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CMS who defines the billing and where sepsis abstraction comes from for quality incentive payments.
I like treat and street patients
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Yes, how CMS used to define.
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Regardless of severe sepsis, SIRS plus source = sepsis.
If patient has fever plus tachycardia, I'm fluid resuscitating, giving broad spectrum abx, admitting, then I'm billing CC.
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You are doing the right thing medically, which is really what we should all just be caring about.
I think it’s important to just combat though that SIRS alone is not sepsis. SIRS itself is somewhat outdated, but still what CMS uses for abstraction. Organ dysfunction is key for the medical definition of sepsis. Certainly we can debate the numbers where defined by agencies while we all probably agree it is truly more of a spectrum with a conical death spiral.
Unfortunately I think we can all also agree the bureaucracy of health care has diminished our control. I agree we have to play billing games unnecessarily as physicians to combat the insurance lobby and threats to Medicare payment cuts to physicians.
I think you should push billing up to a line, but you do need to be careful. I had an older partner in my group who once came from another group. Reportedly the other group was audited and all each had to pay $50K in billing fines.
This is the way.
For critical care, I’m not as aggressive as some of the upthread comments, but even in our standard community shop, 10-12% of patients are slam dunk CC.
Go back to the CPT definitions of “critical care”
“decision-making of high complexity to assess, manipulate, and support vital organ system failure and/or to prevent further life-threatening deterioration”. Vital organ systems INCLUDE but are NOT limited to “ central nervous system failure, circulatory failure, shock, renal, hepatic
, metabolic, respiratory failure”
And note that Medicare (cms) agrees on the above definition, though they disagree on how to time things after the first 30minute block.
So you need either life or organ threatening deterioration, and you need (IMO) to DO something about it, though occasionally IVF and coordinating OR/STAT transfer counts.
Everyone gets the actual shock, the actual respiratory failure needing intubation/BIPAP, and the stroke you give TNK to.
But where on the sepsis curve do you start billing CC? Tachy to 120 with a fever, AKI to 1.5 from baseline of 1.0, lactate of 2.8 and you are admitting them with fluid bolus, serial lactates, broad abx? I say yes, absolutely. Once you are down the serial lactate, 30mL/kg bolus pathway it is absolutely game on. Now a simple appendicitis who had a lactate of 2.1 and normal vitals, personally I would not bill CC but I can image circumstances where it may be proper. There are huge grey zones in the definition and practice.
As far as respiratory failure, at what point of the hypoxia curve are you billing CC? If they have pneumonia, come in w/ RR 22 and sat 88% on RA and need 2-3L NC oxygen to get in the 90s… I would bill that cc. You don’t need intubation/bipap to have hypoxic respiratory failure (and sepsis/organ failure…).
How about code strokes that you DO NOT give TNK to? New aphasia, likely small stroke, easily spend 30min with the code stroke, tele-neuro consult, multiple advanced imaging studies, decision NOT to give TNK but perhaps DAPT, etc. I bill CC for this.
From last shift:
Testicular torsion that I tried to detorse then rapidly coordinated STAT off hours OR treatment for? CC.
Hepatic encephalopathy that was needed an NGT to pour lactulose down? CC.
Afib RVR w/ crushing chest pain relieved by IV dilt rate control? CC
Post-RSV pneumonia w/ new 3L oxygen requirement, dyspnea, AKI? CC
Potassium of 2.3 after diarrhea w/ EKG changes, need for extensive IV repletion? CC
This is the way. You must study the 2023 billing guidelines like an ancient tome of wisdom if you are fee for service.
You are going to have about 5% level 3. That is fine. There are 1/20 people that show up and you do almost nothing for them. Like, yes, you meet them, examine them, and that’s it. No Rx. No imaging. I think its appropriate to have a small amount of level 3 in your billing, because we all know we see literal nothing-burgers. But check your numbers. If you have 15% level 3 I suspect there is something wrong with your charting or coding.
