Coding resources

Discussion in 'Podiatric Residents & Physicians' started by Ankle Breaker, Jul 6, 2017.

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  1. Ankle Breaker

    Ankle Breaker Senior Member 5+ Year Member

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    Outside of doing an ACFAS or APMA coding course...

    What are the best brand of books you can purchase online to get information on ICD-10/ CPT coding?

    I found found some podiatry specific books on amazon but I am unsure how helpful they are or if they include coding for more advanced/complex procedures.

    Any information would be greatly appreciated.


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  3. msuDPM

    msuDPM 7+ Year Member

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    Optum360 Podiatry coding companion is what I use as a 1st year out attending. Not sure if there are better out there, but it provides all codes you will bill, a brief description, corresponding icd10 codes, modifiers that can be used with each code as well as global periods and RVUs for the respective code. If you're looking for how to most appropriately code a FF recon, it's not going to help you much there, but it's a solid base and quick reference. I use it everyday.
     
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  4. bunNfxr

    bunNfxr

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    I generally just google codes, but I recently had to do some research and put together a coding presentation and also found the optum 360 to be excellent. I had some others through the years, which were fine. They are all fairly standaridized. The optum 360 had more detail than I expected
     
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  5. ExperiencedDPM

    ExperiencedDPM

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    Encoder Pro/Optum 360 and Code-X by the AAOS. Code-X is available on the American Academy of Orthopedic Surgeon website.

    The online versions are the best since they allow you to enter various codes to check for CCI edits/procedures that are inclusive to another procedure, etc.

    You must also understand modifiers. Using a 79 or 59 modifier doesn't mean you can now unbundle codes that are inclusive to one another.
     
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  6. Ankle Breaker

    Ankle Breaker Senior Member 5+ Year Member

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    Thank you very much for your responses! This is good information for myself and other new practitioners.


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  7. air bud

    air bud 7+ Year Member

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    If you have plenty of CME or can get your facility to get codex for your group with multiple licenses, then I think that CODEX is the best bang for your buck. Very easy interface. It does a good job of consolidating everything. Keep in mind, these are all aggregates in some form of publicly available info. There is no coding tricks or helpful words. It is literally all of the CMS and other government rules in one spot. If you think these resources will tell you how to get better code/document an established pt level 3 to a 4, then you are mistaken. That is what the coding courses are for. They are well worth the money. I have done the ACFAS course. There are others out there.
     
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  8. air bud

    air bud 7+ Year Member

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    An example of what you might learn at a coding course, and please others correct me if I am wrong:. Doing an Evans and MCDO is a double calcaneal osteotomy. The MUE (medical unlikely edits) is 1, so you can only get paid for 1. So instead of submitting 2 codes and getting paid on 1, submit 1 code and use 22 modifier demonstrating extra work. Similar to doing so on midfoot fusion - there is a code for 1 or 2 midtarsal joint fusions. Fusing the NC and 1st TMT pays the same as doing the 2nd and 3rd TMT and intercunieform. So use a 22 modifier demonstrating the extra work involved. You did a lot of work, get paid for it.
    There is nothing illegal here. You aren't using any unspecified codes or calling something that it isn't. These are the types of things you learn. How to play within the rules. But if you don't understand the rules then you are doing yourself a disservice and putting yourself at risk
     
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  9. bunNfxr

    bunNfxr

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    From experience: Using a 22 modifier puts your claim into adjudication purgatory. You will do it a few times because you want to get paid for what you are worth. But trust me you will give up. You will not get paid on a claim with a 22 modifier for at least 6 months after sending op notes and several lengthy phone calls only to have your claim paid at the same rate without the 22 or maybe have them tack on $35.00 onto a $2000 claim for the "extra work".
    Sorry to whine, but the system is rigged and not in your favor. None of the health care reforms on the left or the right gives physicians any leverage to get paid for what they do.
    I hope you all have a better experience than I did.
     
