G2211 reimbursement

[bronx43]

Are you guys billing the G code consistently and if so, has anyone encountered non payment by either private insurers or managed Medicare?

I have had a private insurer deny several and the patients got stuck with a charge.

I haven’t heard anything from the MA plans but I wouldn’t be surprised if they push the cost onto the patients.

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[gutonc]

Are you guys billing the G code consistently and if so, has anyone encountered non payment by either private insurers or managed Medicare?

I have had a private insurer deny several and the patients got stuck with a charge.

I haven’t heard anything from the MA plans but I wouldn’t be surprised if they push the cost onto the patients.

We're billing it to everyone and if the insurer denies it and denies the appeal, we just reverse the charge. That said, physicians are still getting the wRVU credit for it regardless of payout.

 

[bronx43]

We're billing it to everyone and if the insurer denies it and denies the appeal, we just reverse the charge. That said, physicians are still getting the wRVU credit for it regardless of payout.

Was this something you guys have had to negotiate with the admin?

 

[gutonc]

Was this something you guys have had to negotiate with the admin?

That was admin's decision. Huge, multi-state healthcare system. They tried to have us decide which were appropriate for G2211 billing and that went nowhere.

Now we let the...wait for it...coders and billers decide what to code and bill.

 

[NewYorkDoctors]

well ultimately G2211 is still subject to deductibles and out pocket costs

Unless you have a managed medicaid patient with zero deductible and zero pay (which honestly this Cadillac pseudo-concierge managed medicaid only exists in LA, NYC, and Chicago all liberal "free stuff" strongholds) or someone with cadillac commercial insurance that someone paid top dollar for and is already beyond deductible and out of pocket max (and hence whatever is billed insurance pays 100% of. this is like my aetna insurance I paid top dollar for. see the neph is dead thread for the charges from anesthesia, GI, and pathology for my colonoscopy and EGD. outrageous indeed but i paid nothing lol ) , be wary of this code as it may end up as an out of pocket charge.

as gutonc says, if patient complains billers and coders can just tell the insurance company to reverse the charges

but it might not be worth the headache of hearing of hearing a patient angrily confront the doctor to say "Y U DO THIS?"

in terms of cash payments (not RVUs), I get about $15 or so for the managed medicare population I see

side note: this is a G code yet when I billed it anyway for NYS Managed Medicaid (no Medicare), I still got paid.
shrugs. NYS Medicaid seems to be a bill free for all.

 

[bronx43]

well ultimately G2211 is still subject to deductibles and out pocket costs

Unless you have a managed medicaid patient with zero deductible and zero pay (which honestly this Cadillac pseudo-concierge managed medicaid only exists in LA, NYC, and Chicago all liberal "free stuff" strongholds) or someone with cadillac commercial insurance that someone paid top dollar for and is already beyond deductible and out of pocket max (and hence whatever is billed insurance pays 100% of. this is like my aetna insurance I paid top dollar for. see the neph is dead thread for the charges from anesthesia, GI, and pathology for my colonoscopy and EGD. outrageous indeed but i paid nothing lol ) , be wary of this code as it may end up as an out of pocket charge.

as gutonc says, if patient complains billers and coders can just tell the insurance company to reverse the charges

but it might not be worth the headache of hearing of hearing a patient angrily confront the doctor to say "Y U DO THIS?"

in terms of cash payments (not RVUs), I get about $15 or so for the managed medicare population I see

View attachment 386997

So you’ve had all the managed Medicare plans pay something for the code. That’s good to know that they’re just not dumping thr charge on patients.

 

[dozitgetchahi]

Are you guys billing the G code consistently and if so, has anyone encountered non payment by either private insurers or managed Medicare?

I have had a private insurer deny several and the patients got stuck with a charge.

I haven’t heard anything from the MA plans but I wouldn’t be surprised if they push the cost onto the patients.

I still can’t figure out how to get the G2211 code to “work” in Epic…I found the code and made a button for it on the billing section, but if I code it with a 992xx code + G2211 it won’t close the note and tells me I have to associate diagnoses with it (but I did…). My IT and the billers don’t seem to understand why this won’t work.

