Interdisciplinary team conferences

[Iamnew2]

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Do you all bill for IDT conferences/notes?
What about when you round on the patients same day that you have IDT - do you bill one, both ?

 

[Dansk2011]

I don't think you can bill for conference notes. I bill based off time so conference days I bill a higher level.

 

[Iamnew2]

I don't think you can bill for conference notes. I bill based off time so conference days I bill a higher level.

Do you do a separate progrss note and conference note or just typically one?

 

[Dansk2011]

Do you do a separate progrss note and conference note or just typically one?

It's a separate note but done by someone else. I do daily updates on therapy and progress with PT/OT/SLP in my notes and mention in my note team conference performed on "x" date with expected discharge on "y" date.

 

[Iamnew2]

It's a separate note but done by someone else. I do daily updates on therapy and progress with PT/OT/SLP in my notes and mention in my note team conference performed on "x" date with expected discharge on "y" date.

Ok I do the same. I also write daily updates as long as the therapists update the progress (which can be a challenge!) and then state this patient was discussed in team conf, on such a date, with expected dc of x.

 

[lejeunesage]

I add personally-taken notes from the conference and bill a 99233 based on time.

 

[RangerBob]

I add personally-taken notes from the conference and bill a 99233 based on time.

This is what I do as well. I just write brief notes and a “see paper chart for separate note” since the team note is on paper still.

 

[Iamnew2]

This is what I do as well. I just write brief notes and a “see paper chart for separate note” since the team note is on paper still.

So you write a progress note and add stuff from team conference to the progress note?

 

[lejeunesage]

So you write a progress note and add stuff from team conference to the progress note?

Pretty much.

I add a few lines to my progress note. For instance:

"Held team conference. Progress in therapy is impeded by poorly controlled neuropathic pain. He is already on gabapentin 1200 mg TID. I will add nortiptyline to his regimen.

Nursing reports new-onset urinary retention. This is likely BPH-related. I will initiate a trial of tamsulosin. In the meantime, ISC for PVR > 400 ml.

Current barriers to discharge include pain, lack of independence with bladder evacuation, and lack of caregiver training.

See team conference note for full details."

Then, at the end of my note I add something like:

"35/40/45" minutes spent in patient care today, including time at the bedside and discussion of discharge planning issues in multidisciplinary team conference with nursing, PT, OT, SLP, and social work. Greater than half of this time was spent in counseling and coordination of care."

Then I bill a 99233. I haven't had any trouble billing at this level.

 

[RangerBob]

So you write a progress note and add stuff from team conference to the progress note?

Yes. I do something similar to lejunesage above. I just put in in under a part of my plan, my partner puts it at the bottom of his note. It really doesn't matter--frankly it only matters for our billing-typically the note that matters for compliance is one generated by CM/SW or some other member of the team. In our case, it's a paper template that gets circulated during team. I've also seen ones where the note is shared and everyone just copies/pastes their part into the note, and others where someone (usually CM) types everything out as you discuss it during the conference.

So we just document so we can bill a level 3. And we don't need to go into that much detail--we can summarize, just like we can if we spent 40 minutes talking about stroke recovery with a patient. As long as it's somewhere in the note and we briefly attest to what we discussed (and our compliance department tells me the phrase "patient's current functional status discussed during interdisciplinary team meeting--see paper chart for separate note" is actually sufficient alone), then we're good. I put in some details more because I know nursing/CM find it helpful when talking with family. I also thought that statement was perhaps too vague, and I'd prefer to be on the safer side were I to ever be audited.

I also document time in not only my team notes, but all notes, as most level 3'son rehab tend to be due to time, not complexity. We spent so much time in discussion with member of the team and consultants about patients, all of which counts towards time spent in patient care (in addition to time spent reviewing the EMR, placing orders, etc., though I believe only outpt docs can count the time spent writing their notes in the total time)

 

[DMBandFan86]

It is interesting to read about billing level 3 on conference days. I have not done it. Team conferences themselves are separately non-billable encounters.

Generally speaking, a level 3 service requires a new problem with high risk (i.e. severe exacerbation or elective major surgery). That puts the patient out of rehab if they are that sick. I have had a couple level 3's for inpatient due to acute illnesses that were very complicated, but it is very rare.