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  10. Ankle Breaker

    Ankle Breaker Senior Member 5+ Year Member

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    If a DPM is part of a hospital group/system/network and has the hospital billers/coders communicating with the insurance companies does the hospital have more leverage to get the payments for their doctors vs a small podiatry group fighting with insurance companies?

    Or is this not how it really works?


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  11. bunNfxr

    bunNfxr

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    I have not had that luxury. But from discussions with colleagues, Yes,That is how it really works. You may have an excellent biller with a high rate of collections in a private office. But a larger group can compare several billings from several providers, put the time into talking with a rep and and say to the insurance company that the 22 modifier is not 22 dollars. The work was doubled with 2 osteotomies as is the risk, follow up and work up(even if it isn't). You paid my orthopedist 30% on the last 22 modifier and this case demands a higher percentage increase in RVU components. Contract negotiations include a discussion of fair fees, denials and appeals criteria. And by the way we are the main provider for 70% of the local population, that will have to pay out of pocket if we drop your plan. None of which can be done by a private office. They all think they can, but they do not hold those kinds of cards. Not to mention facility fees and instrument tray fees that are only(Sometimes Possible but more likely for the instrument tray fees) reimbursed when you are attached to a surgical facility.
     
  12. ExperiencedDPM

    ExperiencedDPM

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    Great post. Billing a 22 modifier is certainly more admirable than unbundling and doing "creative billing". An insurance company recently contacted me to review several cases performed by the same surgeon. The doctor performed a bunionectomy with osteotomy, which realistically pays between 500-900 bucks depending on geographic location. This doctor unbundled a single code bunionectomy with osteotomy into 13 codes with a total charge of over $33,000. Yes, you read that correctly. He billed for every possible component of a bunionectomy and then some more. A true pig who WILL get nabbed.

    To get back on topic, understand that if you bill a 22 modifier, it's NO guarantee of additional payment and a virtual guarantee that the case will be reviewed and scrutinized. If any additional payment IS approved, you may be disappointed in the amount and the length of time to obtain a decision.

    If you do decide to use the 22 modifier, do all you can to let the insurer and/or reviewer to understand the reason. When they ask for the op report, make sure the extra work is well documented. You can even make notations on the op report and bracket the extra work and make a note that info is the reason for the 22 modifier. And read and re-read your op report before sending it. I just reviewed a case where I had to deny a subtalar arthrodesis because the resident forgot to dictate that procedure but had all the other procedures. If it's not written, it didn't happen.

    My advice is bill honestly and leave the creative crap to artists. Learn how to bill correctly and not corruptly. If you don't, I ASSURE you that your career will be short lived. The insurers are looking for abusers and fraud more than ever. Buyer beware.
     
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  13. Ankle Breaker

    Ankle Breaker Senior Member 5+ Year Member

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    I have heard that doctors are more willing to get creative with their coding if they're billing a private insurance company. If they are billing Medicare they tend to be a little more ethical. Any truth to this?


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  14. ExperiencedDPM

    ExperiencedDPM

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    I'm not sure if that's true. If they do, it's even worse since you are legally supposed to have one fee schedule. Some may lower the fee for Medicare since they already know the fee schedule. But that doesn't mean they still don't get creative and try to unbundle codes.

    So the short answer is that thieves are thieves and they became arrogant and cocky and believe they are teflon. Until they get caught.

    In my experience these docs try to bilk as much as they can from anyone they can, including Medicare.
     
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  15. ExperiencedDPM

    ExperiencedDPM

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    Another thief gets busted. Michael Rotstein DPM from Florida. Apparently he was billed a lot of 11043 which is debridement into muscle/fascia but was only trimming nails. Medicare nabbed the a-hole and I couldn't be happier. I'm sure this guy was living the good life at the expense of the gov't. Now he owes back 1.5 million, will lose his license and get up to 10 years in jail.