 

[MD46]

In our collection model, over last 3 months I applied the code to around 800 patients, net collected to was around $8200 dollars so around $10 a patient extra. Still not bad as its all cumulative.

 

[VA Hopeful Dr]

Medicare only at this point. Using it heavily.

We're getting paid for it.

 

[bronx43]

Medicare only at this point. Using it heavily.

We're getting paid for it.

all types of Medicare or just traditional with supplement

 

[tylerb1800]

Medicare, medicare advantage, and UHC commercial and exchange are paying G2211. I hear Humana commercial is as well but my area does not have any humana commercial patients.

Which private payers cover the new G2211 code?

Medicare began covering G2211 in January, but private payer coverage varies. The AAFP has compiled a list of confirmed payers.

www.aafp.org

 

[bronx43]

Medicare, medicare advantage, and UHC commercial and exchange are paying G2211. I hear Humana commercial is as well but my area does not have any humana commercial patients.

Which private payers cover the new G2211 code?

Medicare began covering G2211 in January, but private payer coverage varies. The AAFP has compiled a list of confirmed payers.

www.aafp.org

honestly if one is in a high demand area, I can totally see docs not taking private insurances that won’t pay out the code. The 0.33 rvu difference does add up over time.

Private insurances are basically the worst of all worlds at this point, especially as an employed doc. One is much better off seeing a Medicaid pt than a privately insured patient. With the G code, you get more RVUs, all testing gets paid for, better drug coverage, etc.

 

[NewYorkDoctors]

honestly if one is in a high demand area, I can totally see docs not taking private insurances that won’t pay out the code. The 0.33 rvu difference does add up over time.

Private insurances are basically the worst of all worlds at this point, especially as an employed doc. One is much better off seeing a Medicaid pt than a privately insured patient. With the G code, you get more RVUs, all testing gets paid for, better drug coverage, etc.

totally.

the Managed Medicaid plans in NYS and the triple Medicare Advantage / Medicaid patients in NYS literally get everything for free or nearly free.

Ofev costs these patients $4 a month. (FOUR)

The asthma biologics are FREE no copay.

Breztri Aerosphere and AirSupra - free covered no out of pocket costs

When I bill very high high (all justified. I document time spent, I document complexity etc... when insurances ask for my records I provide them and then get second letter later saying all cool here's your money now), I get paid high and these patients don't pay a cent.

life is good for Medicaid patients (in NYS anyway)




Back to the main population at hand, I have noticed that even after deductible, G2211 is still subject to coinsurance
So if you have a Medicare patient or Medicare advantage patient (who does not purchase a supplemental scondary or does not ahev Medicaid), then even if the patient is past the deductible, that G2211 is subject to a coinsurance charge. The patient is on the hook for about 20% of that $15 or so.

As I do my own billing for my solo practice, I am tuned into these details. But for employed physicians I guess just do what the admins say then when patients complaint to you blame the faceless billers/coders/ and admins.


I often joke to patients that when you go to a hospital for medical care (whether inpatient care of going to a hospital office setting), I tell them you can be sure you will be greeted by an administrator, a bureaucrat, and a nurse manager but you won't see any doctors at the front door.

 

[hotsaws]

Are you seeing other services be denied if g2211 is billed? We were considering doing it but our understanding was that we couldn't bill for things like spirometry on the same day. The spiro probably pays around $30 and the g code only around 10-15. I guess for office only with no other services, I could add it since most of my patients would be easy to justify with the way I document.

 

[bronx43]

Are you seeing other services be denied if g2211 is billed? We were considering doing it but our understanding was that we couldn't bill for things like spirometry on the same day. The spiro probably pays around $30 and the g code only around 10-15. I guess for office only with no other services, I could add it since most of my patients would be easy to justify with the way I document.

I am not running into other charges being denied, but then again if I do a 25 modifier injection then I don’t bill the G code.

My hospital hasn’t yet instituted a policy where the charge gets removed if insurances deny it. I may have to stop taking certain private payers altogether. I’m not hurting for new patients.

I wonder when outpatient docs are just going to stop taking private insurance and demand cash pay. What’s the point of dealing with these insurances (takes overhead, time, effort) when you can just accept cash at the door? For most patients there’s no big difference since they’re gonna get a bill regardless.