Now the real question; how do you move a 4–>5. I do NOT recommend any change in your actual practice of medicine! Do the right thing for the patient, always. This is purely the game of ensuring you are documenting your activities in a way that gets you paid for what you have done!
[Almost always, your admissions and transfers are level 5s by definition, so don’t focus your attention on them too much. For admissions, the question is “should this be CC billing?”. It is mostly your DISCHARGED patients where your charting will change 3–>4–>5, and this is where you should initially focus your attention]
On our analysis of many charts, the HIGHEST yield actions:
(1) ALWAYS independently interpret your imaging. ALWAYS. You don’t need to interpret 5 different CTs on one patient, but you ABSOLUTELY should be interpreting 1-2 imaging studies and documenting that very plainly. I love radiology. As a practice, I look at 95% of my films because it is good care. It makes me a better (and quicker) doctor. Now we get paid for documenting we did this. Every single chest X-ray, ankle film, etc. You dont need a full write up. You can just document “no free air” or “no large head bleed” if you gave it a quick skim.
(2) If you get any info from an independent source, note that. I ALWAYS get info from EMS. If you speak to family / pcp / mom+dad / that daughter? NOTE IT. You did it, it is a good thing to do, it also helps your coding.
(3) IF you speak to ANY OTHER HCW aside from the RN, document it. Consultant? noted. Hospitalist? Noted. PCP? Damned straight. Pharmacist, social worker, case manager, PT, mental health clinician, RADIOLOGIST!
(4) If you review old records, note it. You don’t get points for writing a dissertation on old records! However… gosh don’t I always look at the PDMP before I Rx things? Chart it! Did you look at the pharmacy fill history to confirm dosing? CHART IT. Did you get a BMP, and looked at the prior outpatient BMP to confirm their renal function is stable? CHAAAART IT.
If you think about the patients you discharge, many of them (without changing your practice) will have a few of those things above done in their visit, and noting those things, along with your usual and standard care, will make the coding a 5
For those that like the reasons behind rants, recall the 2023 coding and billing changes made the chart entirely driven by MDM, and you get the best two out of three for the categories:
(1) number/complexity of problems
(2) amount / complexity of data
(3) risk / management
Number/Complexity of problems is what you have the least control over in your own charting. To move from the 4–>5, you need to have:
HOWEVER, the 2023 coding guidelines aren’t built JUST on final diagnosis. If there was a serious issue on your differential, that you ruled out with testing, THAT COUNTS. Of course, you need to list realistic items on the differential, and work them up, but they count.
In the words of ACEP “It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity”.
So use your DDX and explain your workup (HEART score 2, troponin negative) to explain the complexity of the arriving complaint, not just the final diagnosis.
———
Now for Amount/Complexity of Data, you have MANY chances to chart a 4–>5
The requirements are to hit two of these three categories:
Category 1: Tests, documents, or independent historian(s)
Category 3: Discussion of management or test interpretation (must be a dialogue, can be text-based/asynchronous, with another HCW)
So, as per my prior post, grabbing an “independent interpretation” is very high yield. If you do THAT, you just need to EITHER speak with another HCW about the case, OR do 3 lab tests / external notes / get an independent history. Many many discharge patients meet this criteria.
———
For the last category, Risk, this is what you need to get up to a 5:
So your admissions get it automatically.
However, everyone you document a discussion about admission / obsv / discharge and they chose discharge? Also get it.
Also anyone that gets IV or IM benzos or opioids.
Also anyone that gets any other potentially dangerous med (starting anticoag! ACEP says IV contrast for CT counts!)
