Pharmacists, we learned this in school

[Twentytwelve2]

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Ethical billing.

I understand physicians and their business needs money to fund the remodeling of their offices and their luxury homes/cars. But as a pharmacist, I have the background knowledge from pharmacy school about CPT code billing frauds to cheat the medicare system (and private insurances). With that said, I want to discuss upcoding. I was a victim of upcoding. Doctors are not allowed to charge for time visits that they didnt not spend in the room with the patient. I was in the room, waiting for 15 minutes while I can hear her talking to another patient in the room adjacent to mine. Then, we had a conversation no longer than 10 minutes. I left, thinking I was going to be billed for what a follow-up visit would typically be. But no, I was billed as long as an initial-new patient visit for 25 minutes. Upping my insurance out of pocket cost to pay for time that I spent waiting for her because she was behind schedule.

What are everyone's thoughts on this? What do you do to prevent unethical billing to cheat the healthcare system? I need help on how to prevent further abuse of upcoding.

 

[beautifulrobot]

Uhm, file a complaint with your insurance company?

 

[owlegrad]

I didn’t learn this in school.

 

[RxPreceptor]

Wouldn't be surprised if billing is done by poorly/under trained medical assistants or if said medical assistants were "coached" to bill things a certain way because that's how "things are done" by so and so MD ("dinosaur" MD often). Way too easy to manipulate parameters like time for billing (who's actually keeping track?)

 

[KeikoTanaka]

Ethical billing.

I understand physicians and their business needs money to fund the remodeling of their offices and their luxury homes/cars. But as a pharmacist

Someone has a chip on their shoulder, all bow before the high moral priest!

Lol it could have been a mistake, or even a like RxVampire said, some MA coded it and the physician signed off.

This is your personal physician, so you come onto a public forum asking for advice, to something you apparently learned about in school? Did they tell you how to pick up your phone and call the office or your insurance company? It seems like a really easy thing to solve!

Also, Follow-up visit, or Initial Visit - This coding is irrelevant of the amount of time spent with a patient. Was this your first time seeing the physician? If so, that's an initial visit.... If you've been to them before... this is a follow up... Just because a scheduled time slot is for 25 minutes for scheduling purposes doesn't mean the billing codes have to be 100% in line with the time. A 13 year old with no past medical history as a new patient vs a 70 year old are both new patients even though the 13 year old needs 15 minutes and the 70 year old needs 30.

 

[confettiflyer]

My docs downcode...when someone’s paying cash, they’ll instruct staff to code for the shortest/lowest intensity appointment possible.


That said, upcoding is buried deep in some online compliance module I blow through every year. Luckily, as a pharmacist, I have zero responsibility in that area and focus on what I was actually trained for and not some vague numbers for which other staff are responsible.

 

[confettiflyer]

Also luckily my school didn’t waste time on this, or maybe it was in some handout, but spending more than 30 seconds on this is a waste of time since most institutions will cover it with compliance training.

 

[mentos]

 

[group_theory]

It sounds like a 99203 E/M coding, new patient - which can be time based, or can be based on level of complexity and decision making and doesn't need to meet "time criteria" as long as it meets documentation criteria. 99203 would typically be a detailed focused history, detailed focus exam, and low complexity medical decision making (which if all 3 criteria are met, would justify a 99203 encounter). An established patient 99213 E/M code would only require 2 out of 3 criteria. Or if you spent 30 minutes talking/counseling the patient, then a 99203/99213 can be used as well. It is the same E/M code whether you bill based on medical complexity or time

For most outpatient primary care settings (or even specialties outpatient setting), most billing will be based on complexity of medical decision making instead of time-based (with certain exceptions)

 

[lord999]

It doesn't work like that, pharmacy does bill on a time basis (for reasons that APhA screwed up), but most CPT codes require only the complexity criteria (or procedural criteria) to be met for billing.

 

[Twentytwelve2]

I did get my insurance involved. The insurance rep. said basically I am being charged for a 25 minute visit. He called billing department from the doctor office and the billing girl told him everything was billed correctly with "proof" that it was a 25 minute appointment.

My co-worker's family member works at an office and they would upcode medi-cal patients all the time. No one is surprised it happens. Our tax payer dollars are being drained due to unethical down right fradulent billing.

Yeah, doctors lose money due to plan discounts so they upcharge in order to recooperate as much as they can from insurance reimbursement rate.

 

[Rouelle]

I fairly often hear hospitalists dictating. Phrases like “greater than 45 minutes were spent, with greater than 50% of that time being involved communicating with and educating the patient” are thrown out there pretty frequently. Based on how much time they spend on the floor and how many patients they see...well, I can do the math.

 

[Twentytwelve2]

I fairly often hear hospitalists dictating. Phrases like “greater than 45 minutes were spent, with greater than 50% of that time being involved communicating with and educating the patient” are thrown out there pretty frequently. Based on how much time they spend on the floor and how many patients they see...well, I can do the math.

Yeah, it is to cheat the healthcare system. I just had a follow up appointment. Asked if I had any reactions and how it was working. Just a few minutes BOOM 25 minute visit code.

 

[sadface]

I am not well versed in this, but perhaps the cited times include the physicians prep time refreshing themselves on the last visit note and reviewing labs, etc?

 

[confettiflyer]

Yup, I see those phrases all the time....add all the times up across all the patients in the unit and you exceed 24hrs.

The beauty is that this puffery is fairly unprovable....someone would have to find the exact patients in the same time frame and subpoena those records...good luck getting anyone to agree to that.

 

[allantois]

Lol

 

[mustang sally]

Did registration have you scheduled as a new patient visit? I would guess that would be why, regardless of how much time the doctor actually spent with you.

 

[Twentytwelve2]

Did registration have you scheduled as a new patient visit? I would guess that would be why, regardless of how much time the doctor actually spent with you.

No, it was a follow-up appointment. It was not billed as new patient.

 

[group_theory]

You seem fixated on the "time" component even though the E/M code can be billed based on EITHER time OR complexity.

A new patient, where you do a focus history and exam, and LOW medical complexity/decision making, is a 99203. Doesn't matter if you spent 5 -10 minutes - it's still a 99203. Most outpatient offices determine charges based on complexity of medical decision making, and not time (with exceptions)

A follow up visit to see (re-evaluate) how you are doing with the medication, side effects, any dosage adjustments, etc. would definitely be a 99213, even if no changes/modifications were made to your treatment regiment. You don't have to spend 25 minutes.

I saw a new patient today with a lung mass. I got a detailed history (both personal, social, and family history since they are all relevant). I got a detailed history of symptoms (which led to the discovery of the lung mass). I discussed the procedure I wanted to do, the indications, the risks involved, as well as alternatives to the procedure. I also discussed what imaging tests I would like to work up and stage, what the next steps are once I get tissue diagnosis, etc. I answered the questions that family members had. I billed the encounter as a 99205 (new patient, high complexity medical decision). Did I spend 60+ minutes? No, it was more like 30-40 minutes in total. But was I justified in charging a 99205? Yes. My documentation can support the 99205 charge.

 

[sakigt]

This must be like auto repair guys. They charge book time then depending on how experienced they are get it done faster then charge you the same rate.

Off topic but may be useful:

Book times can be looked up to see how hard something is too, btw. If the book time is 1-2 hours a monkey could do it. Do it yourself. A little longer maybe watch a youtube video and rent some tools. A clutch replacement on a 1992 Celica Alltrac is 16 hours....NOPE