Thoughts/disagree with me - just trying to get people talking
So - we all got ripped off right!? This is just a balancing act?
My understanding is the procedural cuts did not go through. So in general, if you do everything exactly the same as you did last year you should increase your collections. For those who predominantly bill 99212 and 99213 - those visits increased substantially - 45.8% and 34% respectively. In my locality, a level 2 established visit is now approaching the value of a previous 99213 - "6/7ths".
As of today - 1/4/2020 - Medicare as not updated the fee schedule yet. I wonder if this will result in delays to payments for services rendered at the beginning of the year.
Are we actually going to get paid more though?
I don't know. If you own a PP and you see Medicare you are a creature of your collections and Medicare should pay you more. AMA/CPT have changed the underlying RVU values for the procedures so theoretically if you are hospital based you are earning more RVUs for these same services. Medicare is also paying the hospital more for these services. But whether private insurances plans will adjust their payments - I don't know. It would be based on the Insurance company's contract with the hospital system. If the plan states 125% of current year Medicare - yes I suppose. If you have a Medicare advantage plan that tacks your payment to some sort of %-modified 2015 Medicare value - I don't know. There's talk in some of the other forums of whether the hospitals will actually spit this money out into your paycheck or not. ie. yes, you earned more RVUs but the hospital didn't actually make more money for the service except from Medicare. In the end - all RVU related things have to ultimately tie back to the financial health of your system. If you are an associate in a capped arrangement then your boss may be spending an extra week or 2 at their beach house this year.
The time values have increased for billing?
It takes 20 minutes now to hit a 99213
It takes 30 minutes now to hit a 99214.
These are not exponential or enormous changes but they are increases.
Why are you billing time ie. what's your thought process - past and present.
I've created some "examples" or considerations of the "past". I'm personally skeptical we'll do that much time billing in the future...
-I always write it down to ensure that I can bill it if I need it. Great.
-I fiddle around in the room with the patient on small things like plantar fasciitis and if it hits 15 minutes I bill a 99213. Frowny face.
-I'm discussing complicated problems with complicated patients.
-I discuss surgeries and its the only way I feel comfortable billing a 99204/99214. In fact, if my surgical discussion comes under time I bill a 99213.
-My patients have lots and lots of little problems and nuisances ie. they want to discuss their nails, their bunion, their flatfeet, their plantar fasciitis, and they are a new diabetic. I can't get out of the room.
In regards to most of the above I would say - ask yourself what you are really talking about in the room with the patient.
*Are you prescribing? Does the prescription have risks, complications, side effects that you should discuss.***
*Are you discussing a procedure (minor vs major)?
*Does the procedure have complications?
*Does the patient have risk factors?
***See the definitions table to understand toxic medications.
If you are doing those things - very possibly you don't need time.
Obviously, a truly in depth discussion of a procedure, its risks, its recovery takes time, but if you find yourself at 21 minutes discussing a fusion and you say - damn, I wanted a 99214 - you've probably already hit it on MDM. You are performing a major surgery (do they have risk factors?). Depending on how you describe the complexity of the problem that's probably it.
In regards to describing the complexity of the problem/treatment plant - I would recommend using the exact language of the guidance document to describe the problem and then detailing why its the case. This is likely especially relevant for the 992*4+ series. I sat through the APMA presentation of cases where THEY READ THEIR SLIDES AND IT WAS PAINFUL and in any case - I could come up with a different thought process or wording on many of their situations - which is always going to be the way of things. Everyone thinks about it differently. Consider - a podiatrist and a FM doctor who are both rehabilitating a sprain. Who do you think is more quickly thinking about or talking about ankle surgery - theoretically - we are.
Additional thing - theoretically we don't get credit for things we say someone else is doing. So you don't get credit for patient is diabetic and someone else is managing. You likely need to describe how diabetes is relevant to the problem at hand, how you educated the patient, what steps and considerations you took into as it affects your procedure or plan or their return to WB or how you'll proceed or move if things fail.
Anyway - back to time.
Fiddling in the room till you hit 15 minutes. Obviously that isn't going to get the job done anymore or its going to take another 5 minutes of your time. Ask yourself what you are discussing with the patient..
Where I think this probably occurs the most is that patient with say - plantar fasciitis who is getting better, doesn't believe it, declines all care and won't let you out of the room. I think you need to write down what you are offering them. Its not just patient refused all offers of therapy. Did you offer them oral medication, injection, PT or do you putter on about how you could modify their orthotic again or get them some more felt. Some of those things will justify higher MDM.
