coding & billing

[clubdeac]

Yes f/u's only need 2/3. New patients need 3/3

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[emd123]

Maybe I'm under coding. By what you guys are saying, it seems you'd never have level 2 follow ups. I usually bill some level 2's, mainly because when they show me the average distribution of codes billing in Pain mgmt, nationally and in my state, there's always a certain percentage of level 2's billed by providers at large. Is the whole state and country under billing by billing any level 2's? Generally, you don't want to be an outlier compared to the averages, right?


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[lord_jeebus]

From my reading, 2 out of 3 components - PE, HPI, and decision making - have to be a level 3 or higher to bill level 3. so even if MDM is only level 2, if the HPI and PE are greater than level 2, you can bill appropriately for the higher code.

The problem with this reasoning is that any f/u visit can be manipulated into a level 5, which is clearly inappropriate. The question, then, is for any given f/u visit, how much PE and HPI is medically necessary and appropriate. I don't think the answer is clear. If you use MDM to determine the billable level, I think you will always be safe, but there may be times when "level 4" PE/HPI may be indicated for a case with low MDM, or "level 3" PE/HPI for a case with straightforward MDM. I've reviewed Medicare's E/M guidelines and the AMA CPT guide at length and I don't have a good answer.

 

[Pain Applicant1]

The problem with this reasoning is that any f/u visit can be manipulated into a level 5, which is clearly inappropriate. The question, then, is for any given f/u visit, how much PE and HPI is medically necessary and appropriate. I don't think the answer is clear. If you use MDM to determine the billable level, I think you will always be safe, but there may be times when "level 4" PE/HPI may be indicated for a case with low MDM, or "level 3" PE/HPI for a case with straightforward MDM. I've reviewed Medicare's E/M guidelines and the AMA CPT guide at length and I don't have a good answer.

I generally agree with this post. Nearly all of my History and PE fall into Level 5. I think it's safe to bill by MDM. By the way, this attachment will make your life a lot easier if you want to do everything by the book.

 

[Ducttape]

The problem with this reasoning is that any f/u visit can be manipulated into a level 5, which is clearly inappropriate. The question, then, is for any given f/u visit, how much PE and HPI is medically necessary and appropriate.

theres the key. upcoding by doing unnecessary PE or HPI would be inappropriate. but if you have justification for doing so...

if you bill by MDM alone, but you do not document either a PE or HPI commisurate with the level of MDM, i think you would get dinged too. i do not believe a single component of level 3 is adequate enough documentation to bill a level 3 visit. it seems easier to document an appropriate PE or HPI with a higher level MDM, however.


as a side note, for a follow up on an injection, typically i:
-review the benefits, % and duration.
-review the potential side effects, including those related to steroids if used.
-review the purpose of the injection - not just for pain, but to allow patients to work aggressively on their primary long term therapeutic interventions - ie PT, CBT. i make sure necessary referrals are in place, or home exercise program has been initiated, and discuss how to advance or improve what is being done.
-check Vital signs, examine the site of the injection (skin), the targetted organ systems(generally, musculoskeletal and/or neurologic) (at least 2 organ systems).
-review the course of therapy - when to repeat injections, expected duration of benefits, when to contact the office to discuss the need for further injections, when to schedule routine follow ups.

with the exception of TPIs, imo that should qualify as a level 3.

(a level 2 follow up might be "so you went to PT? no better? go back...")

 

[SSdoc33]

theres the key. upcoding by doing unnecessary PE or HPI would be inappropriate. but if you have justification for doing so...

if you bill by MDM alone, but you do not document either a PE or HPI commisurate with the level of MDM, i think you would get dinged too. i do not believe a single component of level 3 is adequate enough documentation to bill a level 3 visit. it seems easier to document an appropriate PE or HPI with a higher level MDM, however.


as a side note, for a follow up on an injection, typically i:
-review the benefits, % and duration.
-review the potential side effects, including those related to steroids if used.
-review the purpose of the injection - not just for pain, but to allow patients to work aggressively on their primary long term therapeutic interventions - ie PT, CBT. i make sure necessary referrals are in place, or home exercise program has been initiated, and discuss how to advance or improve what is being done.
-check Vital signs, examine the site of the injection (skin), the targetted organ systems(generally, musculoskeletal and/or neurologic) (at least 2 organ systems).
-review the course of therapy - when to repeat injections, expected duration of benefits, when to contact the office to discuss the need for further injections, when to schedule routine follow ups.

with the exception of TPIs, imo that should qualify as a level 3.

(a level 2 follow up might be "so you went to PT? no better? go back...")

i think that is a 4

 

[lord_jeebus]

if you bill by MDM alone, but you do not document either a PE or HPI commisurate with the level of MDM, i think you would get dinged too. i do not believe a single component of level 3 is adequate enough documentation to bill a level 3 visit. it seems easier to document an appropriate PE or HPI with a higher level MDM, however.

I didn't mean to suggest that corresponding PE or HPI was not necessary. What I was trying to say is that if your MDM matches the billed level, it is probably safe to assume that completing PE or HPI at that level and billing that level is always medically necessary and appropriate.

 

[bedrock]

I don't ever bill for a level 2 unless it's for solely an orthopedic problem that has completely resolved. Anything in the spine requires a more involved exam and discussion, even about ways to avoid hurting themselves again.

Keep this in mind. All the orthopedic surgeons I've ever known, bill level 3 for every new and f/u patient. And you know how crap their exams and notes are. So don't ever worry you're overbilling for level 3 if you have decent documentation.

All spine f/u ups are at least a level 3, even if they responded to treatment.
The vast majority of my spine consults and follow-ups are level 4s, with a lesser degree of level 5s for trainwrecks.

No one audits level 3 visits. They look for people coding inappropriate level 4s and 5s. Don't worry about billing level 3s.

Just like speeding, the cops give you a pass to everyone going 6 miles over the limit. They spend their time more efficiently looking for people going 15 mph or more over the limit.

 

[Pacman27]

If you prescribe an opioid, review the UDS, PDMP, 4 A's, ROS, PE, and plan
I would think that warrants a level 4 follow up. In general I think anyone on opioids should be a level 4 if the above is done

Most of my new patients are levels 4's or 5's. But then again I am new to the game and spend about 45 minutes with every new patient. I dont know how some people see 25 to 30 patients. I need to speed things up

 

[clubdeac]

Pacman you're doing exactly what I do. You will start to get busier, become more efficient and therefore ramp up from 10-15/day to 20-25/day with subsequently less level 4 and 5's and more level 3 and 4's to accommodate the time difference. I still however bill a lot of level 5's for my initial visit b/c like you I am thorough and many of them have at least two new issues or one new issue that needs further w/u qualifying them for a level 5 for that specific portion of the note