Clarification on billing?

[Pudortu]

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Working at a new place with RVU incentive. Had a question about placing diagnoses and how I get paid.
If I see a patient and lets say disposition them, should I just put the main diagnoses or multiple diagnoses? If BP slightly high put HTN? Mildly elevated LFTs on labs, put LFTs?
Just for clarification, I'm trying to understand if putting multiple final Diagnoses pays more than just putting one single diagnosis. Any help would be very grateful.

 

[southerndoc]

It may support more complexity to your case, which would help justify a higher code. It may not necessarily pay more as opposed to just justifying more complexity.

Diabetes, morbid obesity, etc. always increases complexity.

I frequently diagnose everything in the book. For example, a recent appendicitis diagnoses looked like this:

• Acute appendicitis, non-perforated with localized peritonitis
• Acute right lower quadrant abdominal pain
• Nausea and vomiting
• Dehydration
• Leukocytosis, unspecified type
• Fever, unspecified
• Diabetes, type II, without complication or long-term use of insulin
• Morbid obesity
• Hypertension, essential

 

[Vandalia]

If the only goal is to maximize billing, then the more diagnoses the better. However, there are two limiting factors that should be obvious. (However, the older I get the more I realize obvious things are often not obvious.)

1) If you list a diagnosis, you had better have accounted for it in your assessment and plan. As an example, in the above list, if DM had never been mentioned before by the patient or in the record, simply listing it without some action (even if only "see PCP") is an easy source of liability. Again, that should be obvious....

2) The second is diminishing returns. I could probably spend 5 minutes clicking on boxes for some patients. But at some point you need to move on.

 

[BoardingDoc]

It may support more complexity to your case, which would help justify a higher code. It may not necessarily pay more as opposed to just justifying more complexity.

Diabetes, morbid obesity, etc. always increases complexity.

I frequently diagnose everything in the book. For example, a recent appendicitis diagnoses looked like this:

• Acute appendicitis, non-perforated with localized peritonitis
• Acute right lower quadrant abdominal pain
• Nausea and vomiting
• Dehydration
• Leukocytosis, unspecified type
• Fever, unspecified
• Diabetes, type II, without complication or long-term use of insulin
• Morbid obesity
• Hypertension, essential

Why? This is a huge waste of time. Appendicitis alone as a diagnosis assuming you got CT imaging, labs, and consulted surgery is easily a lvl 5 chart already without all the added diagnoses.

 

[Pudortu]

Why? This is a huge waste of time. Appendicitis alone as a diagnosis assuming you got CT imaging, labs, and consulted surgery is easily a lvl 5 chart already without all the added diagnoses.

So maybe to clarify...In a RVU system with a CMG, I (not the hospital) get paid based on Chart level (3/4/5), Procedures, EKG, & critical care. Not all the diagnoses I put down (which may support my charting level) get me reimbursed. Just making sure I properly understand. Thanks again.

 

[Hercules]

Absolutely.


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[GeneralVeers]

Why? This is a huge waste of time. Appendicitis alone as a diagnosis assuming you got CT imaging, labs, and consulted surgery is easily a lvl 5 chart already without all the added diagnoses.

I agree. Once you've made a level 5 (admission) the only other things that are going to bump your RVU are critical care, EKG/pulse ox interpretations, and procedures.

It's the patients getting discharged who you have to increase the complexity to bill Level 5. Adding the extra diagnosis, lab interpretations, and specialist consultations should help with that.

 

[Pudortu]

I agree. Once you've made a level 5 (admission) the only other things that are going to bump your RVU are critical care, EKG/pulse ox interpretations, and procedures.

It's the patients getting discharged who you have to increase the complexity to bill Level 5. Adding the extra diagnosis, lab interpretations, and specialist consultations should help with that.

Can you clarify about the pulse ox interpretations? We get paid for that separately? How do you document it?
If I have 5 pulse ox's in the ER prior to dispositioning a patient, do you just "interpret" each one?
Do you put a blurb like "Pulse ox interpreted by me 95%, not hypoxic" ? Thanks for clarifying

 

[BoardingDoc]

I agree. Once you've made a level 5 (admission) the only other things that are going to bump your RVU are critical care, EKG/pulse ox interpretations, and procedures.

