Snf billing help

[PMR’s chill]

How often are you guys billing 99309 on your snf patients? I rarely do, I’m almost always billing 99308 and I feel like I’m under billing.

Also, I was recently told custodial patients at a nursing home are 99335-6’s with place of service 33. If this is the case I’ve been billing these wrong for longer then I want to think about. How often do you bill a 335 vs 336?

I was only using those code for assisted living patients.

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[Iamnew2]

How often are you guys billing 99309 on your snf patients? I rarely do, I’m almost always billing 99308 and I feel like I’m under billing.

Also, I was recently told custodial patients at a nursing home are 99335-6’s with place of service 33. If this is the case I’ve been billing these wrong for longer then I want to think about. How often do you bill a 335 vs 336?

I was only using those code for assisted living patients.

Do assisted living patients get rehab?

 

[DMBandFan86]

Sure can. Home health care normally or outpatient.

 

[sloh]

99308 to 99309 ratio should be around 70/30-80/20 to avoid sticking out as an outlier compared to peers

 

[Iamnew2]

Sure can. Home health care normally or outpatient.

Right I get that but in what capacity would a pmr doc round on ALF pts?

 

[PMR2008]

I round on AL patients frequently. Referrals for managing pain, MSK or neuro issues. I do room visits and also perform injections. Some of them even have a clinic I can use. Visits are obviously infrequent. I would say similar to outpatient. Initial eval, follow up in a few weeks for injections/med changes and a month later to see how therapy is coming along. Than I have the nurse remind me to see the patient in 3 months for check in. Some I only see once a year. You need an area with high cluster of ALs to make it worth it. Most follow ups are telemed. I just got a contract for a 400 resident AL facility as consulting Physiatrist. At any given time 30-50 patients are on outpatient rehab(I see a handful of those referred by therapy). It is complex with scheduling, consent but I have a team that helps me. I see all sorts of pathology. AL patients are sicker than people think.
The IRF patients of 10 years ago are now in SNFs. The SNF patients from 10 years ago are now in the ALs.

 

[PMR2008]

99308 to 99309 ratio should be around 70/30-80/20 to avoid sticking out as an outlier compared to peers

depends. If you are putting your work in and your notes are good I would not worry about being an outlier (Unless you are billing 50+ patients a day in an area with no other Physiatrists). My ratio has changed over the years as the patients have become more complex and I am doing a lot more direct med management.

 

[PMR2008]

How often are you guys billing 99309 on your snf patients? I rarely do, I’m almost always billing 99308 and I feel like I’m under billing.

Also, I was recently told custodial patients at a nursing home are 99335-6’s with place of service 33. If this is the case I’ve been billing these wrong for longer then I want to think about. How often do you bill a 335 vs 336?

I was only using those code for assisted living patients.

Here is a lot to this than " I am under billing". Are your notes hitting all the points. What exactly are you managing and are you recommending meds or actually prescribing them.
Custodial patients are 99335-6. In my practice I usually don't have many custodial patients. I do have plenty of SNF patients though.

 

[Iamnew2]

depends. If you are putting your work in and your notes are good I would not worry about being an outlier (Unless you are billing 50+ patients a day in an area with no other Physiatrists). My ratio has changed over the years as the patients have become more complex and I am doing a lot more direct med management.

This is how I feel as well. I not infrequently bill at a higher rate but I feel I do so much work - as one of the few pm&R docs in the area, I do not only all the typical day in and out rehab and med director duties for all patients, but also all the pain management, wound care, DME, injections, med management, education, conferences with family, social stuff, etc etc - my notes tend to be long and extensive and quite detailed. I feel that billing a 99232 does not do service to all the work I do.

 

[Iamnew2]

Here is a lot to this than " I am under billing". Are your notes hitting all the points. What exactly are you managing and are you recommending meds or actually prescribing them.
Custodial patients are 99335-6. In my practice I usually don't have many custodial patients. I do have plenty of SNF patients though.

Speaking of billing - what do you think is a reasonable rate for a midlevel on a daily basis?Thinking of hiring someone for 1-2 days/week.

 

[DMBandFan86]

I mean billing for service is just following guidelines. If you checked the boxes off during your visit and reflected that in the note then you should bill the appropriate amount of service.

If you bill based on time, then just reflect the amount of time you spent with the patient and what you did for coordinating care, etc.

The only way you get into trouble is if you didn’t perform the services you billed for or didn’t actually spend the amount of time on the day of service. If you bill 100% on time then you should make sure the amount of patients you see is appropriate for how much time you spend on each one.

 

[PMR2008]

Speaking of billing - what do you think is a reasonable rate for a midlevel on a daily basis?Thinking of hiring someone for 1-2 days/week.

Depends on your area. 90-130 per year. Huge range.

 

[PMR’s chill]

Here is a lot to this than " I am under billing". Are your notes hitting all the points. What exactly are you managing and are you recommending meds or actually prescribing them.
Custodial patients are 99335-6. In my practice I usually don't have many custodial patients. I do have plenty of SNF patients though.

I have comprehensive and detailed notes, and also do all opiate/ pain med management when I follow a patient.

So what do you do when a skilled patient transitions to custodial care in a facility that you see patients? Do you stop following? For my practice that really isn't an option as I'm continuing to manage their chronic pain issues.

 

[PMR’s chill]

what what about when a patient switches from skilled to custodial in the same SNF? Now bill 99335-6 and place of service switches to 31?

 

[PMR2008]

I have comprehensive and detailed notes, and also do all opiate/ pain med management when I follow a patient.

So what do you do when a skilled patient transitions to custodial care in a facility that you see patients? Do you stop following? For my practice that really isn't an option as I'm continuing to manage their chronic pain issues.

I don't follow unless I am managing the narcotics. In that case maybe 1/month.
Bill 99356-6 when the switch happens.

 

[CHS1983]

Wanted to piggyback on this.

I predominantly bill 99308 for my stable patients, 99309 for any patient I'm ordering labs, imaging, etc, and 99310 for patients I recommend to be sent out to the ED or time based for long education sessions.

For participating in IDT, is it reasonable to bill a 99309 for a stable patient as I'm discussing with the entire team their DC plan or any other issues? I usually place a time code and the reason behind it.

 

[PMR2008]

99308 for - stable patient, recommending continued PT/OT, or managing OTC drugs
99310 - when significant change in condition, mental status change, risk to life, transfer to ED or 35+ min spent
99309 - for everything else in the middle of 99308 or 99310.
2+ chronic illness or new complaint or side effect of treatment or injection or managing (adjusting, titrating, scheduling, reducing, starting OR making a clinical decision to continue a current dose - including the reason why and other plans) all qualify. But have hit the points in History (4+HPI etc)
I am not a biller/coding expert but have talked to plenty. I have done the above for 10 + years. Please discuss with your own RCM company.

 

[end stage fibro]

Don’t mean to thread hijack, but are you guys using pointclickcare? Any efficiency tips? It is godawful compared to inpt EMRs

 

[PMR2008]

I use an EMR that integrates into PCC and Matrix. PCC is awful.