I haven't billed inpatient encounters based on time (I do outpatient sometimes). For my weekly conferences we spend about 3-6 minutes per patient, and I only talk for 10-20% of the time. In my opinion, a 5 minute team conference doesn't jump from level 2 to level 3. I also don't go back and talk to the patient about it until the next day. The way I'm set up, conference notes only take me about 10 seconds to complete (longer for EMR to load note).

I do have 100% coding oversight, which may be different that other people here. My coders won't give me a level 3 unless I am running a code blue.

 

[RangerBob]

It is interesting to read about billing level 3 on conference days. I have not done it. Team conferences themselves are separately non-billable encounters.

Generally speaking, a level 3 service requires a new problem with high risk (i.e. severe exacerbation or elective major surgery). That puts the patient out of rehab if they are that sick. I have had a couple level 3's for inpatient due to acute illnesses that were very complicated, but it is very rare.

I haven't billed inpatient encounters based on time (I do outpatient sometimes). For my weekly conferences we spend about 3-6 minutes per patient, and I only talk for 10-20% of the time. In my opinion, a 5 minute team conference doesn't jump from level 2 to level 3. I also don't go back and talk to the patient about it until the next day. The way I'm set up, conference notes only take me about 10 seconds to complete (longer for EMR to load note).

I do have 100% coding oversight, which may be different that other people here. My coders won't give me a level 3 unless I am running a code blue.

My partner has worked with the attorney general office running audits on docs and hospitals. He's quite active politically in the field, and he knows his stuff. More than half of his visits are coded level 3--generally because of time.

Team conferences are 100% billable. You're spending time talking with the interdisciplinary team about the patient's care. It doesn't matter if you're only talking for two minutes, since you're participating/listening to the whole thing. It's the same as talking with a consultant--that's all billable (by time). Time spent reviewing the chart, talking to consultants, the entire team (PT/OT/SLP, CM/SW, psych) about the patient's care, in addition to the time spent talking to the patient/educating them. It's really not hard to get to a level 3.

I rarely bill a level 3 for complexity. But I bill level 3's often/when appropriate (usually about half the time). I'm generally told I under-bill compared with my peers, who are closer to 75% level 3's.

 

[DMBandFan86]

I'm not saying you're wrong. I would love to bill for a higher level of care to make more money. Who wouldn't? I am also a worry-wort about the rules.

Your peers are billing 75% of IPR visits as a level 3? Maybe I am the only one that thinks that's a little high. Are they seeing patients 3 days per week or 5+ days per week (as that would make a difference). I currently practice independently so I don't have local IPR peers to compare to, but in my training at multiple facilities I rarely saw a rehab physician put in that much time on rounds or in coordination of care efforts. Perhaps I'm just a lazy physician with bad training, but it doesn't take me that long and I have good outcomes and good patient feedback about communication.

I talk to my consultants and team members often, but for brief interactions. That can be difficult to add up the time to be accurate. I do formal nursing rounds daily on each patient (Mon-Fri), weekly team conference and will call family or discuss in person when needed. I do utilize social work that helps me with some of the communication about length of stay and discharge decisions after weekly conference.

If you are billing level 3 then you are spending more than 50% of the visit total time in counseling or coordination of care. If I am understanding the rules correctly, that is 17.5-20+ minutes per day in just counseling/coordination with each patient. And your peers are doing that 75% visits? (if you have 16 patients that is 4 2/3+ hours a day just on counseling/coordination). I can see billing a level 3 on the initial team conference day: maybe you spent 5 minutes with nursing/consultants, 5 minutes on team conference and then counseled the patient/family about their condition for 5 - 10 minutes. But, usually by the second or third team conference the patient is getting less complicated and requires less time and management.

I am thankful I found this thread, maybe I will start utilizing level 3 billing for more cases.

 

[Iamnew2]

I'm not saying you're wrong. I would love to bill for a higher level of care to make more money. Who wouldn't? I am also a worry-wort about the rules.

