coding & billing

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Tenesma

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i am constantly getting offers to buy

Pain Management Coding & Billing Answer Book (i guess it is a binder filled with looseleaf entries on coding/billing issues)

it is about $500

is it worth it - i am sure you guys get the same mailings...
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I bought it several years ago when I was revising my superbill. I liked the one from 21st Century Edge better. It was very well organized and there was good depth regarding the nuances of billing for each type of procedure. It has been a while since I looked at either of these guides so things might have changed.

Linda Van Horn spoke at the ISIS meeting this year and afterward she was literally mobbed by people asking questions. If some of the meeting staff hadn't intervened I think she would have missed lunch. She also knew a lot about current legislative and political issues. I could have listened to her all day.

I have heard lectures from the contributing author, David Vaughn, several times. He is an attorney specializing in fraud and abuse. He also presented at ISIS. Excellent speaker.

Based on the lectures I'd say the 21st Century Edge book should continue to be a very worthwhile purchase.

http://www.21stcenturyedge.com
 
I asked amphb the same thing a week ago. He recommended Linda van Horn, Joanne Mehmert, and David Vaughn.

I noticed Mehmert will be speaking in October at a CEU for practice managers and CPC at a course. I may wiggle myself to that course.

http://www.decisionhealth.com/conferences/pain2007/

Nashville TN October 10-12, 2007

If we are name dropping, I'd also recommend Googling Amy Mowles. She sets up ASC's for Pain and seems to be the go to for practice management consulting.

Disclaimer: I have never met any of the above, but have only heard very positive comments about these folks.
 
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lobelsteve said:
I asked amphb the same thing a week ago. He recommended Linda van Horn, Joanne Mehmert, and David Vaughn.

I noticed Mehmert will be speaking in October at a CEU for practice managers and CPC at a course. I may wiggle myself to that course.

http://www.decisionhealth.com/conferences/pain2007/

Nashville TN October 10-12, 2007

If we are name dropping, I'd also recommend Googling Amy Mowles. She sets up ASC's for Pain and seems to be the go to for practice management consulting.

Disclaimer: I have never met any of the above, but have only heard very positive comments about these folks.
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For the record, I have no idea who Joanne Mehmert is. I concur with Gorback re Linda and David, however, who are two of the smartest people I know on the subject.

Mr. Vaughn also has a course in December in San Antonio: https://www32.safesecureweb.com/lalawfirm/ArticleAttachments/Brochure.Final..pdf
 
Just answer me this one question...please.
Can I bill 77003 twice for a two level TFESI (medicare/medicaid)? I have received several answers from "experts" and still have no clue.

thanks.
 
stim4u said:
Just answer me this one question...please.
Can I bill 77003 twice for a two level TFESI (medicare/medicaid)? I have received several answers from "experts" and still have no clue.

thanks.
Click to expand...
CPT code 77003 is intended to be reported per spinal region (e.g., cervical lumbar) and not per level. However, I have also been told that Iif I do lumbar and sacral procedures, I should ojnly bill 77003 once. It is my understanding that, for purposes of billing 77003, the spine only has two "regions": cerrvicothoracic and lumbosacral.

So if your two TFESIs were both lumbar, or bother cervical, then you could only bill 77003 once. However, if one was lumbar and the other was cervical, then you could bill for it twice.
 
They're right. When performing lumbar and sacral procedures, 77003 may be billed only once.

Joanne Mehmert was our consultant and we found her to be extremely thorough and knowledgeable. Expensive...but well worth it. She often tag teams with Amy Mowles. We hired Joanne after attending a coding and billing workshop. Amy also lectured and was quite impressive! If I was considering building my own ASC, she'd definately be the "go to" person.
 
stim4u said:
Just answer me this one question...please.
Can I bill 77003 twice for a two level TFESI (medicare/medicaid)? I have received several answers from "experts" and still have no clue.

thanks.
Click to expand...

