e + m

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I admit that I’ve been using the previous e/m standards when billing which isn’t great. Cigna decided this week to start regularly audit e+m codes nationwide. 10% of our practice is Cigna so it’s important I don’t get burned here.

Can someone help me with a very simple list of bullet points of the most recent revision in e+m billing guidelines that I need to include with documentation for e+m codes on level 3, 4, 5 on new and f/u patients?

 

[SgtThunderfistMD]

see attachments

 

[BoardingDoc]

I admit that I’ve been using the previous e/m standards when billing which isn’t great. Cigna decided this week to start regularly audit e+m codes nationwide. 10% of our practice is Cigna so it’s important I don’t get burned here.

Can someone help me with a very simple list of bullet points of the most recent revision in e+m billing guidelines that I need to include with documentation for e+m codes on level 3, 4, 5 on new and f/u patients?

1: Dude, it's been 4 years.
2: You're in for some pleasant surprises. The new EM format is so much better than the old one, and there's so much less documentation required. ROS doesn't matter at all anymore. You don't need to document crap like onset, timing, etc for the sake of billing. It's really a nice change. You just need to wrap your head around the "best 2 out of 3 column" concept. Pain is easy though. You will almost never use column 2, so you can just focus on maxing 1 and 3.

 

[clubdeac]

1: Dude, it's been 4 years.
2: You're in for some pleasant surprises. The new EM format is so much better than the old one, and there's so much less documentation required. ROS doesn't matter at all anymore. You don't need to document crap like onset, timing, etc for the sake of billing. It's really a nice change. You just need to wrap your head around the "best 2 out of 3 column" concept. Pain is easy though. You will almost never use column 2, so you can just focus on maxing 1 and 3.

Never use column 2? I always review data and or order data to meet a level 4. “Independent interpretation of MRI or X-rays” all day long

 

[runfastnow]

If you text/call/talk to spine surgeon about patient it's an easy column 2 moderate/level 4 check box as well.

 

[clubdeac]

If you text/call/talk to spine surgeon about patient it's an easy column 2 moderate/level 4 check box as well.

Agree and I call radiologists all the time to talk about their MRI findings. Boom level 4 middle column

 

[RaceCanyon]

2 chronic conditions addressed today.
Moderate complexity due to spinal procedure recommendation / risk benefit analysis / discussion.

Easy peasy

 

[Ferrismonk]

2 chronic conditions addressed today.
Moderate complexity due to spinal procedure recommendation / risk benefit analysis / discussion.

Easy peasy

This is the easiest.

 

[Ducttape]

easiest, but is it appropriate?

the benchmarks suggest that around half of our coding should be level 3s.

it doesnt sound like that is what some people on this forum are doing.

ortho apparently does 51-60% level 3s.

noninvasive cardiology is 53-64% level 4s.

Better benchmarks for E/M coding comparisons

www.mgma.com

i dont have MGMA access.

MGMA | DataDive | Procedural Profile

The MGMA Data Dive Procedural Profile is an intelligent & intuitive tool for viewing healthcare CPT coding profiles for any provider specialty.

mvmgma.org

 

[runfastnow]

Other physicians not understanding the given rules of the game and not maximizing their productivity is not the problem of those who do.

Can easily play within the rules and have 80+% level 4 when dealing with chronic spine/ortho conditions and any sort of Rx/injection/procedure management.

 

[PMROralBoards]

easiest, but is it appropriate?

the benchmarks suggest that around half of our coding should be level 3s.

it doesnt sound like that is what some people on this forum are doing.

ortho apparently does 51-60% level 3s.

noninvasive cardiology is 53-64% level 4s.

Better benchmarks for E/M coding comparisons

www.mgma.com

i dont have MGMA access.

MGMA | DataDive | Procedural Profile

The MGMA Data Dive Procedural Profile is an intelligent & intuitive tool for viewing healthcare CPT coding profiles for any provider specialty.

mvmgma.org

Ortho also has high productivity cases and don’t have to care about documenting well to meet level 4s to pick up the crumbs. Can’t comment on cardiology.

 

[cowboydoc]

easiest, but is it appropriate?

the benchmarks suggest that around half of our coding should be level 3s.

it doesnt sound like that is what some people on this forum are doing.

ortho apparently does 51-60% level 3s.

noninvasive cardiology is 53-64% level 4s.