Your peers are billing 75% of IPR visits as a level 3? Maybe I am the only one that thinks that's a little high. Are they seeing patients 3 days per week or 5+ days per week (as that would make a difference). I currently practice independently so I don't have local IPR peers to compare to, but in my training at multiple facilities I rarely saw a rehab physician put in that much time on rounds or in coordination of care efforts. Perhaps I'm just a lazy physician with bad training, but it doesn't take me that long and I have good outcomes and good patient feedback about communication.

I talk to my consultants and team members often, but for brief interactions. That can be difficult to add up the time to be accurate. I do formal nursing rounds daily on each patient (Mon-Fri), weekly team conference and will call family or discuss in person when needed. I do utilize social work that helps me with some of the communication about length of stay and discharge decisions after weekly conference.

If you are billing level 3 then you are spending more than 50% of the visit total time in counseling or coordination of care. If I am understanding the rules correctly, that is 17.5-20+ minutes per day in just counseling/coordination with each patient. And your peers are doing that 75% visits? (if you have 16 patients that is 4 2/3+ hours a day just on counseling/coordination). I can see billing a level 3 on the initial team conference day: maybe you spent 5 minutes with nursing/consultants, 5 minutes on team conference and then counseled the patient/family about their condition for 5 - 10 minutes. But, usually by the second or third team conference the patient is getting less complicated and requires less time and management.

I am thankful I found this thread, maybe I will start utilizing level 3 billing for more cases.

It depends where you are. We have morning conference with the WHOLE team every morning, takes about an hour, prior to that we have a huddle with nursing where issues re: patients overnight are talked about. I either see the Medicine team physician or NP or review their notes, they are in house for a few hours daily. Nursing and social work/case manager I deal with multiple itmes a daily throughout the day. I pretty much stay here all day and not infrequently I might see patients multiple times a day - for questions, for family discussions, etc in addition to team conference, talking to therapists, nurses, etc all in addition to seeing the patient. It adds up. i do a TON of coordination of care, and when I am not here or take time off, things seem to fall apart quickly. I would say 95+ percent of our acute care transfers are when I am off on weekends or Friday nights. So don't underestimate this.
I am at a stand alone hospital for rehab. When I used to work for a private group and rounded on the unit patients in a hospital type inpatient rehab unit, it was much more how you say - I came in, rounded, did my thing, care conference, etc. much less work.

 

[RangerBob]

I'm not saying you're wrong. I would love to bill for a higher level of care to make more money. Who wouldn't? I am also a worry-wort about the rules.

Your peers are billing 75% of IPR visits as a level 3? Maybe I am the only one that thinks that's a little high. Are they seeing patients 3 days per week or 5+ days per week (as that would make a difference). I currently practice independently so I don't have local IPR peers to compare to, but in my training at multiple facilities I rarely saw a rehab physician put in that much time on rounds or in coordination of care efforts. Perhaps I'm just a lazy physician with bad training, but it doesn't take me that long and I have good outcomes and good patient feedback about communication.

I talk to my consultants and team members often, but for brief interactions. That can be difficult to add up the time to be accurate. I do formal nursing rounds daily on each patient (Mon-Fri), weekly team conference and will call family or discuss in person when needed. I do utilize social work that helps me with some of the communication about length of stay and discharge decisions after weekly conference.

If you are billing level 3 then you are spending more than 50% of the visit total time in counseling or coordination of care. If I am understanding the rules correctly, that is 17.5-20+ minutes per day in just counseling/coordination with each patient. And your peers are doing that 75% visits? (if you have 16 patients that is 4 2/3+ hours a day just on counseling/coordination). I can see billing a level 3 on the initial team conference day: maybe you spent 5 minutes with nursing/consultants, 5 minutes on team conference and then counseled the patient/family about their condition for 5 - 10 minutes. But, usually by the second or third team conference the patient is getting less complicated and requires less time and management.

I am thankful I found this thread, maybe I will start utilizing level 3 billing for more cases.

Well, that's what my peers are telling me at least. My billers say I do seem to bill less level 3's than the others, and that 2/3-3/4 of their billings seem to be level 3. Maybe it's more 2/3 and I'm off on the 3/4 part--it was a while ago they mentioned it to me. My partner is closer to 2/3. I can verify he is very thorough. The other docs? I don't know them at all, I just know "of" them. So they could be sketchier. Who knows? It's real easy to upcharge everyone when you're the one telling your billers what code you're using. I see some hospitalists who are clearly upcoding. It's unfortunate.