So basically, you need 2 of three to get to level 5. If there is an actual dangerous item on the differential, you get 2 labs and an X-ray and speak with their wife about the history… its a Level 5. Lots of variations on the game. The key, IMHO, is to ensure your differential is documented and your MDM complexity is documented, so those columns are scored appropriately at 5 if you’ve done that work…
(1) number/complexity of problems
(2) amount / complexity of data
(3) risk / management
Number/Complexity of problems is what you have the least control over in your own charting. To move from the 4–>5, you need to have:
- 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment. OR
- 1 acute or chronic illness or injury that poses a threat to life or bodily function
HOWEVER, the 2023 coding guidelines aren’t built JUST on final diagnosis. If there was a serious issue on your differential, that you ruled out with testing, THAT COUNTS. Of course, you need to list realistic items on the differential, and work them up, but they count.
In the words of ACEP “It is not necessary that these conditions be listed as the final diagnosis. An extensive evaluation to identify or rule out these or any other condition that represents a potential threat to life or bodily function is an indication of High COPA and should be included in this category when the evaluation or treatment is consistent with this degree of potential severity”.
So use your DDX and explain your workup (HEART score 2, troponin negative) to explain the complexity of the arriving complaint, not just the final diagnosis.
———
Now for Amount/Complexity of Data, you have MANY chances to chart a 4–>5
The requirements are to hit two of these three categories:
Category 1: Tests, documents, or independent historian(s)
- At least 3 from the following:
- Review of prior external note(s) from each unique source; (each note counts as 1)
- Review of the result(s) of each unique test; (each test counts as 1)
- Ordering of each unique test (each test counts as 1)
- Assessment requiring an independent historian(s)
Category 3: Discussion of management or test interpretation (must be a dialogue, can be text-based/asynchronous, with another HCW)
So, as per my prior post, grabbing an “independent interpretation” is very high yield. If you do THAT, you just need to EITHER speak with another HCW about the case, OR do 3 lab tests / external notes / get an independent history. Many many discharge patients meet this criteria.
———
For the last category, Risk, this is what you need to get up to a 5:
| High risk of morbidity from additional diagnostic testing or treatment | Examples only:
|
So your admissions get it automatically.
However, everyone you document a discussion about admission / obsv / discharge and they chose discharge? Also get it.
Also anyone that gets IV or IM benzos or opioids.
Also anyone that gets any other potentially dangerous med (starting anticoag! ACEP says IV contrast for CT counts!)
So basically, you need 2 of three to get to level 5. If there is an actual dangerous item on the differential, you get 2 labs and an X-ray and speak with their wife about the history… its a Level 5. Lots of variations on the game. The key, IMHO, is to ensure your differential is documented and your MDM complexity is documented, so those columns are scored appropriately at 5 if you’ve done that work…
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I realized pretty quickly early on, as somebody who LOVES min-maxing a lot of things in my life, that min-maxing documentation and billing in EM is a little bit of a fool's errand since the upside is pretty damn capped vs. the effort required.
In EM, it's always better to see another patient than spend more time maxing the record. ESPECIALLY once you've dialed in your templates to the max amount of reimbursement.
With most payors you're gonna be capped at level 4 for a majority of presentations, and the effort to push it to level 5 oftentimes just isn't worth the squeeze.
I would find this out the hard way with all of the internal down-coding done by my group's coders (given their AI tools that they used to help play cat and mouse with the payors with whom we contracted either on a regional or national level).
I was also one of those push CC on everything since that tended to help quite a bit, but as mentioned in this thread, that's where you start getting into audit trouble. Never happened to me though despite being a STDev above my group.
IMHO, for EM, min-maxing documentation perfectly fits the parieto principle: you get 80% of the benefit with 20% of the work.
Of course, it's completely different with other specialties, but in the ED we are pretty constrained.
In EM, it's always better to see another patient than spend more time maxing the record. ESPECIALLY once you've dialed in your templates to the max amount of reimbursement.
With most payors you're gonna be capped at level 4 for a majority of presentations, and the effort to push it to level 5 oftentimes just isn't worth the squeeze.
I would find this out the hard way with all of the internal down-coding done by my group's coders (given their AI tools that they used to help play cat and mouse with the payors with whom we contracted either on a regional or national level).