Better benchmarks for E/M coding comparisons

www.mgma.com

i dont have MGMA access.

MGMA | DataDive | Procedural Profile

The MGMA Data Dive Procedural Profile is an intelligent & intuitive tool for viewing healthcare CPT coding profiles for any provider specialty.

mvmgma.org

Do you drive 1 MPH under the posted speed limit in the left lane next to a semi to ensure the 12 cars behind you don't exceed the speed limit?

If you do the work and document according to the expectations for a level 4, you should bill a level 4. If you bill a level a 3 while doing/documenting level 4 work, you are also committing fraud.

Your complex patient population certainly justifies greater than average number of level 4 visits.

Matching a benchmark is nonsense.

 

[cowboydoc]

Do you drive 1 MPH under the posted speed limit in the left lane next to a semi to ensure the 12 cars behind you don't exceed the speed limit?

If you do the work and document according to the expectations for a level 4, you should bill a level 4. If you bill a level a 3 while doing/documenting level 4 work, you are also committing fraud.

Your complex patient population certainly justifies greater than average number of level 4 visits.

Matching a benchmark is nonsense.

Here’s a snippet of my latest feedback from coding.

Several were bumped from 3 to 4, none down coded. Clearly, I didn’t know about the 96127, which is 0.16 wRVUs if applicable.

 

[clubdeac]

Here’s a snippet of my latest feedback from coding.

Several were bumped from 3 to 4, none down coded. Clearly, I didn’t know about the 96127, which is 0.16 wRVUs if applicable.

View attachment 406773

You’re doing a lot of G2211. Are these mostly opioid patients or do use it on repeat injection patients

 

[cowboydoc]

You’re doing a lot of G2211. Are these mostly opioid patients or do use it one repeat injection patients

Just Medicare with longitudinal plan, which would be COT and others with f/u plan.

 

[myrandom2003]

what screener are you using for the 96127?

 

[mdo1738]

what screener are you using for the 96127?

Looks like PHQ-4

 

[Mr. Osh Kosh]

If you address the patient's chronic neck and back pain by renewing PT and also refill their gabapentin it would be a level 4 visit right?

 

[Status Sciaticus]

Here’s a snippet of my latest feedback from coding.

Several were bumped from 3 to 4, none down coded. Clearly, I didn’t know about the 96127, which is 0.16 wRVUs if applicable.

View attachment 406773

are you working in a HOPD?

 

[cowboydoc]

are you working in a HOPD?

Clinic with HOPD for all fluoro procedures.

 

[Status Sciaticus]

Clinic with HOPD for all fluoro procedures.

looks like your coders are on the ball and appropriately coding your undercoded visits.

 

[SpineandWine]

Clinic with HOPD for all fluoro procedures.

What is 96127?
Is that allowed as a specialist?

 

[mille125]

What is 96127?
Is that allowed as a specialist?

Yes....it is a code for a patient doing screening....

If appropriate you can bill 96127 for depression screening inventories and another 96127 -59 for anxiety screening inventories if you are giving them.

Net pay is about $10 combined for both.


The appropriate ICD 10 code is Z13.31 and Z13.39 if you are doing both.


For those of you on an RVU model neither of these codes have a physician work RVU (it is 0.00) so your hospital or group may not gave you any "credit" for using these codes, Just FYI.

 

[SpineandWine]

Yes....it is a code for a patient doing screening....

If appropriate you can bill 96127 for depression screening inventories and another 96127 -59 for anxiety screening inventories if you are giving them.

Net pay is about $10 combined for both.


The appropriate ICD 10 code is Z13.31 and Z13.39 if you are doing both.


For those of you on an RVU model neither of these codes have a physician work RVU (it is 0.00) so your hospital or group may not gave you any "credit" for using these codes, Just FYI.

What’s appropriate for screening? I assume everyone that walks through the door

What is the screening questionare people are using for depression and anxiety and what does one do with the results?

 

[Status Sciaticus]

How are HOPDs coding the G2211 reimbursement?
Looks like the wRVU is 0.33, but pays out $15. On average at $71/wRVU, it comes out to be $23.43, which makes it a losing proposition to hospitals.

 

[22yis]

Yes....it is a code for a patient doing screening....

If appropriate you can bill 96127 for depression screening inventories and another 96127 -59 for anxiety screening inventories if you are giving them.

Net pay is about $10 combined for both.


