Newbie...can someone please verify my MDM to appropriately bill 99204 for all new patients?

[cameroncarter]

PROBLEM COMPLEXITY (LOW)
-typically low since I keep visits to 1 stable chronic illness

DATA (3 points from category 1) (MODERATE)
-review of CBC and BMP (1pt)
-review of X-ray spine report everytime (1pt)
-review of MRI spine report everytime (1pt)
(I’m in a busy private group so MRI is usually always done)
-review of the same Xray/MRI counts everytime right? I do this out of good practice.

MANAGEMENT (MODERATE)
-RX management OR injection discussion at every visit
-injections count as "minor surgery" right?

This is my approach for all new patients (takes about 30 minutes from start to finish). Do you think it's fair to bill 99204 for this approach?

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[deleted875186]

Looks good in my opinion. What I typically do below.

review primaries referral note (or neurosurgery or ortho surgery)
Review XR or MRI (or will document independent interpretation of MRI and note that I reviewed images with the patient)
Review prescription drug monitoring

Plus at least two diagnoses with progression of illness

99204 every consult, unless they’re literally just sent over with a referral note and no imaging and I’m just going to tell them to start PT.

 

[cameroncarter]

Looks good in my opinion. What I typically do below.

review primaries referral note (or neurosurgery or ortho surgery)
Review XR or MRI (or will document independent interpretation of MRI and note that I reviewed images with the patient)
Review prescription drug monitoring

Plus at least two diagnoses with progression of illness

99204 every consult, unless they’re literally just sent over with a referral note and no imaging and I’m just going to tell them to start PT.

2 diagnoses or problems? if problems, you're pretty much at 99205 level with your approach aren't you?

 

[deleted875186]

2 diagnoses or problems? if problems, you're pretty much at 99205 level with your approach aren't you?

Sorry. I meant two diagnoses, or 2 illness with progression. This satisfies number or complexity of problems. For 99205 you need acute or chronic illness with severe progression. I was told by coders they interpreted this as serious illness or major surgery, essentially nothing I typically see in the clinic. At least how I understand it.

I will occasionally bill a 99205 on time if it’s a crap show and takes forever.

 

[runfastnow]

Problem List:
- Chronic problem with exacerbation or not at treatment goal = almost everyone with stenosis or facet arthropathy = Moderate Complexity
- Two chronic problems = stenosis + DDD, facet arthropathy + DDD, disc herniation + radiculopathy = Moderate Complexity
- This one shouldn't be hard to hit unless you also see general MSK stuff like meniscus tears, etc.

Data:
- Review MRI and/or XR images independently = Moderate Complexity
- If you are billing for the read you cannot double dip. We bill for XR reads at my practice so I can't double dip the XR data points.
- You cannot continually re-review the same study every visit. Once you review the scan you cannot re-count it on future visits.

Management:
- Medication management = Moderate Complexity
- Epidural or RF discussion/sign-up we regard as minimal/low risk (NOT minor surgery) unless someone has significant risk factors - i.e. DM2 ESI blood sugar risk, blood thinners and doing a TFESI, etc. then will bump it up a category.
- SCS, MILD, etc. = minor surgery

 

[IAmTheOne1]

It's hard to believe that ESI/RFA wouldn't quality for moderate classification if any class of medication management qualifies for moderate complexity. Is the risk of Meloxicam or Gabapentin Rx higher than the risk of ESI/RF?

 

[cameroncarter]

Problem List:
- Chronic problem with exacerbation or not at treatment goal = almost everyone with stenosis or facet arthropathy = Moderate Complexity
- Two chronic problems = stenosis + DDD, facet arthropathy + DDD, disc herniation + radiculopathy = Moderate Complexity
- This one shouldn't be hard to hit unless you also see general MSK stuff like meniscus tears, etc.

Data:
- Review MRI and/or XR images independently = Moderate Complexity
- If you are billing for the read you cannot double dip. We bill for XR reads at my practice so I can't double dip the XR data points.
- You cannot continually re-review the same study every visit. Once you review the scan you cannot re-count it on future visits.