It's the patients getting discharged who you have to increase the complexity to bill Level 5. Adding the extra diagnosis, lab interpretations, and specialist consultations should help with that.

From what I gather, the pulse ox thing has basically gone away. The code for it (94760) is now entirely bundled into the overall visit code by Medicare and I think most major insurances have followed suit. That said, agree about procedures and ekgs and things like definitive fracture care.

 

[BoardingDoc]

Can you clarify about the pulse ox interpretations? We get paid for that separately? How do you document it?
If I have 5 pulse ox's in the ER prior to dispositioning a patient, do you just "interpret" each one?
Do you put a blurb like "Pulse ox interpreted by me 95%, not hypoxic" ? Thanks for clarifying

See my comment above in response to veers. Aside from looking this up online, you should talk to your coders about this stuff as they will be able to give you more definite answers about all the nitty gritty stuff.

 

[southerndoc]

1) If you list a diagnosis, you had better have accounted for it in your assessment and plan. As an example, in the above list, if DM had never been mentioned before by the patient or in the record, simply listing it without some action (even if only "see PCP") is an easy source of liability. Again, that should be obvious....

2) The second is diminishing returns. I could probably spend 5 minutes clicking on boxes for some patients. But at some point you need to move on.

It takes me 1 minute to put all those diagnoses in. If it's a new onset diabetes (which I would put in the diagnosis new onset diabetes) or if there's something abnormal, then I address it. Otherwise, they all get a PCP referral and that does the trick. Granted I work in a state where gross negligence clause applies.

One could argue that by not diagnosing it you could be held liable for not recognizing it as a serious comorbidity to their condition.

 

[Rendar5]

It takes me 1 minute to put all those diagnoses in. If it's a new onset diabetes (which I would put in the diagnosis new onset diabetes) or if there's something abnormal, then I address it. Otherwise, they all get a PCP referral and that does the trick. Granted I work in a state where gross negligence clause applies.

One could argue that by not diagnosing it you could be held liable for not recognizing it as a serious comorbidity to their condition.

20-30 patients a shift, 20-30 minutes saved by putting in only enough documentation to allow for a level 5 visit. Extra tasks add up even if they don't take much time individually. Acute appendicitis assuming verified by labs and imaging interpretation and H&P, is a level 5 visit without anything added. Now if it's a fall in an old person who's unsteady and needs social admission and doesn't have much in the way of diagnosis or sepsis w/o source in someone I want to admit, I'll pad the diagnosis list w/ extra diagnoses that are accurate.

 

[southerndoc]

I do most of my documenting after a shift. It's not taking 1 extra minute to put in diagnoses. It's taking 30 extra seconds. You're already in the diagnosis section of the chart. Literally it takes 3 extra seconds for me to type "ty ii dia non witho ins" and hit enter twice for it to place "type ii diabetes, non-complicated, without insulin" in the chart.

I more than make up for the time with the 70+ order sets that are two clicks to get orders in. Abdominal pain r/o appendicitis, right flank pain, left flank pain, etc. that automatically orders labs, CT's, UA, and pain meds with IV fluids and PRN Zofran. Most docs take 2-3 minutes finding this stuff to order.

So I think you're point about time savings doesn't really apply to me as I more than make up for time spent with diagnoses in other areas. More than 70% of my charts are level 5.

 

[Vandalia]

It takes me 1 minute to put all those diagnoses in. If it's a new onset diabetes (which I would put in the diagnosis new onset diabetes) or if there's something abnormal, then I address it. Otherwise, they all get a PCP referral and that does the trick. Granted I work in a state where gross negligence clause applies.

One could argue that by not diagnosing it you could be held liable for not recognizing it as a serious comorbidity to their condition.

I am not arguing with what you provided. My point is that there is an extreme limit to including every possible diagnosis. I have had a mid-level so obsessive she diagnosed myopia in someone wearing glasses - in for a kidney stone. If you are reading every item on the list deciding if the patient has it or not then it will not work out well. Again, if it is a relevant diagnosis it needs to be included, but if it is included and is new it needs to be addressed in some form. Again, I have worked with people who have had that nasty habit. Remember my initial statement, I am talking about things that are obvious that are apparently not obvious to 1% of EM "providers."