I was also one of those push CC on everything since that tended to help quite a bit, but as mentioned in this thread, that's where you start getting into audit trouble. Never happened to me though despite being a STDev above my group.
IMHO, for EM, min-maxing documentation perfectly fits the parieto principle: you get 80% of the benefit with 20% of the work.
Of course, it's completely different with other specialties, but in the ED we are pretty constrained.
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I don’t quite agree. I definitely think we expend way too much time and effort charting instead of on higher cognitive, physician-level tasks. Many skirt through charting though and it shows in their compensation. I maximize use of templates and then extensively edit/personalize. The extra time spent on charting to more accurately reflect the work I performed is definitely worth the extra income to me. The Pareto principle applies, but I’m still taking the extra 20%. Maybe it’s not for everyone and I certainly understand that as we are more than secretaries.
If you told someone that they could make $50-100K more per year if they spent more chill extra time on the computer typing/dictating, I think many would make that choice. They don’t in the moment though because they don’t directly see the total monetary conversion. It really adds up over time. 20% is a decent chunk of change.
I agree though that seeing more patients is king. However, sometimes the volume or system inefficiency constraints don’t allow that to be an option. The only way to increase revenue then is to maximally capture compensation for work performed. Really high earners will do both by seeing more patients than average and also billing better than average.
Shifting 3s to 4s and 4s to 5s helps a lot more than cc billing give the sheer volume of lower acuity patients. 90ish percent of your patients aren’t going to be critical care. The really high earners will bill better critical care, but the biggest bang for their buck is in the increased volume of patients and making sure as many of them as possible are 5s. If your coders aren’t coding at the appropriate level then it’s time to outsource or switch RCM companies.
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Indeed you bring up a good point, some of this is very system and group-specific
The effort vs. pay equation with my particular setup (well, my previous setup), was far overweighted to just seeing another patient rather than trying to get that level 4 to a level 5 (since it would likely get down coded anyway based on that patient's particular payor)
An ESI walking chest pain with Humana in my area is going to be a level 4 max any way you cut that chart, UNLESS you figure out a way to slap critical care on that (which would likely get internally down-coded unless there was some legit CC time done)
I was one of those people that would write up every single chart as a level 5, and I did up until my last day. Didn't mean I got paid level 5 RVUs fro every case.
That was kind of the optimization I was getting at. Sometimes the juice isn't worth the squeeze.
The effort vs. pay equation with my particular setup (well, my previous setup), was far overweighted to just seeing another patient rather than trying to get that level 4 to a level 5 (since it would likely get down coded anyway based on that patient's particular payor)
An ESI walking chest pain with Humana in my area is going to be a level 4 max any way you cut that chart, UNLESS you figure out a way to slap critical care on that (which would likely get internally down-coded unless there was some legit CC time done)
I was one of those people that would write up every single chart as a level 5, and I did up until my last day. Didn't mean I got paid level 5 RVUs fro every case.
That was kind of the optimization I was getting at. Sometimes the juice isn't worth the squeeze.
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Seeing more patients is risky too, just in another way.
Just seeing as many as you safely can and chart aggressively and completely on all of them.
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Yeah. Healthy 28 yo's don't have Medicare so there's they're not defrauding the federal government. If there's only one private insurer in the area, it's possible that they could flag a pattern but there's so much existing level of care denials and so many billers I think it's hard to isolate from the background noise. To be clear, knowingly billing CC on patients that you din't provide CC to is fraud and if one of those charts ends up being scrutinized for other reasons (legal, etc) then you're likely going to not enjoy the consequences.
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That's an accurate spread for a community doc. You should have no 99282s, although I occasionally get some because people want their sutures removed or for us to put a bandaid over their chronic wound. There is no amount of COPA or RISK (unless you lie or send and Rx) to make them higher. I probably have more 99283's than average because I sometimes can't be bothered to write an Rx for "prescription strength tylenol" and Optum, our biller, are a bunch of ****sookers and downcode. We fight back and there is no resolution.