    Was it worth it? I've been around the block a few times and know how these guys think. As I've said before they get greedier by the minute and think they are Teflon.

    This will certainly address Ankle Breaker's question whether docs are a little less creative with Medicare.

    I've said it before and I'll say it again. The government and private carriers are sick of paying fraudulent claims and are on a head hunt. It's not a matter of whether or not someone will get caught. It's more WHEN they will get caught.

    Sorry, but I've worked long and hard to earn my income and these docs nauseate me.
     
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  16. JPS398

    JPS398 2+ Year Member

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    Goodness.
     
  17. Creflo

    Creflo time to eat 10+ Year Member

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    If you are working as an employee for a podiatry practice, and medicare audits the practice and finds that there was overbilling and money is due back to medicare, is the practice or the employee podiatrist liable for this?
     
  18. ExperiencedDPM

    ExperiencedDPM

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    Great question. It depends on how the procedures were billed and if it was billed under the corporation or the individual doctor. Most associates sign an agreement to allow a practice to collect payment on behalf of the doctor. It assigns the practice the reimbursement.

    I would caution all associates to find out how billing is done and to also periodically ask to see claims. I've seen many cases of the billing staff changing the codes without approval of the associate.

    If your name is on the claim.......buyer beware.
     
  19. air bud

    air bud 7+ Year Member

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    I wanted to add some anecdotal evidence when it comes to billing and coding. I had a case today that I asked a few people about. 4 of the 5 people went to my program where we learned very little about coding. These are all very smart people mind you. 2 people that are in private practice said they would bill a 3. 1 of them says he literally never bills 4 on new patient. Maybe once or twice in 2 years. This blew my mind. The other guy says he wouldn't do a 4 because he doesn't think there is enough risk involved. He thinks this is reserved for internists and really sick people. 2 others that work for large groups said yes it is a 4. Scenario:. New diabetic patient presents with right foot pain. Also has discolored thick nails b/l 5th digits. X rays have previously been taken. I reviewed labs including ALT AST A1c (a little elevated), did a injection for neuroma , briefly discussed and answered questions on surgery (said by no means are we there yet) and put on lamisil. I reviewed risks benefits with all and documented that I did all of this. Key word documented. "I personally reviewed LFT taken on 6/30 as part of a CMP and they were within normal limits." We say level 4, 2 private practice people say 3. Keep in mind everybody is only a few years ago.
    However, I am still routinely surprised at my friend's in private practice who do not bill level 4s. For some reason they only think of time and just don't understand data points, MDM and diagnosis. Is it because it is the blind leading the blind? I routinely send requests to the head biller in my large MSG to review and she approves 95 percent of the level 4s I send through.
     
  20. NatCh

    NatCh Senior Moment 10+ Year Member

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    Funny you should say that...

    Fraudulent billing? Trauma codes for elective procedures?

    "There is a lot of coding that's unclear. If you look at online coding forums you see professional coders asking one another how to bill certain procedures and a lot of times you'll see different suggestions. If you look at codingline.com you see experienced podiatrists trying to figure out how to code things. It's not always simple and straightforward.

    At a big group or institution after doing surgery you might just turn over your op report to the billing department, after which a coder tries to match what they read on your report with what they believe to be correct. A coder inexperienced with podiatry might get the wrong set of codes, but its the surgeon's name attached to that bill. Or, the surgeon picks the wrong codes just out of ignorance or inexperience and the coder doesn't catch the error. I think we should give each other the benefit of the doubt before accusing anyone of intentional wrongdoing. Yes, some people are outright committing fraud though -- I believe that, but most coding errors are probably accidental."
     
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  21. NatCh

    NatCh Senior Moment 10+ Year Member

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    Your post brings up another point -- nowadays we have to document in painstaking detail and with gluttonous quantity in order to meet guidelines, to get reimbursed, and to avoid penalization. It ends up creating a three page note where in the past 3/4 of a page would've conveyed the same useful info. When I get referral notes from other doctors I have to sift through all the meaningless (to me) data to find what they actually did. Totally annoying.