Management:
- Medication management = Moderate Complexity
- Epidural or RF discussion/sign-up we regard as minimal/low risk (NOT minor surgery) unless someone has significant risk factors - i.e. DM2 ESI blood sugar risk, blood thinners and doing a TFESI, etc. then will bump it up a category.
- SCS, MILD, etc. = minor surgery

Thanks a ton- really like this workflow!

Do I need to document how I arrived at “moderate MDM” (i.e. review of X gives me Y points etc)?

Also, I have a smartphrase for time-based billing. Do you have one for MDM based billing?

 

[DrMDAware]

Plus at least two diagnoses with progression of illness

Could you share your verbiage for the progression of the Illness (not at goal, stable, worse than before)? Thanks

Management:
- Medication management = Moderate Complexity
- Epidural or RF discussion/sign-up we regard as minimal/low risk (NOT minor surgery) unless someone has significant risk factors - i.e. DM2 ESI blood sugar risk, blood thinners and doing a TFESI, etc. then will bump it up a category.
- SCS, MILD, etc. = minor surgery

I could be wrong but I code MBB, RFAs and ESI as moderate. The risks could be catastrophic IMHO.

Problem List:
- Chronic problem with exacerbation or not at treatment goal = almost everyone with stenosis or facet arthropathy = Moderate Complexity
- Two chronic problems = stenosis + DDD, facet arthropathy + DDD, disc herniation + radiculopathy = Moderate Complexity
- This one shouldn't be hard to hit unless you also see general MSK stuff like meniscus tears, etc.

Sorry don’t mean to dump on ya…I was told the problem list only counted if I’m actively doing something. So for stenosis then ESI. But for DDD I’m not doing doing anything so cannot count it. If I say stenosis = ESI and myofasicla pain = celebrex then it counts as two. I’m open to listening If I was told I correctly

 

[potcake76]

review of the same Xray/MRI counts everytime right?

No.

 

[GlowInTheDark]

We have practiced that injections and discussion of their risks counts. Haven’t had an issue.

I have a smart phrase I throw in that is about a paragraph detailing all the nuance of procedure, it was discussed in detail, risks were clarified, questions were answered, etc.

Similar for medications. Even if we do nothing we’ve discussed these items and almost every encounter is a level 4.

You should also consider the external notes you’ve reviewed. I’ve often looked at 1-2 other physicians notes.

 

[Ducttape]

Thanks a ton- really like this workflow!

Do I need to document how I arrived at “moderate MDM” (i.e. review of X gives me Y points etc)?

Also, I have a smartphrase for time-based billing. Do you have one for MDM based billing?

if you are considering billing for level 5, it would apparently behoove you to use time based billing for that encounter, and document the specific time you in the room arguing with counselling the patient.

Could you share your verbiage for the progression of the Illness (not at goal, stable, worse than before)? Thanks


I could be wrong but I code MBB, RFAs and ESI as moderate. The risks could be catastrophic IMHO.


Sorry don’t mean to dump on ya…I was told the problem list only counted if I’m actively doing something. So for stenosis then ESI. But for DDD I’m not doing doing anything so cannot count it. If I say stenosis = ESI and myofasicla pain = celebrex then it counts as two. I’m open to listening If I was told I correctly

yes. but it is pretty easy to recommend core exercises for DDD, ESI for stenosis, CBT/ACT/yoga/tai chi for fibromyalgia, discuss bariatric surgery referral/place referral.

Epic and i believe most other systems have a Clinical Reference List to give patients info on a particular health issue in their discharge instruction. with 2-3 clicks, you too can counsel patients on everything....

 

[drrosenrosen]

I bill 99205 extremely rarely. If it's super complicated, talking to multiple family members, reaching out to another doctor in real time, or if you spot something truly life threatening. I've billed maybe 3 level 5s in the past year, and one of them I identified as having an MI and sent her to the ER by ambulance. That was the only one I felt I could reasonably get there on MDM. Otherwise if it's truly very complicated and takes a long time, I'll just throw on a time code. Time codes no longer count just face to face - you can include other time directly related to the encounter on the same day, including documentation and communication for coordination of care.