 

[chessknt]

Are you seeing other services be denied if g2211 is billed? We were considering doing it but our understanding was that we couldn't bill for things like spirometry on the same day. The spiro probably pays around $30 and the g code only around 10-15. I guess for office only with no other services, I could add it since most of my patients would be easy to justify with the way I document.

It is an add on code to E/M, shouldnt have any impact at all on other stuff done that day.

 

[tylerb1800]

It is an add on code to E/M, shouldnt have any impact at all on other stuff done that day.

If a -25 modifier is used, then G2211 cannot be billed.

G2211 Add-on Code: What It Is and How to Use It

The care you provide your patients is complex and comprehensive. G2211 will help you get paid more accurately for it.

www.aafp.org

 

[VA Hopeful Dr]

honestly if one is in a high demand area, I can totally see docs not taking private insurances that won’t pay out the code. The 0.33 rvu difference does add up over time.

Private insurances are basically the worst of all worlds at this point, especially as an employed doc. One is much better off seeing a Medicaid pt than a privately insured patient. With the G code, you get more RVUs, all testing gets paid for, better drug coverage, etc.

In my area private insurance pays significantly better than any Medicare plan even with the new G-Code.

 

[dozitgetchahi]

honestly if one is in a high demand area, I can totally see docs not taking private insurances that won’t pay out the code. The 0.33 rvu difference does add up over time.

Private insurances are basically the worst of all worlds at this point, especially as an employed doc. One is much better off seeing a Medicaid pt than a privately insured patient. With the G code, you get more RVUs, all testing gets paid for, better drug coverage, etc.

Unless you’re PP like me.

Big, big difference in cash reimbursement for visits between private insurers and Medicare (and especially Medicaid, which reimburses crapola).

 

[dozitgetchahi]

In my area private insurance pays significantly better than any Medicare plan even with the new G-Code.

Bingo.

 

[hotsaws]

Yeah, same with our practice. Most of the docs don't see any adult medicaid and I see a very limited number of them. It pays very little and doesn't cover most of our services. Pediatric medicaid covers most services we offer, so we see plenty of them. Same with medicare. Some of the docs choose to not even see cash pay only patients. Private insurance is all over the place, some plans cover many services under just the copay but others do basically apply it all to the patient's deductible. Still, quite a few of those patients will or already have met there deductible so they are willing to pay for services.

Sometimes I'm surprised that people are willing to pay a significant amount out of pocket but then I think about how much I spend at the vet just for regular well-visits for my dogs each year.

 

[bronx43]

In my area private insurance pays significantly better than any Medicare plan even with the new G-Code.

A lot of private insurers pay nothing until deductible is met so there’s not much difference for a patient to pay cash upfront versus getting a bill for the same service and having the insurance pick up nothing.
The only difference would be that the $150 through “insurance” would go towards the deductible but since most deductibles are upwards of $3000/year, it’s not a huge incentive.

 

[NewYorkDoctors]

A lot of private insurers pay nothing until deductible is met so there’s not much difference for a patient to pay cash upfront versus getting a bill for the same service and having the insurance pick up nothing.
The only difference would be that the $150 through “insurance” would go towards the deductible but since most deductibles are upwards of $3000/year, it’s not a huge incentive.

exactly. if a patient is sent a bill they may or may not pay.

if they see an extra charge then then end u saying "wait what the heck is this G2211??? why am I paying even more and I am still in pain and my ANA is still 1:80 and my neurotic tendencies have not been fulfilled yet?"

 

[NewYorkDoctors]

here is an EOB from Wellcare insurance for G2211. This patient has Wellcare + Medicare + Medicaid
The Medicaid pays the coinsurance in a separate check

(PHI all removed)

the other parts of the visit was a 99213 and the primary care codes for depression screening, functional status, pain status etc... yadda yadda things that dont get paid

for a provider who only bills a 99213 and has no other office visits on top, this can provide a nice chunk of change

15.01 / (96 - 15.01) * 100% = 18.5%

Nephrology is back in business baby!




























lol no

 

[dgdg]

We are seeing Aetna and United Medicare Advantage plans rejecting the code or paying 1 cent.
I thought if Medicare allowed it, MA plans needed to as well?
Any other experiences or insights to the G2211?