    Edit: I just got a new referral this morning for a dystrophic nail. The note from the PCP is six pages long. Six!
     
    Last edited: Jul 18, 2017
  22. air bud

    air bud 7+ Year Member

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    I agree about having to make things too wordy. I was taught to basically think out loud on paper. Basically more word shows more "thought" by an auditor unfortunately.
     
  23. NatCh

    NatCh Senior Moment 10+ Year Member

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    I saw some old chart notes in my medical record from when I was a child. I'm making up this particular note, but they went something like this:

    S: Difficulty hearing
    O: Cerumin impaction
    A/P: Irrigation

    Now the same visit would need a $10M EHR system and a scribe.
     
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  24. Creflo

    Creflo time to eat 10+ Year Member

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    In response to air bud above, my understanding is that podiatrists can't chart/bill a comprehensive level physical exam due to our limited scope of practice. This is my interpretation from podiatry billing and coding seminar from McVey Seminars. To bill a level 4, you need moderate level medical decision making, which we probably can do. But you need comprehensive history or comprehensive exam to go along with this. The seminar as I understood stated pods don't have the scope of practice to do a comprehensive exam, we aren't licensed in the number of body systems necessary to hit the bullets/body systems. As for why we can't chart a comprehensive history, I'm not clear. Perhaps if we can, we could bill a level 4? So my take is we max out at level 3, again based on my understanding of the seminar. Still learning myself, the only thing I know for sure is that there is a lot of inconsistency of understanding.
     
  25. bunNfxr

    bunNfxr

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    Because to hit a level 4, the number of available bullet points requires a speculum or prostate exam, which I hop you are not doing. (How is it both of your hands are on my shoulders doc?). But you can bill a level 4 based on time, if you document the time, and the reason you needed that much time (6 complicated presenting problems, not patient would not shut up!). But it will be up to the auditor as to whether or not any podiatry exam needs 45 minutes. And this will depend upon what your colleagues bill for the same service, even if you do it better. Ultimately you can bill it. If your billings put you on the far right of a bell curve, you will get audited and spend more time and postage and staff fighting it than you will make. If you have a complicated Charcot, equinus, Ulcer, osteo, nail fungus, ingrown, bunion, restless leg, neuralgia patient and the patient brought each of those concerns to you as a presenting problem and you outlined a plan to treat each one and you EMR captured the time you came into the room and the time you left being greater than 45 minutes than you can and should bill a level 4 in my opinion.
    Unless surgery is done on the next encounter in which case your e&m is included in the surgical RVUs. How many do this .. close to zero... all targets.
     
    Last edited: Jul 20, 2017
  26. msuDPM

    msuDPM 7+ Year Member

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    So, coming up on 1 year out working for a hospital I'll add my two cents. First, I encourage all residents to look into the rules on e/m coding because unlike many "grey areas" of coding (primarily procedural) I do believe e/m is fairly cut and dry. I recommend emuniversity.com to everyone. Once you have the basics down the have a free cheat sheet (http://emuniversity.com/Free/Guide.pdf) which I have printed and on my desk everyday.

    First off to add to air bud's anecdote: Sounds like you have a DM pt (possibly with neuropathy, but in this instance really makes no difference) with a neuroma and onycho for which you did an injection and provided lamisil.