 

[Rendar5]

I do most of my documenting after a shift. It's not taking 1 extra minute to put in diagnoses. It's taking 30 extra seconds. You're already in the diagnosis section of the chart. Literally it takes 3 extra seconds for me to type "ty ii dia non witho ins" and hit enter twice for it to place "type ii diabetes, non-complicated, without insulin" in the chart.

I more than make up for the time with the 70+ order sets that are two clicks to get orders in. Abdominal pain r/o appendicitis, right flank pain, left flank pain, etc. that automatically orders labs, CT's, UA, and pain meds with IV fluids and PRN Zofran. Most docs take 2-3 minutes finding this stuff to order.

So I think you're point about time savings doesn't really apply to me as I more than make up for time spent with diagnoses in other areas. More than 70% of my charts are level 5.

Ok, so let's cut it down even further, say instead of 30 seconds for those extra 7 diagnoses, you take 20 seconds per chart. At 20-30 patients ina shift. That's an extra 7-10 minutes staying after shift typing in extra details that aren't required to bill at a level 5 except for a certain portion of charts. If you want to stay late doing that, sure, but just realize it's not needed for majority of level 5 charts, for most of which 1-3 diagnoses is sufficient complexity.

 

[BoardingDoc]

It takes me 1 minute to put all those diagnoses in.

It's not taking 1 extra minute to put in diagnoses.

???

So I think you're point about time savings doesn't really apply to me as I more than make up for time spent with diagnoses in other areas.

The fact that you're saving time in one area doesn't justify wasting it somewhere else. Why not just take that time you've saved earlier and spend it doing something fun as opposed to entering diagnoses? I mean, do whatever you want to do, but for everyone else reading this I'd personally recommend only charting what is actually going to be beneficial.

I freely admit that I am something of an optimization freak (min/maxing all the way), but this **** adds up to serious amounts of time in the long run. I have a little macro that clicks some basic review of systems boxes for me that some other docs I work with don't have. Each chart takes maybe 3-5 seconds of clicking those boxes manually, vs 1 second to click the premade one. At ~25 charts a shift, 15 shifts a month, 12 months a yr, that adds up to at a bare minimum 2.5 hours of time saved per year that would otherwise be spent clicking checkboxes. I would rather do almost anything with my free time other than clicking ROS checkboxes. 30 seconds per patient for extra diagnoses by the same math adds 37.5 HOURS per year entering in diagnoses that don't get you any extra money.

 

[NITRAS]

Co-morbid conditions and major co-morbid conditions (CC's and MCC's) will effect the DRG of the hospital stay based on the admitting diagnosis. . . but your hospitalist should worry about that.

As long as you have the HPI, history, ROS, PE, and MDM to support your billing. . . . Having an acute New problem with further workup planned will support a high level of MDM. Of course so will worsening of an established problem with two stable established problems. So I guess having a couple established or self limiting problems can be reasonable.

I'm a hospitalist, but I assume your documentation is similar.

 

[Pudortu]

As an aside, if an ortho tech or nurse places a splint for you, do you put a procedure note and just document you supervised the procedure to gain the extra RVU?

 

[GeneralVeers]

As an aside, if an ortho tech or nurse places a splint for you, do you put a procedure note and just document you supervised the procedure to gain the extra RVU?

Yes. I usually walk in while they are finishing the splint, check cap refill and neuro status and examine the splint. Then document that it was applied by myself.

 

[southerndoc]

I am not arguing with what you provided. My point is that there is an extreme limit to including every possible diagnosis. I have had a mid-level so obsessive she diagnosed myopia in someone wearing glasses - in for a kidney stone. If you are reading every item on the list deciding if the patient has it or not then it will not work out well. Again, if it is a relevant diagnosis it needs to be included, but if it is included and is new it needs to be addressed in some form. Again, I have worked with people who have had that nasty habit. Remember my initial statement, I am talking about things that are obvious that are apparently not obvious to 1% of EM "providers."

I'm not quite that bad. Usually it's comorbidities (diabetes, hypertension, dyslipidemia in a chest pain) or related diagnoses (not just appendicitis but also acute right lower quadrant abdominal pain). Believe it or not, I've had an insurer kick back a CT bill because the diagnosis was only appendicitis.

