for example) is that the former needs 10 examination lines (e.g. one for neuro, one for CV, etc.) and 10 ROS.

 

[Flopotomist]

There are TONS of threads on this - this thread was going on a nice line. The off-topic/derailing posts would be MUCH better served in their own thread.

I dunno - I for one was enjoying the relationship between this thread and the "how much salary" thread. I thought a poster asked a good question earlier about how increasing reimbursement rates benefits an academic who is on a strict salary.

 

[EctopicFetus]

Thanks for the reply that helps alot.... I have one more question about salaries in general. Are the online stats on 200k a year in Cali accurate (for say 12 10 hour shifts a month)? I'm not in medicine for the money...but I would like to pay down my 300k debt sooner rather than later or at least prepare myself for a long long payback if the other end of 120k with Kaiser is a more accurate salary estimate

Ahh must have been an AP..

 

[EctopicFetus]

This might be a real dumb question, but where does the money go in academics? Is it that it goes to the research arm and paying those salaries for AA's, PhDs etc? This is my assumption. We see a lot of patients in my residency, not a ton of attendings etc.

Just curious.

Anyone?

 

[MirrorTodd]

Anyone?

Probably comes out the ass-end of the ED. Just kidding.

 

[roja]

Three Words: Critical Care Time

 

[Apollyon]

I dunno - I for one was enjoying the relationship between this thread and the "how much salary" thread. I thought a poster asked a good question earlier about how increasing reimbursement rates benefits an academic who is on a strict salary.

The person even SAID "Sorry, this is off-topic". If you like - yet another - question about salary, you're missing the point of the thread.

As to your question, no benefit, unless it's built into the system.

 

[roja]

The person even SAID "Sorry, this is off-topic". If you like - yet another - question about salary, you're missing the point of the thread.

As to your question, no benefit, unless it's built into the system.

Many places have a faculty practice bonus. Its a pittance compared to private but many of them do offer it. Often based on billing and tenures type things.

 

[Dr. Caveman]

There are TONS of threads on this - this thread was going on a nice line. The off-topic/derailing posts would be MUCH better served in their own thread.

my bad...

 

[NinerNiner999]

Ahem, trying to get back on topic...

There are limits to the level you can bill for certain diagnoses. For those who use the T-system, there is a small number in parenthesis below the name of the form [example: (4) on the upper extremity injury form]. Billing too many level 4's and 5's will get you (and your practice) into trouble. Most groups have billing agencies that keep this from happening, though.

Oh, If you place a transvenous pacer, you can bill for critical care time, cardiac pacing, central venous access, EKG AND rhythm strip interpretation.

Orthopedics splinting allows you to bill for diagnosis, reduction, splinting, and cast care. This can step on the toes of your local orthopods, though (cast care/management can only be billed for once, which means if patients follow in the ortho clinic, the orthopod cannot bil). From what I hear it is good manners not to bill for this item, if for anything to keep your consultants happy. I guess the same could be said for any other "specialty" treatment...

 

[Seaglass]

Oh, If you place a transvenous pacer, you can bill for critical care time, cardiac pacing, central venous access, EKG AND rhythm strip interpretation.

Just remember that you can only bill for critical care time exclusive of any procedures you did - so you can't count the time you spent putting in the line, floating the pacer, or reading the EKG.

 

[Quimby2]

Being that us seniors will be graduating soon, thought it would be great to revise this thread:
1) history from someone other than patient increases the medical decision making complexity (+2 on Marshfield scale)

 

[docB]

Interpretation of O2 sat generates some extra billing. So does interpretation of a monitor strip.

 

[kbrown]

as i am sure that most everyone knows, but i will add...make sure to bill for critical care time. The time you spend placing CVP, Sv02, art line, chest tube, monitoring the pt on said machines, counts as a different level of billing. It is tricky billing, but it gets higher reimb. just be sure to include it. i can't remember all of the specifics on it (i am only an intern), but our staff get reminded often about CC billing. It requires that you include a short synopsis about what you did, why and how much time it took.

 

[NinerNiner999]

as i am sure that most everyone knows, but i will add...make sure to bill for critical care time. The time you spend placing CVP, Sv02, art line, chest tube, monitoring the pt on said machines, counts as a different level of billing. It is tricky billing, but it gets higher reimb. just be sure to include it. i can't remember all of the specifics on it (i am only an intern), but our staff get reminded often about CC billing. It requires that you include a short synopsis about what you did, why and how much time it took.

