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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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
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.
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.
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.
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.
Sorry for the rudimentary questions, but if billing is actually based on Medical complexity and I’m billing a 99204 and I’m explicitly stating the medical complexity at end of my note…..
1-still have to include ROS in my H+P?
2- do I have to include family history?
3- do I have to document a physical exam of the entire body or can I just document MSK and Neuro?
I would prefer to not document ROS, FH, or physical exam beyond MSK+Neuro if possible.
4-For a follow up level 4 visit, can I just document in a SOAP note format?
(but with stated complexity at the end of that note)
Sorry for the rudimentary questions, but if billing is actually based on Medical complexity and I’m billing a 99204 and I’m explicitly stating the medical complexity at end of my note…..
1-still have to include ROS in my H+P?
2- do I have to include family history?
3- do I have to document a physical exam of the entire body or can I just document MSK and Neuro?
I would prefer to not document ROS, FH, or physical exam beyond MSK+Neuro if possible.
4-For a follow up level 4 visit, can I just document in a SOAP note format?
(but with stated complexity at the end of that note)
You don't need an ROS at all.
You don't need FH at all.
You don't need to document any specific number of PE findings at all.
To get a lvl 4 just make sure that you document
1: That they are being seen for either one acute problem, one chronic problem with exacerbation, or two stable chronic problems.
2: Interpret imaging or prescribe a medication or plan an injection.
If you don't do both of those things, it's a 3. If you do both, it's a 4. You literally don't need anything else.
You don't need an ROS at all.
You don't need FH at all.
You don't need to document any specific number of PE findings at all.
To get a lvl 4 just make sure that you document
1: That they are being seen for either one acute problem, one chronic problem with exacerbation, or two stable chronic problems.
2: Interpret imaging or prescribe a medication or plan an injection.
If you don't do both of those things, it's a 3. If you do both, it's a 4. You literally don't need anything else.
You don't need an ROS at all.
You don't need FH at all.
You don't need to document any specific number of PE findings at all.
To get a lvl 4 just make sure that you document
1: That they are being seen for either one acute problem, one chronic problem with exacerbation, or two stable chronic problems.
2: Interpret imaging or prescribe a medication or plan an injection.
If you don't do both of those things, it's a 3. If you do both, it's a 4. You literally don't need anything else.
For example a patient with low back and neck pain where you are ordering an xray, interpretting a lab or prescribing a medication is level 4.
Notice -or- not -and-
Caveat to reading imaging -- I was told from billing consultant you can't read the same MRI each visit and have that count. So ordering new imaging or reading one for the first time.
Also with procedure ordering there should be documentation of discussion of risk.
Use the E/M Calculator from the experts at Codify. Check CMS Documentation Guidelines, Time-Based Coding, and get on the fast track to E/M level accuracy.
www.aapc.com
first, you need to document problems addressed, 1 or more than 1, and whether stable or acute and how acute.
second, you need to document the data reviewed, how many, and whether you discussed with others or did an independent determination. included is the tests ordered.
third, you have to discuss risk of treatment, including prescriptions, surgical options, and severity of surgery.
by the book, in milles example, it is AND that gets you a 4. OR will only give 3. in that example what pushes it from a 3 to a 4 is prescription medication ie moderate complexity medical decision making.
2 or more stable illnesses with 1 xray order and no prescription gives a 3.
2 or more stable illnesses with 1 xray order including prescription drug management is 4:
and this is 2 stable illnesses without new review of imaging or ordering imaging but with prescription drug management:
its the Risk of Complications and/or Morbidity or Mortality of Patient Management that makes the biggest difference.
you can play with the calculator. i put in 2 stable illnesses (same level as 1 chronic illness with exacerbation) with ordering 3 instead of 2 tests (xray, MRI and HgA1C for example) and got a 4 even with no RIsk.
likewise, 2 illnesses, no data reviewed and moderate risk (ie prescription drug management or minor surgery with identified risk factors) gets a 4, so those diabetics getting an epidural is a 4.
Caveat to reading imaging -- I was told from billing consultant you can't read the same MRI each visit and have that count. So ordering new imaging or reading one for the first time.
Also with procedure ordering there should be documentation of discussion of risk.
Use the E/M Calculator from the experts at Codify. Check CMS Documentation Guidelines, Time-Based Coding, and get on the fast track to E/M level accuracy.
www.aapc.com
first, you need to document problems addressed, 1 or more than 1, and whether stable or acute and how acute.
second, you need to document the data reviewed, how many, and whether you discussed with others or did an independent determination. included is the tests ordered.
third, you have to discuss risk of treatment, including prescriptions, surgical options, and severity of surgery.
by the book, in milles example, it is AND that gets you a 4. OR will only give 3. in that example what pushes it from a 3 to a 4 is prescription medication ie moderate complexity medical decision making.
