Coding/Billing 2023

[DMBandFan86]

The main coding changes for 2023 affecting inpatient and consulting physiatrists.

Some benefits, easier to write a note to qualify as a level 2 based on medical complexity.

But then they added an extra 10 minutes for level 2 time-based coding for follow ups and an extra 15 minutes for level 3. That is certainly going to lower the ability to bill based on time for inpatient. Am I reading this correct? Also 5 minutes extra for initial inpatient visit.

I usually don't bill a lot of level 3's anyways, but 50 - 64 minutes is a lot of time even with conferences. Doesn't help with medicare physician cuts as well.

---

Members don't see this ad.

 

[sloh]

Yea, should code based off medical complexity for most cases, and even more so with the changes

 

[PurpleSmiley]

The changes with the increased time also includes any time it takes you to review labs, medications, documentation, counseling/education, care coordination with therapy/case management/nursing/etc, clinical work-up, orders, etc on the day you see a patient. It's not just face to face time anymore. So on team conference days for patients I'm spending time writing the team conference note, a progress note, talking to the entire team, counseling patients and family after, so I certainly feel that I'm meeting the time requirement.

 

[RangerBob]

The changes with the increased time also includes any time it takes you to review labs, medications, documentation, counseling/education, care coordination with therapy/case management/nursing/etc, clinical work-up, orders, etc on the day you see a patient. It's not just face to face time anymore. So on team conference days for patients I'm spending time writing the team conference note, a progress note, talking to the entire team, counseling patients and family after, so I certainly feel that I'm meeting the time requirement.

Those things all counted before. Previously 50% or more of your time had to be face to face with the patient.

Does anyone have a good summary/link re the new changes? Does time spent on writing your notes count now as it does for outpt providers?

This is a bummer... I had thought the time changes wouldn't go through. We had a decent number of level 3's by time, but there's a big difference between 35min and 50 minutes. Plus the Medicare cuts...

 

[PurpleSmiley]

Those things all counted before. Previously 50% or more of your time had to be face to face with the patient.

Does anyone have a good summary/link re the new changes? Does time spent on writing your notes count now as it does for outpt providers?

This is a bummer... I had thought the time changes wouldn't go through. We had a decent number of level 3's by time, but there's a big difference between 35min and 50 minutes. Plus the Medicare cuts...

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf?fbclid=IwAR2oAVNjVDCE3euqSrCX1AH9PrPXrpTLCWy4ggNJSqTo9sdKlUR9pd7W3YY

- Specifically, page 20 talks about what counts within time. Now there's no need for 50% or more of the time is face to face - although on my unit, face to face time usually is about 50% of the total time spent.

 

[RangerBob]

https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf?fbclid=IwAR2oAVNjVDCE3euqSrCX1AH9PrPXrpTLCWy4ggNJSqTo9sdKlUR9pd7W3YY

- Specifically, page 20 talks about what counts within time. Now there's no need for 50% or more of the time is face to face - although on my unit, face to face time usually is about 50% of the total time spent.

View attachment 363771

Thanks.

I guess the "documenting clinical information in the electronic or other health record" sort of counterbalances the additional time added, as that wasn't something that counted prior. Still, I don't see too many 50+ minute patient encounters in my future...

It looks like prolonged service still applies once you're over 60 minutes though, correct?

 

[RangerBob]

Am I reading things correctly that our HPI and exam really don't matter anymore? (From a billing standpoint, as long as somewhere in our note our complexity is justified?)

 

[DMBandFan86]

Am I reading things correctly that our HPI and exam really don't matter anymore? (From a billing standpoint, as long as somewhere in our note our complexity is justified?)

The guidance I have is "medically appropriate" history and exam. Yea! Goodbye nearly pointless 10-point ROS. The only bad thing I have seen with outpatient documentation over the last year is some bad physical exams or people just not doing/documenting what they did.

It looks like prolonged service still applies once you're over 60 minutes though, correct?

Time over 64 minutes now. Can bill for each additional 15 minutes and stack the code.

The changes with the increased time also includes any time it takes you to review labs, medications, documentation, counseling/education, care coordination with therapy/case management/nursing/etc, clinical work-up, orders, etc on the day you see a patient. It's not just face to face time anymore. So on team conference days for patients I'm spending time writing the team conference note, a progress note, talking to the entire team, counseling patients and family after, so I certainly feel that I'm meeting the time requirement.

Time for EMR documentation and ordering is now included. But I'm pretty sure people were including this prior anyways. I mean unless you have someone following you all day with 20 stop watches, how do you really know how much time you spend doing all these things. Especially with multi-tasking. I really just do my best guess. But is that going to help in an audit?

Many bill level 3 H&P's based on time. Very rare that an IPR patient would get level 3 based on complexity (probably shouldn't be in IPR). You now have to spend 75-89 minutes on each H&P. Even with a complex patient from outside hospital with lots of records wouldn't take me that long. If you did admit orders the day before that wouldn't even count. For me they are shutting down level 3's.

Yea, should code based off medical complexity for most cases, and even more so with the changes

I agree. Even on a very simple IPR patient, I sometimes write discontinued Tylenol or whatever bowel medication that would get me to a level 2 for the day based on prescription drug management. If there is nothing else better, at least I did something and should justify a level 2. Almost all IPR patients meet level 2 based on number and complexity of problems.