My billers recommend I bill what's appropriate and what I'm comfortable with. Some days (Saturdays) I'm looking to get in/out as quick as I can, so if there are no big fires to put out, it's more of a level 2 day overall. Team conference days we spent a lot more time in coordination of care, so more level 3's that day. Like Iamnew2, we have a daily huddle where we review all patients, dispo issues, etc. So there are level 3's sprinkled around here and there. Therapists and nurses grab me in the halls, etc. I'm willing to be you put in more time than you realize. Don't forget all the chart reviews, etc. Unfortunately time spent writing notes doesn't count for inpatient (though it does for outpt visits now).

Yes, you're correct on the interpretation of the numbers. Though counseling is included in that 50%, so that includes time spent talking with the patient. It's not hard to hit 35 minutes taking into account all the people you're talking with (therapists, consultants, etc.), counseling the patient, exam, review of the chart, etc. Lol, with Epic my chart review was very fast, but Cerner isn't as efficient so that unfortunately adds more time!

I knew some physiatrists who never bill a level 2--they were worried billing a level 3 is a risk for an audit. But you're always at risk for an audit, and if your documentation supports your coding, then there's nothing to worry about. If you're genuinely putting in the time, it's appropriate to bill for it.

 

[DMBandFan86]

We have morning conference with the WHOLE team every morning, takes about an hour, prior to that we have a huddle with nursing where issues re: patients overnight are talked about.

I am all about creating value for my patients. What benefits would I gain by adding an additional 1 hour meeting every morning that nursing, aides, therapy, social work, all staff, etc all have to attend? People already hate meetings. I'm just trying to understand what you talk about (assuming avg 16 patients, ~4 min per patient) on a daily basis that everyone needs to hear. We have already addressed discharge and therapy goals in team conference. Where I work we currently use microsoft teams and are offices are either adjacent or close enough to discuss frequently. Encompass and other facilities do the daily administrative morning meetings, but that is for the medical directors and they are compensated for that separately. Which I assume we are not talking about since that is administrative.

So anyways, if I want to bill level 3 for 50-75% of IPR visits based on time I need 17.5+ minutes per day in coordination/counseling alone:

1-2 minutes nursing huddle with consultants present + 5 min on team conference days + 30 seconds extra social work discussion + 2-5 minutes interactions with therapy. Honestly that is probably shooting on the high side as I don't need to talk to social work daily on every patient or therapy necessarily. I also only spend about total 15-20 minutes on nursing rounds. But, if I do start an extra daily 1 hour meeting with WHOLE team then I can add an extra 4 minutes of time per patient. Estimating high, that still leaves me with 5 minutes of direct family and patient counseling on team conference days and 10+ minutes on other days that I would need to document and perform.

My practice style is different than yours, which if fine. In my situation I can see justifying a level 3 on conference-days based on time for some patients, but otherwise I wouldn't reach 50-75% billing.

On a side note, I have been in 1+ hour family meetings that I never went back and billed higher. So, I think I will start doing that now and probably should have been. I have a scribe and try to get my notes done early or I can see other people.

I guess I have been trained not to code on time as much as you guys do. Which is why I am still hesitant. I always had in my head to use time-based coding for special situations where I went above and beyond in patient care. Like a lengthy goals of care meeting or something. Not something that I just do on a daily basis as a rehab director.

 

[RangerBob]

I am all about creating value for my patients. What benefits would I gain by adding an additional 1 hour meeting every morning that nursing, aides, therapy, social work, all staff, etc all have to attend? People already hate meetings. I'm just trying to understand what you talk about (assuming avg 16 patients, ~4 min per patient) on a daily basis that everyone needs to hear. We have already addressed discharge and therapy goals in team conference. Where I work we currently use microsoft teams and are offices are either adjacent or close enough to discuss frequently. Encompass and other facilities do the daily administrative morning meetings, but that is for the medical directors and they are compensated for that separately. Which I assume we are not talking about since that is administrative.