Hi All,

Disclaimer: as some of you know, I've formed a dedicated pain medicine billing, coding, and auditing company. We will answer specific questions posted here to contribute to the forum, and hopefully this is not offensive nor considered too much of an advertisement. Should you wish more information about our services, feel free to PM me. 😀

77003 follows the same coding rules as 76005. It is payable per REGION- cervical, thoracic, lumbar AND sacral all separately payable. the AMA's CPT Assistant answered this question back 2001 or 2002. To paraphrase, someone asked, "If an injection is done at L5/S1 is the xray payable for both regions?" AMA responded YES it is. They later amended the answer to say if ONE injection is done between L5 and S1 you can only bill for ONE xray, as opposed to TWO injections in TWO regions. PM me if anyone is interested in the exact date this was published and I will dig it out for you. If you have CPT Assistant Archives from the AMA, search under 76005 and you will find it.

One of our staff has worked with Joanne and she is VERY good. Incidentally, we posed this exact scenario to her and (L5 TFESI and S1 TFESI injections) and she said that according the the AMA, it was billable twice- once for lumbar and once for sacral. However, she emphasized that "she wasn't crazy about doing it" and when you are one the border like this, you better save very clear images showing one injection in the lumbar region and one injection in the sacral region, in case anyone questions it. It depends on how aggressive you want to be. Having a copy of the AMA's guidelines in your compliance folder would also be helpful.

So for example, some theoretical situations:
if you did a cervical, thoracic, lumbar TFESI, you could bill 77003 x3
if you did a cervical and sacral, you could bill 77003 x 2
if you did a lumbar TFESI and Sacral TFESI, you could bill 77003 x 2
if you did three lumbar TFESIs, you could bill 77003 x 1
 
SO what would you guys suggest that I do about the following. I am forming a group with some orthopods and they have hired billing and coding people for their stuff and said I can just use their people for mine as well. However, I'm figuring that they would need to be proficient in pain mgmt coding & billing to really do a good job. Am I thinking corrrectly?

Would you recommend sending one of them to a course in this, me going to the course(gonna be darned near impossible getting time off) or hiring someone who already knows this stuff? Or am I over-reacting and pretty much anybody can bill & code for pain mgmt?

Thanks for any help!
 
Lizard1 said:
SO what would you guys suggest that I do about the following. I am forming a group with some orthopods and they have hired billing and coding people for their stuff and said I can just use their people for mine as well. However, I'm figuring that they would need to be proficient in pain mgmt coding & billing to really do a good job. Am I thinking corrrectly?

Would you recommend sending one of them to a course in this, me going to the course(gonna be darned near impossible getting time off) or hiring someone who already knows this stuff? Or am I over-reacting and pretty much anybody can bill & code for pain mgmt?

Thanks for any help!
Click to expand...

PM sent. But your intuition is correct. If the billing department is IN HOUSE (ie employed by you in the building), you could use their billing and coding people, but they need to be specifically trained in the nuances (and there are MANY of them) of pain management coding. DO NOT let the orthopods believe otherwise; ortho and pain billing/coding is a totally different beast.

If they are outsourcing their billing, then I would not use their company unless that company also *specializes* in pain management billing (in addition to ortho).

For example. when I was in fellowship, my Anesthesiology department had contracted with an anesthesiology billing company. They did great billing for ANESTHESIA. They also decided to use the same company for the pain clinic. DISASTER. We're talking in-office medicare stim trials that went unbilled for 5 or 6 months at a time, because the anesthesia billing company had no idea how to handle it. In fact, they said it was un-billable and had to be done in the OR! Tens of thousands of dollars were lost on that alone, not to mention all the other improperly billed pain procedures.
 