 

[j4pac]

The guidance I have is "medically appropriate" history and exam. Yea! Goodbye nearly pointless 10-point ROS. The only bad thing I have seen with outpatient documentation over the last year is some bad physical exams or people just not doing/documenting what they did.


Time over 64 minutes now. Can bill for each additional 15 minutes and stack the code.


Time for EMR documentation and ordering is now included. But I'm pretty sure people were including this prior anyways. I mean unless you have someone following you all day with 20 stop watches, how do you really know how much time you spend doing all these things. Especially with multi-tasking. I really just do my best guess. But is that going to help in an audit?

Many bill level 3 H&P's based on time. Very rare that an IPR patient would get level 3 based on complexity (probably shouldn't be in IPR). You now have to spend 75-89 minutes on each H&P. Even with a complex patient from outside hospital with lots of records wouldn't take me that long. If you did admit orders the day before that wouldn't even count. For me they are shutting down level 3's.


I agree. Even on a very simple IPR patient, I sometimes write discontinued Tylenol or whatever bowel medication that would get me to a level 2 for the day based on prescription drug management. If there is nothing else better, at least I did something and should justify a level 2. Almost all IPR patients meet level 2 based on number and complexity of problems.

Well…if you work 8 hours and you say that you spent 45 minutes face to face with 14 patients, math says that you were likely overbilling. You also could have a patient call you out on the time spent. Now…it’s going to be impossible for them to track time. My EMR, Epic, actually tracks time spent in the chart, which now becomes pretty nice.

Worth noting, technically, the prep time is only suppose to count the date of service. So prepping the night prior, if you’re that type of person, doesn’t count toward the time. But of course, nobody can prove you didn’t.

 

[lejeunesage]

Sorry, what is "prolonged service" again? I've never billed for anything over a level 3.

 

[Iamnew2]

The guidance I have is "medically appropriate" history and exam. Yea! Goodbye nearly pointless 10-point ROS. The only bad thing I have seen with outpatient documentation over the last year is some bad physical exams or people just not doing/documenting what they did.


Time over 64 minutes now. Can bill for each additional 15 minutes and stack the code.


Time for EMR documentation and ordering is now included. But I'm pretty sure people were including this prior anyways. I mean unless you have someone following you all day with 20 stop watches, how do you really know how much time you spend doing all these things. Especially with multi-tasking. I really just do my best guess. But is that going to help in an audit?

Many bill level 3 H&P's based on time. Very rare that an IPR patient would get level 3 based on complexity (probably shouldn't be in IPR). You now have to spend 75-89 minutes on each H&P. Even with a complex patient from outside hospital with lots of records wouldn't take me that long. If you did admit orders the day before that wouldn't even count. For me they are shutting down level 3's.


I agree. Even on a very simple IPR patient, I sometimes write discontinued Tylenol or whatever bowel medication that would get me to a level 2 for the day based on prescription drug management. If there is nothing else better, at least I did something and should justify a level 2. Almost all IPR patients meet level 2 based on number and complexity of problems.

I haven’t read the changes yet but level 2’s already pay next to nothing like 52 bucks or something they expect us to bill level 1? I don’t think many patients would be level 1 - if a patient was a level 1 they wouldn’t be in the hospital. So level 3 now are 74 minutes of a mix of face to face with documentation review and speaking with pt/OT/case managers am I getting this correctly? Also for those who work in snf/ltach as independent contractors under a company that like my former company took 35percent of income what’s left for the doctor - like 50 bucks per visit?

 

[sloh]

I haven’t read the changes yet but level 2’s already pay next to nothing like 52 bucks or something they expect us to bill level 1? I don’t think many patients would be level 1 - if a patient was a level 1 they wouldn’t be in the hospital. So level 3 now are 74 minutes of a mix of face to face with documentation review and speaking with pt/OT/case managers am I getting this correctly? Also for those who work in snf/ltach as independent contractors under a company that like my former company took 35percent of income what’s left for the doctor - like 50 bucks per visit?

It’s always been about 50 bucks per patient with SAR work. We make it up with sheer volume. Also, SAR is generally lucrative bc of the high volume of follow-ups, not initial visits.

 

[DMBandFan86]

Sorry, what is "prolonged service" again? I've never billed for anything over a level 3.

Service over the time for level 3. Additional code. Usually for long family conferences or code status discussions that get lengthy. Or when you have to call 4 family members because there is no POA.

 

[lejeunesage]

Service over the time for level 3. Additional code. Usually for long family conferences or code status discussions that get lengthy. Or when you have to call 4 family members because there is no POA.

What's the CPT code for that? And do you use that in addition to or in lieu of 99233

 

[Iamnew2]

Service over the time for level 3. Additional code. Usually for long family conferences or code status discussions that get lengthy. Or when you have to call 4 family members because there is no POA.

Wow I have never known that existed or used that! And I have spent sooo much time in my former gig with some patients - sometimes 30-40 + minutes daily just for face to face stuff.

 

[DMBandFan86]

99418 is the 2023 code. What I understand the old codes will be gone. Use for first 15 minutes prolonged and then stack every additional 15 minutes if needed. This is addition to the level 3 time billing. So if you are doing an IP follow up 65-79 min you would bill level 3 on time and also 99418.

 

[DMBandFan86]

Don’t know what the reimbursement is. May be only 5 bucks lol.