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I can not for the life of me understand why any group would use a biller who's parent company literally directly incentivizes them to bill less, instead of more.
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CPT defines billing.. CMS has recently agreed to follow them. CPT = AMA.. but you are right. CMS does for quality.
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Obviously every group is set up differently. Going from 3 to 4 and 4 to 5 and 5 to CC is about $50 for each level up. Thats the pay to your group / whoever has the contract. This is based on total RVUs which is how the contract holder gets paid and thats $50 from medicare,,, more for commercial/ BCBS and less for Medicaid / self pay in most instances.
If you are worried about this I would work with your billing company to see their requirements. If you use optum as your RCM shame on you for supporting the evil empire (if you have a choice).
If you are worried about this I would work with your billing company to see their requirements. If you use optum as your RCM shame on you for supporting the evil empire (if you have a choice).
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Me neither. We have had numerous discussions with admin over the past 18 months. Schiit moves slowly unfortunately. Word around the grapevine is that things will change in the next 12-18 months.
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I also think that while RCM is a billing and coding function we will see the AI driven adoption on the coding side. For EM as mentioned above it’s gotten relatively simple in 2023.. coders will miss things that an AI program wont. I could see one day it all going through a govt program to code. TIL then Fantom and others will hawk their wears. I imagine there is more usefulness for AI for pcps. Truth is it can likely be trained to give feedback if a certain physician / NPP keeps missing something. (Of course that program would be separate as the feds or a private (likely optum owned) clearinghouse has no incentive to help.
The new world of EM means RCM companies have to be best at collecting that dollar and providing quality reports.
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Yes I think AI is already being used by some billers.
At least it will (hopefully) be consistent.
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Will be dependent on the payers. Their behaviors seriously varies by region.
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A couple of points:
- You do not need to interpret >1 test. If you order 3 tests and interpret only one, you are still considered as high complexity.
- You do not have to interpret it for a specific thing: "CT interpreted by me as no evidence of fecal impaction" for an abdominal CT suffices.
- Don't forget reviewing your state PDMP, immunization history, etc. counts as reviewing external records. Document those. I have a macro for each.
- When you order a head CT, you are doing so to rule out potentially life-threatening intracranial hemorrhage. Stating this will put your problems addressed as high. Combine this with reviewing PDMP, immunization history/prior notes, and interpreted the CT and you're at a level 5.
- Seeing psychiatric patients is often underbilled. Sign an involuntary psychiatric hold and it's high risk for problems. You are considering hospitalization at an inpatient psychiatric facility. Psych hold + hospitalization consideration = level 5. Likewise, considering admission without a hold but talking to your behavioral health assessor gets you a level 5.
- Discussion with sepsis has many points. Lactate >4 almost always qualifies for life-threatening presentation worthy of critical care. However, make sure you bill for only the minutes you spend with the patient, documenting, discussing with consultants, etc. Every patient you bill critical care for should probably have at least 2 re-evals. Can be very brief, but it helps document you are actually spending the time with them.
- Don't be shy to bill critical care for patients you discharge. Anaphylaxis, multiple nebs, etc. It's rare, but it does occur. Give >1 parenteral rate-lowering or blood pressure agent (diltiazem, labetalol, hydralazine), then you're treating hypertensive urgency (high risk problem) and needing intensive monitoring. At the very least a level 5 even if you don't interpret an image, but also worthy of critical care time.
- Admitting patient: consideration for admission + talked with hospitalist. Document it and you're at a level 5. No need to interpret imaging studies.
- You do not need to interpret labs. Only ordering them.
- Ordering an MRI? Most places typically admit for MRIs. If you're ordering one, you're doing so "in lieu of admission" by doing it in the ER. Therefore, admission considered. Couple that with a high-risk problem rule out (cauda equina, stroke) and you've got level 5. Independent interpretation of the MRI seals the deal to stand up to any audit.