Ligament said:
Hi All,

Disclaimer: as some of you know, I've formed a dedicated pain medicine billing, coding, and auditing company. We will answer specific questions posted here to contribute to the forum, and hopefully this is not offensive nor considered too much of an advertisement. Should you wish more information about our services, feel free to PM me. 😀

77003 follows the same coding rules as 76005. It is payable per REGION- cervical, thoracic, lumbar AND sacral all separately payable. the AMA's CPT Assistant answered this question back 2001 or 2002. To paraphrase, someone asked, "If an injection is done at L5/S1 is the xray payable for both regions?" AMA responded YES it is. They later amended the answer to say if ONE injection is done between L5 and S1 you can only bill for ONE xray, as opposed to TWO injections in TWO regions. PM me if anyone is interested in the exact date this was published and I will dig it out for you. If you have CPT Assistant Archives from the AMA, search under 76005 and you will find it.

One of our staff has worked with Joanne and she is VERY good. Incidentally, we posed this exact scenario to her and (L5 and S1 injections) and she said that according the the AMA, it was billable twice- once for lumbar and once for sacral. However, she emphasized that "she wasn't crazy about doing it" and when you are one the border like this, you better save very clear images showing one injection in the lumbar region and one injection in the sacral region, in case anyone questions it. It depends on how aggressive you want to be. Having a copy of the AMA's guidelines in your compliance folder would also be helpful.
Click to expand...


Actually, Joanne was the one who said we COULDN'T bill twice for 77003. She repeated what ampaphb said...there are only two regions...cervicothoracic and lumbosacral. We addressed this in Aug 2006, if your answers are from 2001, things may have changed, or if your answer is more recent, then our protcol may be out of date. I'll call and ask her.
 
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PainDr said:
Actually, Joanne was the one who said we COULDN'T bill twice for 77003. She repeated what ampaphb said...there are only two regions...cervicothoracic and lumbosacral. We addressed this in Aug 2006, if your answers are from 2001, things may have changed, or if your answer is more recent, then our protcol may be out of date. I'll call and ask her.
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That is interesting PainDr, hopefully we are both correct in this sense; we also personally spoke with Joanne about this specific issue in August 2007, and that was the concensus at that time (that it could be billed twice if done in seperate regions ie L5TFESI and S1TFESI). We discussed the above mentioned CPT article with her. She did emphasize that this is a grey area and not an exact science.
 
So, I guess there still is no clear answer...
 
stim4u said:
So, I guess there still is no clear answer...
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Do you think medicare is going to allow you to bill for 77003 twice? what about those who do a bilateral 2 level epidural? Bill it 4 times?
You need to do what makes you money and at the same time do what is right. All you are going to do is raise red flags and get yourself audited, and that is a lose-lose situation.
Who does a cervical and a lumar epidural on the same day anyways? Hope you are not doing that too often either...
 
77003 is per level - my notes have been audited and have been paid w/ 77003 used for different areas...

who does bilateral 2 level transforaminals?????? what the???
 
Tenesma said:
77003 is per level - my notes have been audited and have been paid w/ 77003 used for different areas...

who does bilateral 2 level transforaminals?????? what the???
Click to expand...

you may well have been paid - that just means they will ask for the money back down the road.


I checked with my LCD - if you have a verifiable source you are wiling to share with us, I will gladly charge per level, but till then, the $76 is just not worth the OIG knocking on my door
 
Hi all,

For those who are the more experienced practitioners out there: What course or book or even both would u suggest to improve on improving on billing in the pain world.

Any help is appreciated.
 
listen Kwijubo... or whatever you nickname is.

I am asking a question on a forum.
Looking for advice and comments.
Not some pent-up pain doctor looking to impose his biased opinion on billing.
Read the forum, there are experts questioning gray zones of billing all the time. If we are covering all our overhead costs and prices keep on rising on supplies monthly, why not maximize one's billing. I just need the facts, sport, not your jibberish...
 