 

[sloh]

Medicare advantage is unequivocally worse than straight medicare in almost any and every conceivable manner.

 

[dgdg]

I thought MA had to provide what Medicare B provides, at minimum.
Anyone else with experience, success, tips with MA?

 

[bronx43]

We are seeing Aetna and United Medicare Advantage plans rejecting the code or paying 1 cent.
I thought if Medicare allowed it, MA plans needed to as well?
Any other experiences or insights to the G2211?

I have not heard of rejections from MA but have had it rejected by private payers.

At the same time, it’s possible that the hospital hasn’t gotten reimbursed but it simply hasn’t reached my attention yet.

If you have enough volume, you should stop accepting MA. It’s absolute garbage - worst of all worlds.

 

[sloh]

If you have enough volume, you should stop accepting MA. It’s absolute garbage - worst of all worlds.

Wow just read this Reddit thread as well:

https://www.reddit.com/r/medicare/s/236fASXUFR

 

[dgdg]

Anyone with Aetna MA paying G2211 more than one cent?

 

[deleted1180461]

If you are on an eat-what-you-kill contract with a hospital paid per wRVU, can the hospital deny wRVUs for G2211 because they don't reimburse enough? I've done the math and the global payment for this code from CMS is $16.04

wRVU is 0.33 and tRVU is 0.49 ($32.74/RVU conversion factor x 0.49 = $16.04 payment to facility).
This means the wRVU breakeven would be $16.04/0.33 = $48.61/wRVU.

So, if you're getting paid $48/wRVU or less, the hospital will make money by adding this charge onto your notes.
But if you're getting paid more than $48/wRVU (I am significantly higher than this, which is well below MGMA median rates), the hospital will actually lose money on this because they will have to pay you more in RVU production than they actually collect from Medicare.

The hospital is not allowed to pick and choose which codes they credit wRVUs for, correct? I suspect that is where that is going (as we are mostly medicare and medicaid) with this code. I suppose I could negotiate something in between so I get something more than zero and the hospital doesn't lose money on the code. However, before we have this discussion, I want to know if this is actually customary and allowed if you are paid per wRVU. I feel pretty confident it's not but am unclear how big of a stink I should make out of this.

 

[bronx43]

If you are on an eat-what-you-kill contract with a hospital paid per wRVU, can the hospital deny wRVUs for G2211 because they don't reimburse enough? I've done the math and the global payment for this code from CMS is $16.04

wRVU is 0.33 and tRVU is 0.49 ($32.74/RVU conversion factor x 0.49 = $16.04 payment to facility).
This means the wRVU breakeven would be $16.04/0.33 = $48.61/wRVU.

So, if you're getting paid $48/wRVU or less, the hospital will make money by adding this charge onto your notes.
But if you're getting paid more than $48/wRVU (I am significantly higher than this, which is well below MGMA median rates), the hospital will actually lose money on this because they will have to pay you more in RVU production than they actually collect from Medicare.

The hospital is not allowed to pick and choose which codes they credit wRVUs for, correct? I suspect that is where that is going (as we are mostly medicare and medicaid) with this code. I suppose I could negotiate something in between so I get something more than zero and the hospital doesn't lose money on the code. However, before we have this discussion, I want to know if this is actually customary and allowed if you are paid per wRVU. I feel pretty confident it's not but am unclear how big of a stink I should make out of this.

It would open up a whole can of worms for hospitals to not honor Medicare approved CPT codes.

If you do the math, hospitals actually lose money on quite a few of the line by line items for which they pay us based on wRVU. For instance, a 99214 medicaid visit only pays $76 in my state. Medicare only pays $128 for non-facility and $96 for facility.
This means that they lose money on every Medicaid patient and barely make money for the level 4 facility Medicare visit.

When you add in overhead that hospitals have to pay, then they really lose money hand over fist based on what they pay their employed clinicians.

However, that's not how the math is done. We are loss leaders in this business - nothing more than order-ers of ancillary services. They charge privately insured patients $1500 for a lumbar spine MRI. And $500 for an abdominal US. They simply give us a small share of this revenue.