- Ordering an IV-contrast study should trigger your coder to place the risk of complications as high. You don't need to give parenteral opioids or admit the patient for this. CT PE protocol with you interpreting the images is enough to get you a level 5 (IV contrast + independent interpretation).
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We've been specifically warned about billing critical care on discharged patients.
I think anaphylaxis or opiate overdose where you're the one ordering the Epi or Narcs and then observing is reasonable (as do our billers), but giving three nebs for asthma and discharging w critical care billed is pretty sus. You're essentially labeling them as "status asthmaticus" and then discharging them?
This is coming from an aggressive biller of CC time.
Narcan and Epi, as you mention, are very common CC discharges.
I do not bill 3x nebs alone as CC (I recall, a solid 15 years ago, being told at the pedi hospital they always did...)
Now if I give three nebs and steroids and magnesium infusing and they looking shockingly better but hang out in the ED 4hr and shared decision making means they leave... then I may.
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One thing lost here is the actual time requirement.. yes pretty much everything counts for that 30 mins but it’s hard to really say you spent 30 mins on some of these cases. To each their own. I bill cc regularly and think i do so appropriately but the more we skew from the accepted norm to what is 1-2 standard deviations the more likely you are to get into trouble.
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I agree with the overall point that the more you skew from the norm the more you are at risk. As a whole I think EPs under bill critical care though and so it is completely okay to be one standard deviation higher, just don’t be two. We often delegitimize certain things that are definitely critical care because they are routine for us and we see many other far sicker patients. Classic example is transient hypoglycemia.
But meh, it’s so easy to get to 30 minutes. EPs often lose track of time and undersell how much time they spent. You can easily argue 30 minutes for every critically ill patient just with evaluating them initially, one reevaluation, talking to one consultant and charting alone, not even including obtaining history from another source, reviewing prior records, interpreting diagnostic testing, discussing with other healthcare staff, any extra consultant discussions, and occasionally multiple reevaluations. Who in an audit is going to argue against how long it took you as a non-Radiologist to interpret a CT? 30+ minutes is easy, justifiable and appropriately compensates you. Plus I think everyone should be spending at least 30 minutes time on every critically ill patient because it’s good patient care and they deserve it if sick.
If you have a prolonged ED course with extra management and possibly including transfer it’s also easy to justify billing 99292. These should be a much lower percentage of your critical care billing, but it’s worth being appropriately compensated for your work and time spent.
I have zero worries about billing 30-40min of cc on the vast majority of patient I see who have critical complaints.
Most of us see around 2pt/hr. That’s 30min/patient. Sicker patients take a bit longer. Done.
Most of us see around 2pt/hr. That’s 30min/patient. Sicker patients take a bit longer. Done.
But seriously—
5min history exam
5min reading PMhx and old stuff in the emr
5min (split up) ordering labs and meds and redosing meds and fluids
5min typing your note; 10minutes if it’s a doozy
5min reviewing the imaging and formal reports. Oh and labs results too! And the ekg!
5minutes arranging admission and sign out.
Add 5minutes for any consultant
Add 5minutes for any family etc discussion
Add 5-15 minutes for arranging a transfer.
Then add tons of time when there is an actually issue with any of these processes…
No one is going to balk that these tasks take 5minutes, and you do then on almost every actually sick patient!
Probably the only ones that don’t close are the allergic reaction that you give epi up front. 10minutes up front, 10 minutes at discharge to get the instructions and Rx and all set up… I try to walk by the room once an hour x 2-3 to check they are doing ok, so hopefully that takes about 10 minutes too.
5min history exam
5min reading PMhx and old stuff in the emr
5min (split up) ordering labs and meds and redosing meds and fluids
5min typing your note; 10minutes if it’s a doozy
5min reviewing the imaging and formal reports. Oh and labs results too! And the ekg!