 

[Agast]

How not to get audited

Mix in some level 3s

 

[callmeanesthesia]

I bill 99205 extremely rarely. If it's super complicated, talking to multiple family members, reaching out to another doctor in real time, or if you spot something truly life threatening. I've billed maybe 3 level 5s in the past year, and one of them I identified as having an MI and sent her to the ER by ambulance. That was the only one I felt I could reasonably get there on MDM. Otherwise if it's truly very complicated and takes a long time, I'll just throw on a time code. Time codes no longer count just face to face - you can include other time directly related to the encounter on the same day, including documentation and communication for coordination of care.

Agree, 99205-99215 is usually “sent patient to ER.” Suspected cauda equina, new onset chest pain, altered mental status, etc. sometimes for medical trainwrecks - ESRD plus a-fib on blood thinners, plus cancer on chemo, with extensive spine pathology that should really have a total reconstruction but can’t medically.

 

[runfastnow]

I agree with you guys that CESI, RF, etc. have risk have gone back and forth on it a few times. Ultimately our EMR and billers/coders recommend keeping it as low unless there is additional complication risk like I mentioned - DM2, blood thinners, etc. Maybe I'm wrong and underselling complexity on some patients. However - a lot of my patients in the Diabetes Belt do have these so a lot get bumped to moderate.

I counsel pretty extensively for patients on their symptoms and reviewing MRIs so we end up discussing their DDD, facet arthropathy, stenosis, etc. and give my opinion on treating each process and what I think our meds/injections/PT/HEP are doing for each. So if I counsel/educate on these things then I count it as a problem.

The exacerbation verbiage from CMS is pretty vague IMO and the "not at treatment goal" gives quite a bit of wiggle room in my interpretation.

From our EMR my breakdown:
99202 - 18% | 99212 - 11%
99203 - 27% | 99213 - 45%
99204 - 56% | 99214 - 44%
99205 - 0% | 99215 - 0%

I see a fair amount of MSK/sports stuff which accounts for a lot of lower billing - i.e. acute ACL/meniscus tear in a young person = order MRI + OTC meds = 202/212.

 

[RoloTomassi]

I agree with you guys that CESI, RF, etc. have risk have gone back and forth on it a few times. Ultimately our EMR and billers/coders recommend keeping it as low unless there is additional complication risk like I mentioned - DM2, blood thinners, etc. Maybe I'm wrong and underselling complexity on some patients. However - a lot of my patients in the Diabetes Belt do have these so a lot get bumped to moderate.

I counsel pretty extensively for patients on their symptoms and reviewing MRIs so we end up discussing their DDD, facet arthropathy, stenosis, etc. and give my opinion on treating each process and what I think our meds/injections/PT/HEP are doing for each. So if I counsel/educate on these things then I count it as a problem.

The exacerbation verbiage from CMS is pretty vague IMO and the "not at treatment goal" gives quite a bit of wiggle room in my interpretation.

From our EMR my breakdown:
99202 - 18% | 99212 - 11%
99203 - 27% | 99213 - 45%
99204 - 56% | 99214 - 44%
99205 - 0% | 99215 - 0%

I see a fair amount of MSK/sports stuff which accounts for a lot of lower billing.

I have very similar breakdown, just fewer 2s

 

[SSdoc33]

15% -03
85%- 04

dont sell yourself short. this really adds up over time

 

[callmeanesthesia]

View attachment 358714
How not to get audited

Mix in some level 3s

Post-injection/RFA, patient doing great, f/u prn - level 2. Successful MBB, proceed with RFA per plan - level 3.

 

[Ducttape]

thats a pretty reasonable breakdown, but i would suggest fewer 99202 and 99212....

you might want to not schedule routine RFA follow up - or schedule them 6-8 months out.

they can call to move up follow up sooner if RFA doesnt help.

you should use those (currently) level 2 slots for patients that require some treatment...

 

[SSdoc33]

Post-injection/RFA, patient doing great, f/u prn - level 2. Successful MBB, proceed with RFA per plan - level 3.

that post injection is a level 3, the pre-RF a level 4 IMHO

 

[lobelsteve]

One of my tracked metrics is wrvu per visit. Neat to see it broken down to that.
Over last 6 mo it was 3.75. Includes OV and all office based procedures.