Sorry about that.
There is just a lot of questionable stuff that goes on out there and it has really damaged our field. There are some many 'gray lines' that can be crossed, but in the end, what really happens to our field? The system has been/is being abused and it is what leads to the rapidly decreasing reimbursements.
I don't know about you, but I do some peer review work, and there is so much abuse. I have asked the company to send me only injections performed without fluorscopy. You have no clue how many blind bilateral L1-5paravertebral (MB) blocks are done everyday, and companies pay for it over and over again.
NY actually pays far more for an interlaminar epidural for work comp/no fault than a transforaminal because people were doing tons of bilateral 5 level trannies!
In regards to this thread, I had dinner with a pain doc who told me he does 300 injections a week(with a PA who performs injections as well for him) and he told me he bills fluoro x4 for his bilateral 2 level transforaminals(he doesnt do interlaminar and is mostly medicare), after he asked me if I perform trigger point injections or transforaminals for back pain...

So, again I apologize for being obnoxious/rude. I think we are from the same area, so if I could help you with any overhead/reimbursement issues please feel free to IM me. And you are right, this is a forum for learning and sharing thoughts and experiences.
 
for billing 77003 for each level. Those guys are the man, I have no idea who they are, but I respect their opinions based on their comments from this site.
 
Kwijibo said:
Sorry about that.
There is just a lot of questionable stuff that goes on out there and it has really damaged our field. There are some many 'gray lines' that can be crossed, but in the end, what really happens to our field? The system has been/is being abused and it is what leads to the rapidly decreasing reimbursements.
I don't know about you, but I do some peer review work, and there is so much abuse. I have asked the company to send me only injections performed without fluorscopy. You have no clue how many blind bilateral L1-5paravertebral (MB) blocks are done everyday, and companies pay for it over and over again.
NY actually pays far more for an interlaminar epidural for work comp/no fault than a transforaminal because people were doing tons of bilateral 5 level trannies!
In regards to this thread, I had dinner with a pain doc who told me he does 300 injections a week(with a PA who performs injections as well for him) and he told me he bills fluoro x4 for his bilateral 2 level transforaminals(he doesnt do interlaminar and is mostly medicare), after he asked me if I perform trigger point injections or transforaminals for back pain...

So, again I apologize for being obnoxious/rude. I think we are from the same area, so if I could help you with any overhead/reimbursement issues please feel free to IM me. And you are right, this is a forum for learning and sharing thoughts and experiences.
Click to expand...

It is understandable that this is a heated thread. These billing/coding rules are set up to cause exactly this sort of cognitive dissonance amongst us doctors. If we are not sure how to bill/code, then the insurance companies get to keep their money and pay us less.

Also, it seems that some of the posters are commenting about different things. There is a difference in billing per region Vs. per vertebral level.
 
gorback said:
What, exactly, is the problem with doing that?
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Do they discount the lumbar ESI if you do cervical on the same day? sometimes i would do both for patients who are from out of town so that they do not have to come 2 times.....i don't think there is anything wrong with saving patient's time and helping with their pain.
 
p.s. what billing software and clearing housese are you guys using? Any warnings on any particular product? How did you guys get in- house billing started?
 
C Fiber said:
Do they discount the lumbar ESI if you do cervical on the same day? sometimes i would do both for patients who are from out of town so that they do not have to come 2 times.....i don't think there is anything wrong with saving patient's time and helping with their pain.
Click to expand...

This is the only downside that I know of, which is why I asked the question. The other consideration is the patient's expenses (two facility fees instead of one). You can expect to be paid 50% on the second procedure (so bill the most expensive one first).

When patients ask me why I can't do both at the same time I just honestly tell them about the fee reduction and 99% of the time they are appalled (as am I) that insurance companies do this. I've had a few feisty patients who called up the carrier and fussed but that accomplishes nothing.

The concept behind this, as it was explained to me by an insurance medical director, is that you are not being paid just for the difficulty of the procedures. They also consider your time. When you do two or more procedures at once they figure you don't have down time like prepping, room turnover, etc.

I once ran a spreadsheet comparing a morning of multiple procedures and a morning of single procedures and this actually seemed to work out as a wash. Of course the model will change with different parameters (how long you set turnover time, procedure execution time, type of procedure, etc). Your mileage may vary.
 