... And a provider must be physically present in the room during that time. Grab a midlevel if you have one and have them stay in the room while you see other patients

 

[BADMD]

... And a provider must be physically present in the room during that time. Grab a midlevel if you have one and have them stay in the room while you see other patients

I'm not sure that a midlevel is sufficent. You definitely can't have a resident do it and then bill for it.

But, looking something up on Uptodate and talking to the family about the condition is part of critical care time. Crossing the 35 minute mark isn't hard when you start including things like that.

 

[Jeff698]

... And a provider must be physically present in the room during that time.

You don't have to be in the room for critical care to count. You can be somewhere else, in house, doing things like reviewing imaging and lab data, discussing the case with consultants and preparing transfer arrangements.

Very tricky area, here.

Take care,
Jeff

 

[crewmaster1]

Are there any good courses or books on this subject? I can't believe some doc hasn't created a weekend course or something to teach people the tricks(or even just the basics)? I sure hope I learn a lot more about this in residency, because leaving med school I know very little about it.

 

[SolidGold]

Are there any good courses or books on this subject? I can't believe some doc hasn't created a weekend course or something to teach people the tricks(or even just the basics)? I sure hope I learn a lot more about this in residency, because leaving med school I know very little about it.

ACEP sponsors courses like this one on reimbursement and coding:

http://meetings.acep.org/meetings/rc2

Last one in Feb. was in Vegas, and Nashville is the site for the meeting in May.

 

[Mr. Freeze]

The concept of FFS seems odd to be applied in the EM realm, but what LITTLE I know about billing comes from EMS. Is FFS fairly systemic, or somewhat regional? All the EM physicians I know are salaried, but for all I know, the pool of money their salary comes from might be FFS based. They're also all contractors moreso than hospital employees.

Just curious how prevalent it is. It seems like there are a lot of opportunities for creativity!

 

[NinerNiner999]

FFS (fee for service) if failry prevelant in EM, and most IC positions (independent contractors) are paid on a FFS basis. This can actually be fairly lucrative. Groups (especially large contract groups) that pay fixed hourly rate or salary are dependent on inidividual physician productivity in some way, shape, or form. There is a wide variety of creative variation from group to group.

Incentive bonuses, profit sharing, and sometimes hourly pay rate are tied into productivity, and this too varies by contract. Of course, if you are a FFS IC, your bottom line is solely dependent on how many patients per hour you can see, how complex they are, what procedures you perform, and, as this thread relates, how well you document and record what you do on your chart.

Most groups (including those who oversee IC's) have their own billing company that codes and bills based on your documentation. One of my attendings put it this way - the amount that you bill is placed in the hands of someone who may have little more than a high school education. The more you can write and the easier it can be read, the more you will be able to bill.

HERE'S ANOTHER BILLING TIP:

Avoid diagnoses that start with chronic, such as (Chronic toe pain). Instead use the phrases "Acute distal extremity pain," "Musculoskeletal pain.," and "Arhritis." Three diagnoses that when combined, make your chart more complex (and more billable).

My favorite example he gave me was "Acute Hymenoptera Envenomation." It billed more than simply saying "Beesting."

Don't use the word "intoxication" for drunk/drugged patients. "Toxidrome" implied a higher level of complexity. Ex: "Alchol Toxidrome"

 

[BKN]

lastly any facial repair is a complex repair, so i hear.

I think the physician must indicate in his record that a laceration repair was a "complex closure" to bill it as such.

 

[Jeff698]

Other lac repair suggestions:

If you use scissors in any way to do any debridement, it's no longer simple. If you need to remove some excess tension and drop a SQ stich, it's a complex lac.

Two or three extra words on your chart (or boxes on your template) can dramatically increase your billing.

Take care,
Jeff

 

[EMIMG]

Medical Command of EMS - billable from what I am told.
Peak flow interpretation after a breathing treatment - billable

Be careful of wording. I know this started off with mentioning S/P Assault - I would not use those words..."Alleged" assault is much better.

Also, for those that mentioned US and billing - yes, it is billable, but need credentialing process and the guidelines for procedures (IV) indicated it must be used in real-time and permanent storage of the images must be done.