 

[Agast]

I never bill level 2. At the very least I give advice on what exercises and activities I would like them to continue or avoid, and explain signs of when they may need a repeat procedure. Takes a minute of your time and now it’s a level 3.

 

[runfastnow]

Thanks a ton- really like this workflow!

Do I need to document how I arrived at “moderate MDM” (i.e. review of X gives me Y points etc)?

Also, I have a smartphrase for time-based billing. Do you have one for MDM based billing?

We use ModMed for EMR which tallies all the points and predicts and then automatically enters the billing level. It's correct about 90% of the time. I change as needed if it doesn't capture something correctly or will change to time based as needed. No need for tallying the points in your note for the insurance bean counters IMO.

 

[Ducttape]

One of my tracked metrics is wrvu per visit. Neat to see it broken down to that.
Over last 6 mo it was 3.75. Includes OV and all office based procedures.

thats pretty high. given that level 3 follow ups are 1.3 wRVU and level 4 follow ups are 1.92 and level 4 new patients is 2.6.

gotta do a lot of high wrvu injections to bring it up to 3.75.

 

[cameroncarter]

ok so I'm seeing some mixed things about what which injections may constitute "moderate complexity".

We can all agree that stim trials, CESIs, RFAs are moderate....what about joint and bursa injections? peripheral nerve blocks...even TPIs?

 

[RoloTomassi]

ok so I'm seeing some mixed things about what which injections may constitute "moderate complexity".

We can all agree that stim trials, CESIs, RFAs are moderate....what about joint and bursa injections? peripheral nerve blocks...even TPIs?

If a mid-level can do it = minor.
If MD/DO should do it = enough for moderate risk.

 

[deleted875186]

Honestly, every injection but a TPI I count as moderate. E and M guidelines are subjective.

 

[Taus]

Fluoro spine procedure = moderate risk, level 4 mdm per my practice compliance and billing/coding people

 

[clubdeac]

thats pretty high. given that level 3 follow ups are 1.3 wRVU and level 4 follow ups are 1.92 and level 4 new patients is 2.6.

gotta do a lot of high wrvu injections to bring it up to 3.75.

are these the new updated E/M wRVU values? Our hospital has yet to update us to the current numbers

 

[Ducttape]

Fluoro spine procedure = moderate risk, level 4 mdm per my practice compliance and billing/coding people

it is so variable. my coding department said bread and butter - facets, ESI - are level 3. im not sure there is a consensus.

 

[Doctodd]

can i bill 99205 if i do planks and wall squats in the room with the patient? win win

 

[bedrock]

it is so variable. my coding department said bread and butter - facets, ESI - are level 3. im not sure there is a consensus.

Your billing dept is wrong. Level 3 are peripheral joint injections /TPI

Neuroaxial injections are level 4. The increased risk and complexity is why those are a level 4 office and why spine injections pay 4-5 times more than a peripheral joint injection.

 

[macman]

Do not forget that contributory diagnoses count as relevant diagnoses. In other words if someone has diabetes, anticoagulation, low bone density, etc. even if you are not directly treating those issues if they affect your medical decision making, they count.

So they might only be seeing you for low back pain but if they have medical issues that contribute to your decision-making you can count those as relevant problems for your billing and coding for that visit

 

[gaschicago]

Can someone explain their interpretation chronic illness-stable vs progression/treatment side effects? If on the first visit you see someone with 5-6 months of worsening low back pain with occ radiation into the legs do you consider that as "stable" low back pain or progression of low back pain?

Still not completely clear on this coding guideline

 

[DrMDAware]

Do not forget that contributory diagnoses count as relevant diagnoses. In other words if someone has diabetes, anticoagulation, low bone density, etc. even if you are not directly treating those issues if they affect your medical decision making, they count.

So they might only be seeing you for low back pain but if they have medical issues that contribute to your decision-making you can count those as relevant problems for your billing and coding for that visit

I was told this was not true since I’m not managing their diabetes, anticoagulation etc.