So no, I highly doubt hospitals will start denying G2211. That's pennies compared to what they are making on the back end. The last thing they want is to p*** off their PCPs, oncologists, and cardiologists, who all generate 7 figures worth of ancillaries.

 

[deleted1180461]

It would open up a whole can of worms for hospitals to not honor Medicare approved CPT codes.

If you do the math, hospitals actually lose money on quite a few of the line by line items for which they pay us based on wRVU. For instance, a 99214 medicaid visit only pays $76 in my state. Medicare only pays $128 for non-facility and $96 for facility.
This means that they lose money on every Medicaid patient and barely make money for the level 4 facility Medicare visit.

When you add in overhead that hospitals have to pay, then they really lose money hand over fist based on what they pay their employed clinicians.

However, that's not how the math is done. We are loss leaders in this business - nothing more than order-ers of ancillary services. They charge privately insured patients $1500 for a lumbar spine MRI. And $500 for an abdominal US. They simply give us a small share of this revenue.

So no, I highly doubt hospitals will start denying G2211. That's pennies compared to what they are making on the back end. The last thing they want is to p*** off their PCPs, oncologists, and cardiologists, who all generate 7 figures worth of ancillaries.

So when they come to me in a few months and tell me they have looked at the payments and aren’t going to credit RVUs for that one specific code, I should tell them what exactly? I’m unclear if that’s actually a contract breach.

Because I imagine they would keep billing and collecting on it and have me document to support it but just not give me any RVUs for it and pocket the little they make off the physician fee in addition to the facility fee for that code. Obviously I will refuse to document it if I’m not getting any wRVUs for it so they can’t bill at all. Seems very stupid.

 

[bronx43]

So when they come to me in a few months and tell me they have looked at the payments and aren’t going to credit RVUs for that one specific code, I should tell them what exactly? I’m unclear if that’s actually a contract breach.

Because I imagine they would keep billing and collecting on it and have me document to support it but just not give me any RVUs for it and pocket the little they make off the physician fee in addition to the facility fee for that code. Obviously I will refuse to document it if I’m not getting any wRVUs for it so they can’t bill at all. Seems very stupid.

I mean, I guess it's a case by case basis. Are you in a big group? If everyone in the group pushes back together then the hospitals may back off and pay out the code.
Also, is this a rural or metro position? Rural hospitals that have a hard time recruiting usually won't pull these kinds of shenanigans.

 

[deleted1180461]

I mean, I guess it's a case by case basis. Are you in a big group? If everyone in the group pushes back together then the hospitals may back off and pay out the code.
Also, is this a rural or metro position? Rural hospitals that have a hard time recruiting usually won't pull these kinds of shenanigans.

Rural and I’m solo in my specialty. I was just trying to see if this really was a shenanigan (withholding RVUs for the code until they see how it’s paid), and it sounds like it is in fact shenanigans. Hopefully I just have to gently push back and they’ll realize it’s not worth 7-8k/yr to make me angry. It’s just annoying it happened at all. I have seen bean counters anger and lose doctors over less.

 

[bronx43]

Rural and I’m solo in my specialty. I was just trying to see if this really was a shenanigan (withholding RVUs for the code until they see how it’s paid), and it sounds like it is in fact shenanigans. Hopefully I just have to gently push back and they’ll realize it’s not worth 7-8k/yr to make me angry. It’s just annoying it happened at all. I have seen bean counters anger and lose doctors over less.

So did they already approach you saying they won't pay it out?

 

[deleted1180461]

So did they already approach you saying they won't pay it out?

They said they would trial the code for a few months, see how the payors are reimbursing it then determine if they will continue to bill it and credit my RVUs if so. Every single patient I see qualifies for this code.

I approached them with the code. I thought they would be thrilled but then I realized why they were hesitant when it turned out this code has a paltry facility fee and if only Medicare was paying they would pay me out at a higher wRVU rate than what they collect for the total RVUs (tRVU). I imagine they are trying to see if their commercial payors make up the difference (unlikely).

 

[bronx43]

They said they would trial the code for a few months, see how the payors are reimbursing it then determine if they will continue to bill it and credit my RVUs if so. Every single patient I see qualifies for this code.