The appropriate ICD 10 code is Z13.31 and Z13.39 if you are doing both.


For those of you on an RVU model neither of these codes have a physician work RVU (it is 0.00) so your hospital or group may not gave you any "credit" for using these codes, Just FYI.

Because PHQ4 screens both anxiety and depression, can you use 96127 & 91627-59?

And is it worth doing this with the hassle of dealing with + screens?

 

[BobBarker]

G2211 they probably lose some. It takes them a long time to figure this stuff out.

 

[mdo1738]

How are HOPDs coding the G2211 reimbursement?
Looks like the wRVU is 0.33, but pays out $15. On average at $71/wRVU, it comes out to be $23.43, which makes it a losing proposition to hospitals.

I get 0.33 RVU for it at my HOPD. Hospital is aware of the slight loss, and are also aware they easily make it up in spades with the facility fees on procedures.

 

[mille125]

Yes....it is a code for a patient doing screening....

If appropriate you can bill 96127 for depression screening inventories and another 96127 -59 for anxiety screening inventories if you are giving them.

Net pay is about $10 combined for both.


The appropriate ICD 10 code is Z13.31 and Z13.39 if you are doing both.

How are HOPDs coding the G2211 reimbursement?
Looks like the wRVU is 0.33, but pays out $15. On average at $71/wRVU, it comes out to be $23.43, which makes it a losing proposition to hospitals.

I work at one part time and they pay it. They are generally losing money or breaking even on all E/M codes. You are there because of facility fees.

 

[mille125]

Because PHQ4 screens both anxiety and depression, can you use 96127 & 91627-59?

And is it worth doing this with the hassle of dealing with + screens?

Yes 96127 and then 96127 -59
Only you can anwer the hassle questions. Everything you screen has the potential to be positive and needs to be addressed/documented.

Also if you are in an HOPD, the wrvu for this code is 0.00

 

[SpineandWine]

Yes 96127 and then 96127 -59
Only you can anwer the hassle questions. Everything you screen has the potential to be positive and needs to be addressed/documented.

Also if you are in an HOPD, the wrvu for this code is 0.00

How do you address a positive depression and anxiety score?
Offer therapy vs. psychiatry? Ask suicidal questions?

 

[mille125]

How do you address a positive depression and anxiety score?
Offer therapy vs. psychiatry? Ask suicidal questions?

If you are going to test for it, their has to be a reason, right? Even if you just refer or council. Otherwise, why are we ordering it.

 

[myrandom2003]

Per chatgpt:
If you're not providing counseling but are identifying a positive PHQ-4 result and addressing it by offering a referral—without conducting a behavioral intervention—you should not bill CPT 96217. That code requires 16–37 minutes of health behavior intervention.

 

[mille125]

Per chatgpt:
If you're not providing counseling but are identifying a positive PHQ-4 result and addressing it by offering a referral—without conducting a behavioral intervention—you should not bill CPT 96217. That code requires 16–37 minutes of health behavior intervention.

I don't use Chat GPT for really important things. I think that it may have missed the boat.

96127 is not billed per time or requires any time. It is simply a code for administering the assesment.

This is supported by the fact that the wRVU is 0.00. If it required 16-37 minutes the wRVU would not be 0.00

 

[myrandom2003]

I don't use Chat GPT for really important things. I think that it may have missed the boat.

96127 is not billed per time or requires any time. It is simply a code for administering the assesment.

This is supported by the fact that the wRVU is 0.00. If it required 16-37 minutes the wRVU would not be 0.00

You sir, are correct. It is only for doing and documenting the test. However, it does have a non-facility PE rvu of 0.13 for 2025

 

[22yis]

Per chatgpt:
If you're not providing counseling but are identifying a positive PHQ-4 result and addressing it by offering a referral—without conducting a behavioral intervention—you should not bill CPT 96217. That code requires 16–37 minutes of health behavior intervention.

Counseled patient on sleep hygiene, deep breathes, mindfulness care options and offered referral to pain psychology.

 

[mille125]

You sir, are correct. It is only for doing and documenting the test. However, it does have a non-facility PE rvu of 0.13 for 2025

Yes..but the wrvu which is how physicians get reimbursed when they work in HOPDs or for facilities is 0.00

You are quoting one aspect. The malpractice rvu is 0.01 and the work rvu is 0.00 so total rvu is 0.14 or so.

If total rvu was 0.00 then pay from payor would also be 0.00