 

[clubdeac]

Can someone explain their interpretation chronic illness-stable vs progression/treatment side effects? If on the first visit you see someone with 5-6 months of worsening low back pain with occ radiation into the legs do you consider that as "stable" low back pain or progression of low back pain?

Still not completely clear on this coding guideline

"worsening" = progression

 

[callmeanesthesia]

I was told this was not true since I’m not managing their diabetes, anticoagulation etc.

That’s definitely wrong. If it affects the complexity of your medical decision making it counts. Poorly controlled diabetes, a fib on anti coagulation, morbid obesity, etc, all may impact your treatment plan. Well-controlled HTN on one medication probably doesn’t.

 

[DrMDAware]

That’s definitely wrong. If it affects the complexity of your medical decision making it counts. Poorly controlled diabetes, a fib on anti coagulation, morbid obesity, etc, all may impact your treatment plan. Well-controlled HTN on one medication probably doesn’t.

I hope you’re right my friend. How would morbid obesity affect my ESI - using a longer needle? I don’t mean to be flippant.

I’m just trying to understand in what scenario it would bump up the level of billing? Are there any you could share? I’m genuinely curious. Thanks

 

[callmeanesthesia]

I hope you’re right my friend. How would morbid obesity affect my ESI - using a longer needle? I don’t mean to be flippant.

I’m just trying to understand in what scenario it would bump up the level of billing? Are there any you could share? I’m genuinely curious. Thanks

Morbidly obese affects the complexity of caring for them. Higher risk of complications from procedure due to poor visualization on fluoro, higher risk of respiratory complications from sedating meds, higher risk if you send them to a surgeon.

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

From page 16:
“
The level of risk of significant complications, morbidity, and/or mortality can be:
● Minimal
● Low
● Moderate
● High
Here are some important points to keep in mind when documenting level of risk. You should document:
● Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality
…”

 

[Ducttape]

That’s definitely wrong. If it affects the complexity of your medical decision making it counts. Poorly controlled diabetes, a fib on anti coagulation, morbid obesity, etc, all may impact your treatment plan. Well-controlled HTN on one medication probably doesn’t.

you are correct that comorbidities will increase the complexity of your primary diagnosis, but you actually have to provide treatment to be able to use the comorbidity to upcode your diagnosis.

you can upcode your encounter if the comorbidity makes the procedure more complex

morbid obesity - i sometimes document:
1. increased difficulty in performing the procedure due to size ("will communicate with Radiology Technician if table can accommodate patient")
3. probable increased radiology requirements.
4. if obesity is "causing" diabetes, document:
-checking HgA1C and discuss how injections affect long term management
-discuss with patient that they need to monitor their BG much more closely for 5 days after injection
-if you did recommend they increase their insulin (if they have sliding scale)
-reduced dose of steroid because of concerns of hyperglycemia
-you reviewed charts and discussed with patient their prior experience with steroid injections with respect to their BGs

Can someone explain their interpretation chronic illness-stable vs progression/treatment side effects? If on the first visit you see someone with 5-6 months of worsening low back pain with occ radiation into the legs do you consider that as "stable" low back pain or progression of low back pain?

Still not completely clear on this coding guideline

your example is progression (or exacerbation) of chronic stable back pain.

if the patient's pain is at baseline a 6, and the patient for example comes in with pain 8-9, document that the pain has increased, and document how the increased pain has affected functioning - "she cant hardly ever vacuum any more."

thats progression or exacerbation of stable back pain.

 

[NITRAS]

can i bill 99205 if i do planks and wall squats in the room with the patient? win win

If you do for 60 minutes. . . .

 

[deleted875186]

Obesity - recommend weight loss to improve back and leg pain

Done, 99214

 

[callmeanesthesia]

you are correct that comorbidities will increase the complexity of your primary diagnosis, but you actually have to provide treatment to be able to use the comorbidity to upcode your diagnosis.

you can upcode your encounter if the comorbidity makes the procedure more complex

morbid obesity - i sometimes document:
1. increased difficulty in performing the procedure due to size ("will communicate with Radiology Technician if table can accommodate patient")
3. probable increased radiology requirements.
4. if obesity is "causing" diabetes, document:
-checking HgA1C and discuss how injections affect long term management
-discuss with patient that they need to monitor their BG much more closely for 5 days after injection
-if you did recommend they increase their insulin (if they have sliding scale)
-reduced dose of steroid because of concerns of hyperglycemia
-you reviewed charts and discussed with patient their prior experience with steroid injections with respect to their BGs


your example is progression (or exacerbation) of chronic stable back pain.

if the patient's pain is at baseline a 6, and the patient for example comes in with pain 8-9, document that the pain has increased, and document how the increased pain has affected functioning - "she cant hardly ever vacuum any more."

thats progression or exacerbation of stable back pain.