I approached them with the code. I thought they would be thrilled but then I realized why they were hesitant when it turned out this code has a paltry facility fee and if only Medicare was paying they would pay me out at a higher wRVU rate than what they collect for the total RVUs (tRVU). I imagine they are trying to see if their commercial payors make up the difference (unlikely).

I would speak to other clinicians and see if they are having the same problem. My hospital wasn’t paying it out then a bunch of us spoke out and they ended up giving me a bonus based on the code last quarter.

 

[deleted1180461]

I would speak to other clinicians and see if they are having the same problem. My hospital wasn’t paying it out then a bunch of us spoke out and they ended up giving me a bonus based on the code last quarter.

Not paying it out for the same reason?

I don’t think if you’re on an RVU system they can pick and choose which codes you get. It’s all or nothing right? You either get all the codes converted to a RVU or else you go to collections based system. Not Pick and choose, Some are net losers for the hospital some are winners with fat facility fees. At least in radiation anyway.

 

[bronx43]

Not paying it out for the same reason?

I don’t think if you’re on an RVU system they can pick and choose which codes you get. It’s all or nothing right? You either get all the codes converted to a RVU or else you go to collections based system. Not Pick and choose, Some are net losers for the hospital some are winners with fat facility fees. At least in radiation anyway.

I think our hospital just wasn't aware that hospitals in general were paying it out. However, I do think the pressure of multiple different specialties pushing them to reimburse us did eventually cause them to pay it out.

I've never heard of a hospital picking and choosing which CPT codes they will pay.

 

[VA Hopeful Dr]

I think our hospital just wasn't aware that hospitals in general were paying it out. However, I do think the pressure of multiple different specialties pushing them to reimburse us did eventually cause them to pay it out.

I've never heard of a hospital picking and choosing which CPT codes they will pay.

I think part of the issue is that there was a good bit of initial confusion about which payers would actually pay for this. In my state, Medicaid 100% does not. Most but not all of the commercial payers do.

To combat this, our version of Epic gives you a warning if the insurance the patient has covers the code and you haven't used it.

 

[NewYorkDoctors]

Here is one EOB from one of the managed medicare/medicaid patients i see. this patient was a COPD stable, DM2 stable, HTn stable, HLD stable, CKD stable patient that I just reviewed labs and listened to and renewed meds on. good job patient
nothing more I did than a standard 99213. I just tacked on the g2211 and it gave me a cool extra $19.01 (17%) for just clicking a button

Date(s) Of Service	Procedure Code(s)	MOD1	MOD2	POS	NOS	Charged	Allowed	Copayment	Total Amount Paid	EOB Code	Message Code
Total Interest	$0.00
Total Discount	$0.00
Total	$199.60​	$133.14​	$4.00​	$129.14​
07/15/2024	99213			11	1	$180.00​	$113.54​	$3.41​	$110.13​	185	03
07/15/2024	G2211			11	1	$19.60​	$19.60​	$0.59​	$19.01​	185	01

 

[chessknt]

I think part of the issue is that there was a good bit of initial confusion about which payers would actually pay for this. In my state, Medicaid 100% does not. Most but not all of the commercial payers do.

To combat this, our version of Epic gives you a warning if the insurance the patient has covers the code and you haven't used it.

Same here, medicaid doesnt pay for this (and hilariously requires a preauth to bill for smoking cessation and lung cancer screening) and probably 60% of private insurance does. It is truly a magical world where the insurance company can just decide not to pay for a service at all even after CMS approves it on top of the other preauth bull**** for inferior cheaper medicines.

 

[VA Hopeful Dr]

Here is one EOB from one of the managed medicare/medicaid patients i see. this patient was a COPD stable, DM2 stable, HTn stable, HLD stable, CKD stable patient that I just reviewed labs and listened to and renewed meds on. good job patient
nothing more I did than a standard 99213. I just tacked on the g2211 and it gave me a cool extra $19.01 (17%) for just clicking a button

Date(s) Of Service	Procedure Code(s)	MOD1	MOD2	POS	NOS	Charged	Allowed	Copayment	Total Amount Paid	EOB Code	Message Code
Total Interest	$0.00
Total Discount	$0.00
Total	$199.60​	$133.14​	$4.00​	$129.14​
07/15/2024	99213			11	1	$180.00​	$113.54​	$3.41​	$110.13​	185	03
07/15/2024	G2211			11	1	$19.60​	$19.60​	$0.59​	$19.01​	185	01

Why wasn't that a 99214?