1) 300 procedures/week - that is 60 procedures a day - impossible with two people (dr and nurse practitioner) because they would have to see over 60 patients for consultations and follow-ups a day and guarantee that EACH E&M converts to a procedure - so now you are talking about 120 patient encounters per day... 60 patient encounters per provider.... which means 7.5 minutes per procedure, consultation and follow-up... not to mention time for documentation of those visits (dictations, etc...)... unless he has a system we can all learn from....

2) medicare will pay for up to 2 77003s per encounter if you can document and code with modifiers the right way

3) it is interesting how insurance companies dis-incentivize multiple procedures on the same day... i have run the numbers comparing multiple versus single and it works out better to never do multiple procedures.... even those guys that are doing 2 level TFESI should be thinking about doing one level on Monday and the 2nd level on Tuesday and billing each one as a 64483/77003 (x2) [approx $130 in a hospital based practice x2 = $260] versus 64483/64484/77003 [approx $160] so a $100 loss.... makes you scratch your head... of course i don't do this because it is a bit unethical and mean to the patients... maybe that is how that guy does 300 procedures/week...
 
I'll bet he doesn't need a night light. Given the readings from my xray badge, if I did even 300/MONTH I'd be way over the limits.

I know of a guy in Texas who does 300+/month. He has a whole entourage of PA's, RNs, etc to handle the evals. I can't imagine that the care is all that good.

Good care doesn't seem to matter any more though. I expect a pain clinic to open at Wal-Mart any day now, right next to the cath lab.
 
i run a solo practice - and i try really hard to be a well-rounded pain guy... i perform procedures on about 15-20% of patients that i consult on - so not a REAL block jock (but close to it)... i average 20-30 E&Ms/day... and I have to admit that I can't keep all the patients straight without relying heavily on my EMR... especially when a bunch of them share the same last name....

so in my opinion if you are doing more than 50 procedures a week you really start running into scary territory.... unless of course you just don't care (about patients and good outcomes)...
 
There are some issues being confused here. Medicare, with some exceptions, does not decide the definition of a code. That is the AMA's million dollar baby. What we first need to do is translate procedures into accurate coding language to get paid for what you do- no more, no less.
So, in this case, the AMA has defined the code 77003 as "code-able" per region and the regions are cervical, thoracic, lumbar and sacral. See AMA's CPT Assistant Archives Sept 2002 and Dec 2005 (specific to L5 and S1) and other "clinical vignette" examples. I know a doctor that had this information copied to him by BCBS when he tried to bill fluoro per level, same region, and they asked for his notes.

Medicare LCDs determine under what circumstance a procedure will be covered. If your local Medicare carrier has made an LCD that they will not cover procedures in 2 separate regions on the same day because it's "not medically necessary", then they can do that. That is NOT the same thing as them taking money back because you "falsely" coded a service you provided, i.e. billed and were paid for two fluoros in one region.
Right now, there is no NCD limiting the number of regions treated at the same time. I know some local Medicare carriers will pay, and some won't, for treatment in 2 different regions on the same day *when medically necessary* (which is a completely separate flame war. 😀 ) Of course, you will probably have to use modifiers (e.g. 59) on the fluoro to get it paid and you will have to take the multiple procedure discount (50% on 2nd injection, but paid 100% on 2nd fluoro- you really have to weigh lower payment vs. patient satisfaction having to come x2). I have even seen one case where THREE fluoro regions were billed and paid by Medicare on one poor train wreck...

Hypothetically, if you were to do a bilateral L3 and L4 TFESI, you could only bill 77003 one time (NOT x4) because it is one region. (Maybe this doesn't happen in reality, but it's a good example for coding, if not for medicine.)
If you do a T11, T12 and L1 TFESI, you could bill 77003 twice, once for thoracic and once for lumbar.
If you do a bilateral L5 and S1 TFESI, you could bill 77003 twice, once for lumbar and once for sacral.