2 or more stable illnesses with 1 xray order and no prescription gives a 3.
its the Risk of Complications and/or Morbidity or Mortality of Patient Management that makes the biggest difference.
you can play with the calculator. i put in 2 stable illnesses (same level as 1 chronic illness with exacerbation) with ordering 3 instead of 2 tests (xray, MRI and HgA1C for example) and got a 4 even with no RIsk.
likewise, 2 illnesses, no data reviewed and moderate risk (ie prescription drug management or minor surgery with identified risk factors) gets a 4, so those diabetics getting an epidural is a 4.
I think it is impt to understand this so let my reiterate.
There are three general categories. You need to have two of these three groups to bill level 4
Complexity of problems
Complexity of data
Risk of complications
Complexity of problems level 4 ...you need 1 chronic problem with exacerbation OR 2 stable chronic problems (that you are treating) OR one acute problem
Complexity of data level 4 ......you need 1 Order a new test OR 2 Review a test someone else ordered OR 3 Discuss a test with another doctor
Risk of problems level 4 .....you need 1 Prescribe a medication OR 2 Discuss a minor or elective surgery
Of note reviewing a test that you previously ordered does not count in Complexity of Data
So as an example
A patient that you see for neck and low back pain that you write a prescription for is level 4
Same patient that you did not write a prescription for but you order a new MRI is also a level 4
I believe this is how it is done but if I missed something please let me know.
You don't need an ROS at all.
You don't need FH at all.
You don't need to document any specific number of PE findings at all.
To get a lvl 4 just make sure that you document
1: That they are being seen for either one acute problem, one chronic problem with exacerbation, or two stable chronic problems.
2: Interpret imaging or prescribe a medication or plan an injection.
If you don't do both of those things, it's a 3. If you do both, it's a 4. You literally don't need anything else.
I think I know your answer but If our patients fill out a paper h+P which is (eventually) scanned in and includes meds and PMH, then when I do my dictated (dragon note) can I not include irrelevant meds and irrelevant PMH/PSH?
Meaning I would prefer to not include eye drops, their last colonoscopy, etc.
I’m working with a new EHR and trying to speed up my notes.
I think I know your answer but If our patients fill out a paper h+P which is (eventually) scanned in and includes meds and PMH, then when I do my dictated (dragon note) can I not include irrelevant meds and irrelevant PMH/PSH?
Meaning I would prefer to not include eye drops, their last colonoscopy, etc.
I’m working with a new EHR and trying to speed up my notes.
Here's an example of a 99204 I wrote today. Everything in the MDM after the first 3 lines is a macro I use for all MBBs. Note took me literally 2 minutes to write.
HPI HPI: New patient presenting for evaluation of chronic low back pain, worsening since approximately September/October of last year. Unable to take NSAIDs due to prior gastric bypass. Over the past 2-3 weeks, pain has worsened. Reports similar pain in the cervical region, with symptoms extending up and down the neck.
This note was completed with the assistance of voice recognition software. Please excuse any typos or misspellings. Please contact the office with any concerns. ROS ROS as noted in the HPI Physical Exam Facet loading POSITIVE BILATERALLY in the lumbar region.
Paraspinal TTP noted in the lumbar region. Procedure Documentation Test Interpretation:
X-rays of lumbar spine (today): Mild facet arthropathy at L4-5 and L5-S1, degenerative disc disease at L5-S1 Assessment / Plan
1. Spondylosis of lumbar spine
Chronic lumbar spondylosis/facet arthropathy with refractory pain despite conservative management, limited to acetaminophen due to history of gastric bypass. Examination and imaging confirm facet-mediated pain. Will proceed with bilateral L4-S1 medial branch blocks (MBB) to confirm diagnosis, with plan for radiofrequency ablation (RFA) at same levels if positive response. Cervical pain likely facet-mediated as well; will address at future visit after lumbar intervention.
Will plan on diagnostic MBB of BILATERAL L4-5, L5-S1 at next visit with ultimate plan for RFA of the same levels.
Justification for interventional procedure:
1. Patient has moderate to severe pain 9/10 which interferes with ADLs
2. Pain has been present for >3 months and has failed to respond to conservative measures including OTC analgesics, behavior modification and home exercises
3. Patient has no untreated radicular symptoms
4. No alternative pain generator suspected beyond facetogenic pain at this time.
I think I know your answer but If our patients fill out a paper h+P which is (eventually) scanned in and includes meds and PMH, then when I do my dictated (dragon note) can I not include irrelevant meds and irrelevant PMH/PSH?
Meaning I would prefer to not include eye drops, their last colonoscopy, etc.
I’m working with a new EHR and trying to speed up my notes.