 

[dgdg]

Palmetto GBA contractor has denied our G2211 code. Will look at more.

A long time ago Trailblazers Medicare contractor for our region was denying payments for B12 injection administration codes, but then when Palmetto took over, started paying again.

 

[NewYorkDoctors]

Why wasn't that a 99214?

i was really fast about it since the patient was stable. "let's go through your labs, take a listen to you, review some screening items. you're all up to date. need refills? any new issues? no? see you in a few months! call sooner if you have any issues"

 

[VA Hopeful Dr]

i was really fast about it since the patient was stable. "let's go through your labs, take a listen to you, review some screening items. you're all up to date. need refills? any new issues? no? see you in a few months! call sooner if you have any issues"

So? Unless you're billing on time the amount of time a visit takes doesn't matter. I've seen 5 patients this morning so far, only 1 was a 99213 and that was a 20-something patient with stable ADHD and literally nothing else. Everyone else was a level 4.

 

[bronx43]

i was really fast about it since the patient was stable. "let's go through your labs, take a listen to you, review some screening items. you're all up to date. need refills? any new issues? no? see you in a few months! call sooner if you have any issues"

You got 2 chronic stable problems and prescription medication management. That’s 99214.

 

[bronx43]

Same here, medicaid doesnt pay for this (and hilariously requires a preauth to bill for smoking cessation and lung cancer screening) and probably 60% of private insurance does. It is truly a magical world where the insurance company can just decide not to pay for a service at all even after CMS approves it on top of the other preauth bull**** for inferior cheaper medicines.

Yet they still pay $30k a pop facility fee for a laminectomy for degenerative disc. Clown world.

 

[NewYorkDoctors]

So? Unless you're billing on time the amount of time a visit takes doesn't matter. I've seen 5 patients this morning so far, only 1 was a 99213 and that was a 20-something patient with stable ADHD and literally nothing else. Everyone else was a level 4.

im hedging a bit. i did not go into such great detail onto those ancillary things. the focus was on COPD. some patients i also see their primary care. so I am "managing it" i just did not delve into so much other than a cursory "recent labs stable. great job."

certain insurance ask for me record audits. While i always pass and they always pay me, I find doing that extra step somewhat tedious.
so i go by time instead.

this brings up the whole argument of complexity versus time.

yes I am aware only anesthesia and CCM bill by time. I billed plenty of MICU in the past.

the point here is that when I try to bill higher levels, some times the record audits do not pass and they deny the 99214/99215.
Usually to get them to pass the audit, I have to write some gigantic note and provide all the records I reviewed (prior labs, radiology , hopsital records etc). I do write gigantic thought provoking and detailed notes for my consults. (because I am sending these notes to other doctors and I cannot be seen as a jackas s)

but for the primary care patients I see, I usually keep a timeline of all the workup done in their PMhx (screening, chronic issues like HBV labs imaging, what other specialists are doing) then I template the most garbage of templated notes for submission (no else sees these notes besidse the insurance company)

That is a very tedious step. My office staff are not capable of doing that (somewhat) clinical step

Therefore my approach is if nothing serious is going on and I just say uh huh high cool buh bye you're great in a 5-10 minute face to face time, then I just bill level 3 and move on. level 3 never gets audited unless I put a -25 modified and did a ton of procedures (which I do for my pulmonary consults.)

This way I can ensure my 99213 getting paid without the hassle of having to compile records for an audit request which might not pass unless i wroet some gigantic note for it.


I guess one way to justify using the lower level despite "so many chronic issues" is like a nephrologist

CKD3-4 is the major thing

T2DM may have caused it and the nephrologist paid lip service to it. but unles the nephrologist actively manages the DM, then can include E11.22 as an ICD10 code but should not erally coutn that to the E&M services to bump up from level 3 to 4.

dunno if this makes much sense...

TL;DR - im trying to avoid getting an audit. while most times i pass the audit and get paid if I have the notes, sometimes i don't want to write such a long note to justify level 4 when i just want to finish the visit and move on.