So anyways, if I want to bill level 3 for 50-75% of IPR visits based on time I need 17.5+ minutes per day in coordination/counseling alone:

1-2 minutes nursing huddle with consultants present + 5 min on team conference days + 30 seconds extra social work discussion + 2-5 minutes interactions with therapy. Honestly that is probably shooting on the high side as I don't need to talk to social work daily on every patient or therapy necessarily. I also only spend about total 15-20 minutes on nursing rounds. But, if I do start an extra daily 1 hour meeting with WHOLE team then I can add an extra 4 minutes of time per patient. Estimating high, that still leaves me with 5 minutes of direct family and patient counseling on team conference days and 10+ minutes on other days that I would need to document and perform.

My practice style is different than yours, which if fine. In my situation I can see justifying a level 3 on conference-days based on time for some patients, but otherwise I wouldn't reach 50-75% billing.

On a side note, I have been in 1+ hour family meetings that I never went back and billed higher. So, I think I will start doing that now and probably should have been. I have a scribe and try to get my notes done early or I can see other people.

I guess I have been trained not to code on time as much as you guys do. Which is why I am still hesitant. I always had in my head to use time-based coding for special situations where I went above and beyond in patient care. Like a lengthy goals of care meeting or something. Not something that I just do on a daily basis as a rehab director.

Sounds like you run a really efficient operation with minimal issues, which is great. On our unit at least, the AM huddle is where we go over dc issues, storm-clouds, and can connect regarding therapy issues. Ultimately it saves the team time by having us all there together. Ours is about 30 minutes for 20 patients (from which my partner and I split the census in half). Then there's conversations here/there throughout the day, but the stuff we need therapy + CM/SW + MD/DO involved in together are typically taken care of by then. Team conference isn't enough since it's only once per week and lengths of stay are so short.

Our team finds it helpful. But most of them are also paid hourly, so there's not as much aversion to meetings when you're getting paid to be there.

Maybe our patients are just more complicated, or we're just more inefficient. Who knows. It's how the unit has been doing things since before I started (mostly--when I started it was just SW/CM/therapy, and I decided it'd be helpful to be there as well), and it's how about 50% of the sites I trained at in residency did things. Though at the VA it was usually double the time with 1/4 the patients. Which made it much more relaxed!

You may already know this, but once you get to 65 minutes in patient care you can actually bill for prolonged service as well. I believe it essentially doubles what you make on that encounter, which makes sense as it's the equivalent of seeing another patient and billing a level 3. AAPM&R had a whole section about it in one of their flyers they send us all every few months (the ones you probably put straight in the recycling bin because usually there's nothing useful in them...).

Same prolonged service billing applies for outpt to, though I'm not sure what the time requirements are there.

 

[lejeunesage]

Personally, I only bill levels 3s on 2 occasions:
1. Team conference days.
2. When there's a medical complication. I almost never consult Medicine. So if a patient has anything from worsening fluid overload to new diagnosis of atrial fibrillation or a DVT, I'm the one making the diagnosis and initiating treatment. That makes me pretty confident when I bill a level 3.

Otherwise, I stick to level 2s. I'd say that levels 2s make up 75% of my billings and level 3s 25%.

 

[Dansk2011]

Personally, I only bill levels 3s on 2 occasions:
1. Team conference days.
2. When there's a medical complication. I almost never consult Medicine. So if a patient has anything from worsening fluid overload to new diagnosis of atrial fibrillation or a DVT, I'm the one making the diagnosis and initiating treatment. That makes me pretty confident when I bill a level 3.

Otherwise, I stick to level 2s. I'd say that levels 2s make up 75% of my billings and level 3s 25%.

I do the same. Although now I have full time IM coverage so not often for complexity. Most my level 3s are on team conference days or when I have family meetings. There are still times when I am starting 2 new meds and getting imaging/labs etc which I will bill a level 3 but honestly it ends up being based on time anyways.

 

[Iamnew2]

I do the same. Although now I have full time IM coverage so not often for complexity. Most my level 3s are on team conference days or when I have family meetings. There are still times when I am starting 2 new meds and getting imaging/labs etc which I will bill a level 3 but honestly it ends up being based on time anyways.

I do the same when starting new meds, getting labs, etc. Same re: time. With my patient population, its not difficult for a lot of time to add up during the day given all the needs, questions, education, etc.