Are you talking about modifier 22 for more complicated procedural services? Yeah, I’ve billed that a few times when a procedure took longer than usual due to patient anatomy. For example, trying to navigate a TFESI around hardware and osteophytes. I think you have to specifically document how much more time than usual it took, what made it more difficult and even then a lot of payors don’t pay any extra for it.

 

[deleted875186]

Are you talking about modifier 22 for more complicated procedural services? Yeah, I’ve billed that a few times when a procedure took longer than usual due to patient anatomy. For example, trying to navigate a TFESI around hardware and osteophytes. I think you have to specifically document how much more time than usual it took, what made it more difficult and even then a lot of payors don’t pay any extra for it.

I believe they’re discussing medical complexity for MDM for office visits.


My understanding is the guidelines are quite subjective, coders are just interpreting what they think, so long as you can reasonable defend that a secondary diagnosis contributed to your decision making, and you document something, I don’t see how you’d get in trouble if audited.

 

[callmeanesthesia]

Patient this morning, referred for back pain, typical multilevel degenerative changes on MRI. Noted short of breath walking the 200 ft or so from reception to exam room, with no know cardiac or pulmonary diagnoses. Mild anemia (likely iron deficiency) on labs sent from PCP, last colonoscopy 20 years ago, bilateral pitting edema, and early systolic murmur, grade 2. Also DM2, not controlled. For the back I recommended PT, but I’m sending her back to her PCP for possible cardiology and GI referrals. Level 5.
Problem/diagnosis: 1 or more chronic illness with severe exacerbation, progression, or side effects.
Data: Extensive: labs, MRI report, review of PCP notes, plus personal review of MRI.
Treatment: debatable. Recommending consults that will lead to invasive tests. Discussed possible injection options for spine. But only ordered PT. Probably call it moderate risk overall.

 

[SSdoc33]

your best bet is to focus on the problem at hand. dont go looking for other systems, etc to up your billing. #1, we are not cardiologists. #2 every time you have to sigificantly change your documentation, it takes more of your time.

 

[lobelsteve]

your best bet is to focus on the problem at hand. dont go looking for other systems, etc to up your billing. #1, we are not cardiologists. #2 every time you have to sigificantly change your documentation, it takes more of your time.

Recommending putting billing over patients' health.

Not recommended.

 

[callmeanesthesia]

your best bet is to focus on the problem at hand. dont go looking for other systems, etc to up your billing. #1, we are not cardiologists. #2 every time you have to sigificantly change your documentation, it takes more of your time.

It’s not a common scenario for me, just and example of when one could reasonably bill a level 5. Not looking to up billing, patient came in with unevaluated and potentially life-threatening comorbidities. Yes it took more time - I had to go find my stethoscope in the back of a high cabinet.
Still, I do enjoy feeling like a real doctor sometimes.

 

[bedrock]

It’s not a common scenario for me, just and example of when one could reasonably bill a level 5. Not looking to up billing, patient came in with unevaluated and potentially life-threatening comorbidities. Yes it took more time - I had to go find my stethoscope in the back of a high cabinet.
Still, I do enjoy feeling like a real doctor sometimes.

Level 5 justifiable in this case

 

[deleted875186]

It’s not a common scenario for me, just and example of when one could reasonably bill a level 5. Not looking to up billing, patient came in with unevaluated and potentially life-threatening comorbidities. Yes it took more time - I had to go find my stethoscope in the back of a high cabinet.
Still, I do enjoy feeling like a real doctor sometimes.

I agree, you took a lot of time to evaluate and review a crap ton of info, easy level 5.