I want to be clear that I have no issue with a plain old fashioned follow-up plantar fasciitis as a 99212. Still in pain but very satisfied with treatment course and going to continue to do the conservative things you offered. Great, no issue with 99212 - come back if you need more. Not everything is a 3 or a 4..
Last of all from above - the patient who presents with a ton of small stuff (Hi, I'm here and I didn't even write all my problems down!)
Coding this is going to depend on what the problems are and what you do. This is historically one of my least favorite encounter types. Almost as bad as bag of shoes. My suspicion is that for most people through time they've billed a 99203 on this and thought - ugh. this is what I bill for new plantar fasciitis where I'm in the room 10 minutes.
There may be a 99204 available here depending on how things line up and what treatments you offer potentially acquired more easily than trying to bill this as time last year (45 minutes).
What I'm referring to here is "my nails hurt" + maybe I just found out I'm diabetic + the top of my foot hurts + my heel hurts + I have tingling/numbness in my toes but I don't think I'm diabetic + my skin is scaling and I have flat feet. Aside - this is the patient who has 10 problems and interrupts you when you try to talk about one problem to ask about another. Hush. I'm going to get to that.
-What I'm NOT referring to is - Diabetic + ulcer to fat + hammertoes/subluxation/equinus.
That's pretty clearly meeting 99204+ on the problem column complexity side (probably fits - an acute complicated injury ie. a systemic finding diabetes + a local finding or perhaps its 2 chronic problems - you'll have to make your case (and obviously you'll need the write discussion/procedures etc to seal the 4 deal). In the past a lot of people were not billing this as a 99204. The ACFAS course would have said - beef your HPI/PE and bill this as a 9904. Now that the HPI/PE requirement is gone depending on your treatment plan this should
not be a 99203 if you're meeting 2 columns. The APMA people said that specifically part of the reason they wanted the documentation requirement done away with was so podiatrists could comfortably bill 4's without thinking they had to pull out a stethoscope.
Anyway - lots of problems visit. Depends on what they are - consider if you think you can meet 99204 for these. Probably having diabetes as one of the problems increases your comfort level since it in general makes everything riskier and gives you 1 of 2 chronic problem. 2 chronic problems that are stable will get you to level 4 complexity.
Alternatively, If you ultimately say to the patient - look - today I'll discuss 2 things. Come back in 1-2 week and I'll discuss 2 more things - a follow-up 99213 it not that far below a 99203 this year (like $20?) and with the documentation rules now it makes it a lot more tolerable than finding yourself trapped in one of those awful 8 problem paragraph notes.
Improvement in the Problem system.
I think the new system is an improvement over the previously problem points system. Its relatively flexible and yes, different people will interpret the same problem into different levels of complexity. The prior system of new/established and a certain number of points really was a turd.
Should I bill 5's.
If you haven't done it before - you should take a hard look at the sheet and consider your practice. My office doesn't even have 99205/15 in our fee schedule. We should add it.
As far as things like admissions: my residency practice should definitely be charging 5s for clinic patients who need admission. We were admitting the patient to the hospital. Prescribing IV abx. Preparing for major surgery+ risk factors + testing on septic/infected/limb risk etc. Definitely.
This is probably a subject of argument, but (in my opinion) you need to actually be doing these things if you are going to bill it. If you say - gosh, you seem infected. I think you need to go to the hospital where you can get a BKA and antibiotics - I'm skeptical you should bill the full 5 if you are just punting to an ED and ending your management. Telling the patient what is going to happen to them isn't the same thing as being the person signing the order on the Vanc/Zosyn. Again, my opinion.
As far as just plain old booking a surgery - I think the thing that's interesting is the complexity column. The simple truth is we all do surgery on people with risk factors ie. diabetes. The complexity column spells out the risk of life or limb. Both are required.
Should I bill 4s.
Definitely. Assuredly I skipped a lot of 4s or waffled or wondered on cases that were definitely 4s but I wasn't sure/worried/wondered if I was meeting the HPI/PE documentation. We are all doing 4s. We're even doing 4s on non-diabetics. Hell, I think the ACFAS billing people would have said plantar fasciitis + diabetes should be considered for a 4.
Should I bill 4s on everything I prescribe on
The management column is just one of the columns you have to meet. There are plenty of things that will hit 4 in the prescription column but most likely 3 in the problem column.
Is there still any sort of system where I need to do x-rays to get data points to make my visit work?
If I understand it right you don't get data consideration for a test you performed/interpreted yourself.
You didn't say anything about the middle column from that table
It has a place. ie. re-interpreting an MRI gets you half-way on a 4 or 5. I'm ABPM certified but I try not to order a lot of tests
This seems insanely long enough for now. I'll take a stab at different cases in different ways another time.