    I typically start at level of risk and work backwards. You provided "prescription drug management" this is automatically "moderate risk" (and also true for everytime your write a rx). OK, next you have data points. You reviewed labs and xrays, only 2 points and good for "low complexity" BUT you have a new patient with a new problem to you which automatically is 3 points and "moderate complexity" and since your MDM level is determined by your 2 highest categories, your MDM is moderate and qualifies for a level 4. Pretty straight forward, and good news is that MDM level should ALWAYS drive your coding. Now for the downside hinted at above, a new level 4 requires a COMPREHENSIVE history AND physical. As far as history goes I see no problem, it includes 4 of NLDOCAT factors, 10 ROS, and complete PMH/PSH/SOC/FAM Hx (all should be on a new pt form). As for physical, I can see how this becomes a grey area for this as per 1997 rules requires 2 bullet points from 9 organ systems. Personally, I believe you can reasonably consider 8 of them in your exam (Constitutional, Respiratory, Cardiovascular, Lymphatic, Musculoskeletal, Skin, Neurologic, Psychiatric). Beyond that I suppose you need to decide if you needed to note something regarding their Eyes, EENT, Neck, or Abd for your exam. If you have a problem with this, I suppose coding a new 4 is not for you and I do understand this (I do not often code 99204's). BUT if you think that you should be compensated for meeting CMS guidelines for MDM, history taking and pretty much all of the physical exam, but you didn't feel right noting their conjunctiva was intact or "no obvious masses" for neck (because youre just a podiatrist, afterall ;)) then I think that is also fair. Nearly every FP has a nearly identical PE template for their charting, do you REALLY think they physically examined every bullet point everytime? The flip side to this is that a established 4 only requires a detailed physical exam and is fairly easily obtainable. In all I do believe podiatrists as a whole do under code on E/M simply because they have never specifically reviewed the guidelines and operate on generalizations.

    Quick last note on coding on time. The only two requirements are that the minimum time threshold has to be face to face and AT LEAST half has to be coordination of care. The patient could be seen for onychomycosis and you spent 25 minutes explaining what nail fungus is and the side effects of lamisil and the next 20 explaining directions to the lab for the pt to have their LFTs checked. It is still a level 4 as long as you document (and can prove in case of an audit) that you spent the time. Granted if you did this for every patient you could only see about 10 per day. Ha.

    Additionally just for reference and because all of my e/m coding is tracked, my most recent month breakdown ended up about 25%/65%/10% for level 2/3/4.
     
    Last edited: Jul 20, 2017
  27. Ankle Breaker

    Ankle Breaker Senior Member 5+ Year Member

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    Great post!




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  28. air bud

    air bud 7+ Year Member

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    Read your colleagues charts. Ortho, FP, Rheum....etc. eyes: visual acuity intact (they walked into the room and can clearly see. They follow your movements...). Ears: auditory ability present:. They acknowledge and answer your questions... Is this every time? No. As previously said you start with MDM and risk and work backwards. When that is met, you then add basic info on General exam, pysch, eyes, ears, respiratory (no respiratory distress noted). Quit undervaluing yourself and over valuing your colleagues. Yes it requires mixing 97 and 95 guidelines. But it is very easy to do a 9 part physical exam and whatever part ROS exam. The ROS is a list of boxes the patient checks.
    I think it comes down to people not knowing the rules. The physical exam, PMSH, ROS etc is the easy part. The HPI 4+ is even easier. Every chart should have 4+ HPI. So it comes down to MDM. Book a procedure on a patient that has a 90 day global? Moderate. Do a procedure with a 10 day global on a patient with risk factors like DM, CKD etc? moderate. Listen I understand there is still some gray area. Am I going to bill a 4 for a ingrown nail on patient that is DM, CKD and CHF that you put on AB? No. But that is absolutely moderate decision making.

    Also, at my practice, I do not get paid to read x-rays. Radiology reads them about an hour later. So I automatically have 2 data points when I independently read and review x-rays. And then I check their most recent labs including A1c. And document this. I understand how this is hard for a private practice person to do, but it takes 2 minutes for a person on EMR and in a big MSG to do. Anyways, I completely disagree with the concept of pods not billing level 4s. Maybe I will feel differently when I get audited. But I did everything I documented and I documented everything I did. And it took me longer to do my charts.
     
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