I was able to speak to Joanne Mehmert again about this question. She felt that the verbage from the AMA clearly supports billing 77003 x2 and that the practice was defensible if questioned (audited). HOWEVER, with an aggressive prosecutor, she did say that it might be harder to show evidence that you had to perform more work, since the 2 nerves are so close. A more clear-cut example that we discussed was a L4 TFESI with a sacro-iliac injection. She said she would feel completely comfortable billing 77003 x2 for that because it is more obvious. An even more foggy example we discussed: LS/S1 interlaminar w/ a sacro-iliac injection. Medically, these are totally different procedures, and I would see the extra work in performing the second fluoro. BUT since they both border on the sacral region, the "common man" (read "insurance weasel") will tend to say they are both sacral (I mean, they both have an "S") and therefore are one region. In this case, she would only bill ONE fluoro.

Of course you don't want to bill inaccurately and subject yourself to audit. But at the same time, not billing for services that you did because you're afraid to, is a good way to go out of business. With the Medicare cuts, it's getting harder these days for ethical doctors who don't want to be block jocks to make a buck.
If it were my practice, I would either purchase the AMA's coding resources and read them myself (about $300) or write and ask the AMA your questions (you have to be a member -$420- for this, but it is an awesome online service that I have used several times) and get the info straight from the horse's @&#- I mean mouth! 😉

PS- ASIPP, ISIS and Decision Health all provide coding classes in pain management. Again, if it were my practice, I would attend the courses myself and/or have the person who reviews all my claims attend one of these classes. Or you could pay for someone who's certified to come to your office and train everyone-then you can have them tailor the class to your practice. Be sure to list any courses you pursue and who attends in your HIPAA folder as a compliance training.
 
local medicare rules can be a bit nuts...

my carrier just decided that it is "medically unnecessary" to provide a trigger point in conjunction with any other interventional procedure.... so for example, i did a trigger point of the trapezius (that works like a charm every 3-4 months for this lady) in conjunction with an L4 TFESI for radiculitis.... and they nixed the trigger point....

even though i used the appropriate modifiers and ICD codes to explain what happened - and then appealed their decision with my notes - they basically told me to go shove it somewhere dark...
 
but here is another 77003 issue

is an SI joint 77003 or 77002 --- initially i was coding 77002 but was told by several professional coders i should change to 77003 since it is para-spinal... Like a facet joint - kind of...

i have been charging 77003 ever since - but i still scratch my head...
 
Tenesma said:
but here is another 77003 issue

is an SI joint 77003 or 77002 --- initially i was coding 77002 but was told by several professional coders i should change to 77003 since it is para-spinal... Like a facet joint - kind of...

i have been charging 77003 ever since - but i still scratch my head...
Click to expand...

Hi Tenesma, since this is getting quite away from the OPs question, we'll answer your question in a new thread shortly.
 
Not to beat this fluoro coding issue to death, but how many fluroo levels are people billing for a L4,5,Ala MBB one sided series. I typically bill just one 77003 code, but the ala may be consider part of the sacrum. I guess this is pushing it...right.

any thoughts.
 
wouldn't push your luck - just use 77003 once...
 
Didn't want to make a new thread for this. I've been having a lot of patients returning for their f/u's after RFA, facet injections, ESIs etc and they are doing great. Not to toot my own horn, hehehe. I still do a thorough eval, document pain reduction and what improvements they have in function and even document their prior pain level and functioning. I don't schedule a f/u but have them call me if pain returns. What would you bill for this visit. I've been billing a level 3. Is that ok??
 
If they come in and say, "Doing great. Call you when I need you," I usually do a 2. Maybe I should do a 3, but if its a quick nothing visit, with no rx no follow up planned, I do a 2. If I prescribe something, then a 3. If some new issue comes up, and it gets more complication, write a script, multiple diagnosis, then 4. 5 if very complicated.
 
For procedure follow-up, if pain is improved to 0/10, I bill level 2. If there is still some pain, I reason that there is enough re-evaluation by me into the etiology and treatment options for the pain to justify documenting and billing a level 3.
 