5minutes arranging admission and sign out.
Add 5minutes for any consultant
Add 5minutes for any family etc discussion
Add 5-15 minutes for arranging a transfer.
Then add tons of time when there is an actually issue with any of these processes…
No one is going to balk that these tasks take 5minutes, and you do then on almost every actually sick patient!
Probably the only ones that don’t close are the allergic reaction that you give epi up front. 10minutes up front, 10 minutes at discharge to get the instructions and Rx and all set up… I try to walk by the room once an hour x 2-3 to check they are doing ok, so hopefully that takes about 10 minutes too.
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I get how it can be justified but every EM doc knows its a bit made up on a chunk of patients.. thats the just the truth..
Sure. We get how the sausage is made. And there aren’t any stopwatches around.
From an ethical POV, I feel very OK if, occasionally, I’m hyper-efficient dropping orders on my cellphone while getting report from EMS on some HHS glucose 1000 obtunded SNF patient who cannot give history, read their entire chart in <5min while getting interrupted 20x, drop that DKA orderset w/ Ceftri for equivocal UTI/sepsis in 60s flat, write my note like a coked out Stephen King, and text the intensivist for admission using entirely emojis. I might have actually spent 18 minutes? I’m not sure? I did all the steps! I went back on checked on him a couple times. I got the nurses to two 2x finger sticks after we started all the insulin! Oh and event found the MOLST form that says DNR and got it scanned into the chart. Its 34 minutes of critical care! I don’t want to commit any fraud, but at some point there are estimates, and usual and customary practice (IMO). In the balance, I strongly suspect that this is more than made up for the underbilling we perform all the time, and all the times I’ve stayed late helping arrange for care, and transfers, and the like.
But I think where you and I would 100% agree is on the “softer” critical care billing, ESPECIALLY of patients and families that are awake and oriented and present… you really need to ensure you spend the time you chart.
I do think it would be a fun exercise to try and ACTUALLY time the time we spend on these cases. Not the time in room. How do you even assign time when two nurses are talking to you at once and the Uco is telling you to pick up the critical lab value on line 4. And the CONSTANT ADHD of scrolling your EPIC list, looking at every lab that just got back, oh the Cr is 2.2? Let me see an old. OK its chronic. What the guy in 7 has a positive trop. Squirrel! Wait why didn’t the Zofran Rx go though to CVS? I sent it electronically? No I’m not calling it in! I’ll send it in. Orders the guy in 7 ASA. Where is his EKG…. Imagine the poor guy with a stopwatch and clipboard trying to sort it out visually.
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I agree. I think the main point is we all stretch this. I am a pretty liberal with CC. I dont think I under I’ll cc and frankly I generally don’t under bill. I have learned this ins and outs of the new documentation guidelines. I think this is the key. Of course I’m 100% RVU based. Every incentive to be good at this. But I’ll just say i see over 2 pph.. i have definitely spent 75% of my shift providing critical care on a time basis. Some patients take me 10 mins.. some patients take 25 mins.. I simply say that some patients i can get done in under 5 mins especially if i have a scribe.. but much like giving an annoying patient and RX to get them out (to get to the next patient) we should be honest about our behavior and why we do what we are doing.
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- Dec 19, 2020
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I’m fine stretching it. Just because we can take care of a patient super fast, that shouldn’t be what’s expected for compensation. I doubt lawyers work super fast to try to decrease billable hours. Ethically and legally, I don’t think anyone should intentionally inflate time that isn’t justified. You should bill an amount of time that is reasonable, but no need to err on the cautious side. AMA, CMS, etc. created the silly rule of needing at least 30 minutes, but then needing 74 minutes to get to the next level (which they recently increased). They could just look at any cc chart and give you cc reimbursement based upon the patient being really sick. We don’t have to put down a time for levels 1-5. There’s a lot of variable time with those patients as well. Hence back to playing the game.
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