New heme patients - 4 or 5?

[AmiSansNom]

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New community oncologist. For new heme patients (anemia, leukopenia, MGUS, VTEs), do you typically bill 99204 or 99205? I have seen both being done by different physicians. Is there a nuance to this? Do you bill 4 or 5 more for these visits?

 

[HemeOncHopeful19]

The billing criteria are really not that complicated for someone that can finish medical school, residency and fellowship IMO, although they are occasionally vague enough to create gray areas. I feel like a lot of people just don’t take the time to really try to learn it maybe because they don’t feel like it should be part of being a doctor? I don’t think most benign Heme falls into those gray areas.

Most benign Heme new visits are gonna be a 4 in my book. I usually file it under “new problem with uncertain prognosis” (because I’m working it up and don’t have a true idea what it is yet) and “reviewed at least 2 external notes + lab tests”, or alternatively if you prescribe something “prescription rx”

To get to a level 5 from that point you basically need a combination of 2 things (there’s a few other possibilities but these are the ones I usually am considering):
- threat to life or bodily function
- discussed management with another healthcare provider
- therapy requiring intensive monitoring for toxicity

Things that are potentially life threatening like ITP requiring Rituximab/Promacta or anemia requiring blood transfusion could probably be a 5.

I think anyone putting MGUS as a 5 is probably doing it wrong and I’d love to hear their argument otherwise.

DVT/PE on the other hand probably can fall into those gray areas. I believe the “threatens life or bodily function” guidance actually does refer to if it was left untreated… I would argue PE or even DVT fits there. I’m less sure what I would say about a DOAC requiring intensive monitoring for toxicity but someone on Warfarin might qualify.

Alternatively if you are somehow spending 60+ minutes on the new encounter then go ahead and bill a 5

 

[gutonc]

I generally agree with @HemeOncHopeful19 here. Most of these are going to be 99204s, but you can occasionally spin a 99205 out of it with a little extra work. And obviously, if you spend more than an hour on it, you're going to bill on time. But you can get an easy 99204 with 20 min worth of actual work.

 

[AmiSansNom]

Thank you both!

 

[aafisahar]

Why not bill on time?

 

[gutonc]

Why not bill on time?

Because they usually take 10 minutes.

But to be clear, both @HemeOncHopeful19 and I said that if you spend 60 minutes on it, absolutely bill a 99205.

 

[aafisahar]

Because they usually take 10 minutes.

But to be clear, both @HemeOncHopeful19 and I said that if you spend 60 minutes on it, absolutely bill a 99205.

Sure, but that also includes chart review. I do cardiology, not heme, but just a decent chart check takes 10 minutes, maybe look at a smear, talk to the patient for another 10, and document for 5, and it'll end up being close to 60.

 

[gutonc]

Sure, but that also includes chart review. I do cardiology, not heme, but just a decent chart check takes 10 minutes, maybe look at a smear, talk to the patient for another 10, and document for 5, and it'll end up being close to 60.

Your math is kind of off. 10+10+5 != 60.

You're not wrong about the amount of time it actually takes though. Most classical heme consults could be managed by a modestly competent M3. Which is not to say that there's not a lot of super complex classical heme stuff out there, just that the vast majority is stuff that PCPs should be handling on their own, but won't.

 

[aafisahar]

Your math is kind of off. 10+10+5 != 60.

You're not wrong about the amount of time it actually takes though. Most classical heme consults could be managed by a modestly competent M3. Which is not to say that there's not a lot of super complex classical heme stuff out there, just that the vast majority is stuff that PCPs should be handling on their own, but won't.

You also gotta put your finger on the scale. I've been doing time based for all new consults with no issues, including the 22 year with palpitations and the 77 year old with multivalvular disease, heart failure.

 

[gutonc]

You also gotta put your finger on the scale. I've been doing time based for all new consults with no issues, including the 22 year with palpitations and the 77 year old with multivalvular disease, heart failure.

"Putting your finger on the scale" is also sometimes called "Medicare fraud" so I like to keep my fingers off the scale.