The level of coding still needs to be medically justified. It would not be hard to perform and document a comprehensive history and comprehensive physical exam on every patient, but that doesn't mean that it is reasonable to bill a level 5 follow-up for every patient. Proper documentation is necessary to bill for the level that you deserve, but medical necessity determines the level of patient visit that is justified.

If a patient comes back to clinic after a procedure with 0/10 pain, stopped all their pain meds, and functioning at a high level with no other pertinent problems or complaints, is there medical necessity for spending 15 minutes face-to-face with that patient, or doing the things that enable billing a level 3 or 4 visit? I don't see it.

As CMS puts it, "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."
 
E&M is based on history, exam, and complexity of problems treated or evaluated. If all are not appropriate in documentation then upcoding or downcoding is fraud.
 
lobelsteve said:
E&M is based on history, exam, and complexity of problems treated or evaluated. If all are not appropriate in documentation then upcoding or downcoding is fraud.
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This is correct...

clubdeac said:
Didn't want to make a new thread for this. I've been having a lot of patients returning for their f/u's after RFA, facet injections, ESIs etc and they are doing great. Not to toot my own horn, hehehe. I still do a thorough eval, document pain reduction and what improvements they have in function and even document their prior pain level and functioning. I don't schedule a f/u but have them call me if pain returns. What would you bill for this visit. I've been billing a level 3. Is that ok??
Click to expand...

...and therefore this is billed as a level 2. The reason being is that the HPI and PE may allow for a higher level of billing but your MDM will put you at a level 2. That is, unless you bill per time. Don't forget that it's very easy to investigate how much time is spent with each patient in most EHRs.
 
speaking of billing, how are members preparing for ICD-10 coding? Are you reading the manual on MSK, pain, etc. Or leaving it up to the administrators to figure it out?thanks.
 
Pain Applicant1 said:
This is correct...



...and therefore this is billed as a level 2. The reason being is that the HPI and PE may allow for a higher level of billing but your MDM will put you at a level 2. That is, unless you bill per time. Don't forget that it's very easy to investigate how much time is spent with each patient in most EHRs.
Click to expand...
For a level 2, the MDM has to be considered straightfoward, right? Minimal number of diagnoses or treatment options/minimal amount and or complexity of data/minimal risk of complications and or morbidity&mortality.

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.

Additionally, a simple difference between a level 2 99212 and level 3 99213 might boil down to the addition of the following for 99213:
- Review of Symptoms problem focused for 99213 (not required for 99212);
-exam of affected body area or organ system and one other body area/organ system for 99213 (only 1 body area or organ PE required for 99212)

so if you do an injection, review the possible side effects and document that they did not occur, and do a, for example, back and neurologic exam, you can rightfully bill a 99213, even if MDM is straightforward...
 
The level defaults to the least complex of the HPI, ROS, PE or medical decision making. That way, even if you document a level 5 H and P, if it's just a stubbed toe, it's still a level 2.

Likewise, if it's super complex (level 5) but your physical exam only has one or two body parts, it defaults down to a three (or even 2).


Sent from my iPhone using SDN Mobile
 
Ducttape said:
For a level 2, the MDM has to be considered straightfoward, right? Minimal number of diagnoses or treatment options/minimal amount and or complexity of data/minimal risk of complications and or morbidity&mortality.

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.

Additionally, a simple difference between a level 2 99212 and level 3 99213 might boil down to the addition of the following for 99213:
- Review of Symptoms problem focused for 99213 (not required for 99212);
-exam of affected body area or organ system and one other body area/organ system for 99213 (only 1 body area or organ PE required for 99212)

so if you do an injection, review the possible side effects and document that they did not occur, and do a, for example, back and neurologic exam, you can rightfully bill a 99213, even if MDM is straightforward...
Click to expand...

I stand corrected, you're right. I've been underbilling some of my notes then. I don't know how I missed that. New patients require all 3 but follow ups only require two components. As long as History and Exam are EPFs you can bill it as a Level 3. Thanks for catching that.
 
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