 

[southerndoc]

The fact that you're saving time in one area doesn't justify wasting it somewhere else. Why not just take that time you've saved earlier and spend it doing something fun as opposed to entering diagnoses? I mean, do whatever you want to do, but for everyone else reading this I'd personally recommend only charting what is actually going to be beneficial.

Like posting on SDN while at work (as I'm doing now)?

I freely admit that I am something of an optimization freak (min/maxing all the way), but this **** adds up to serious amounts of time in the long run. I have a little macro that clicks some basic review of systems boxes for me that some other docs I work with don't have. Each chart takes maybe 3-5 seconds of clicking those boxes manually, vs 1 second to click the premade one. At ~25 charts a shift, 15 shifts a month, 12 months a yr, that adds up to at a bare minimum 2.5 hours of time saved per year that would otherwise be spent clicking checkboxes. I would rather do almost anything with my free time other than clicking ROS checkboxes. 30 seconds per patient for extra diagnoses by the same math adds 37.5 HOURS per year entering in diagnoses that don't get you any extra money.

Perhaps I wasn't clear before. I don't document every little thing that's wrong with them. Comorbidities and related things. No, I don't just stop at acute appendicitis. I also document other related things. Diabetes is a serious comorbidity that needs to be documented especially with cellulitis, chest pain, etc.

I also have macros and can dictate my HPI portion while clicking macros for ROS and physical exams. I have a ton of them -- chest pain, chest pain leg swelling, right/left flank pain, etc. Makes it very quick to document.

 

[southerndoc]

As an aside, if an ortho tech or nurse places a splint for you, do you put a procedure note and just document you supervised the procedure to gain the extra RVU?

Didn't realize we are allowed to do this. I usually just free text that I examined post splint, but we're allowed to do a procedure note that we supervised them?

 

[GeneralVeers]

Didn't realize we are allowed to do this. I usually just free text that I examined post splint, but we're allowed to do a procedure note that we supervised them?

My understanding of the rule is that documenting "splint checked by MD" and "neurvascular status intact before and after splinting" allows us to bill for the splint placement.

 

[southerndoc]

My understanding of the rule is that documenting "splint checked by MD" and "neurvascular status intact before and after splinting" allows us to bill for the splint placement.

I'm definitely losing RVU's by not doing this. Will have to start.

 

[Rendar5]

I get credit also even if I say splint placed by RN or medic as long as I do post splint evaluation.

 

[southerndoc]

I get credit also even if I say splint placed by RN or medic as long as I do post splint evaluation.

What all do you write as your procedure note?

 

[Money Moniker]

As you guys may have heard, medicare will do away with level 1-5 designations and just go to a flat rate of $135 per "visit." What is that likely to do to EM compensation, in your opinion?

 

[GeneralVeers]

As you guys may have heard, medicare will do away with level 1-5 designations and just go to a flat rate of $135 per "visit." What is that likely to do to EM compensation, in your opinion?

It depends on what hoops they make us jump through to get to $135. If charting is simplified then I don't need a scribe which is potentially $10-$20/hr savings. I can't see this becoming reality anytime soon. The reason for the current "levels" is so they can get away with downcoding charts to save money. It's all a game.

 

[Hercules]

As you guys may have heard, medicare will do away with level 1-5 designations and just go to a flat rate of $135 per "visit." What is that likely to do to EM compensation, in your opinion?

Implementation is not until 2019 with a likely pushback to 2020 with a comment period going through September 2018.

I would expect no impact on EM as Verma’s current proposal since I believe it included an exclusion for ED visits.


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[deleted109597]

It's just the E/M codes for office visits, not facility based ones.
But don't fool yourselves, if this passes then they'll go for facility next.

Doubtful it will change our documentation requirements. We still have to clicky box everything for quality metrics, even if it won't change our payments.

 

[EM Junkie]

Agreed that adding a couple of extra diagnoses (when present) can justify the complexity of care provided (more of a hospital billing issue than your own).

That being said, as Medical Director, I'd get charts sent to me every so often where the ED doc admitted someone to inpatient status for UTI. UTI does not buy you a > 2 midnight stay in the hospital. However, UTI, delirium, severe sepsis, hypokalemia (as an example) would justify the admission, and also get you 30 minutes of critical care time.