Using 99215 and 99205

[paingains]

I work at an HOPD where we are required to book new patient and follow up time slots for 45 minutes.

I actually do spend over 40 minutes chart reviewing, counseling, completing my note, filling multiple medications through an antiquated and slow EMR, and chatting with the patient with whatever is on their mind (most pts over >65y, and many just want someone to talk to). Every single one of these encounters meets for 99215 based on time alone. I keep reading and hearing stories about how billing 99215 is in the very small minority and will trigger an audit which is complete bs for physicians like me who actually spend this much time on patient care and I'm not "moving the meat" or churning through patients to keep the lights on by any means (I see 12-15 pts per day). I can understand having 15 minute time slots and billing 99215 as a red flag.

Anyone else in a similar set up billing almost exclusively 99215+? Is it true that billing predominately 99215, however, even in an appropriate setting seeing around 15 or less patients per day will still trigger an audit? Thanks.

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[SgtThunderfistMD]

40 x 15 = 600 minutes. If you are sure you are working 600+ (probably closer to 700-800 minutes since 99205 requires 60+ minutes) a day you can justify it.

But caveats:
-are you sure the 40+ minutes is actually necessary, or are you just bloating the time since you have to fill the 45 minutes?
-and secondly, you need to change the way the clinic works and make visits shorter. you'd make more money seeing double the patients and billing 99214's on MDM.

 

[clubdeac]

Who is making these asinine 45 min rules for EVERY visit? That’s ridiculous

I would fight to at least cut your follow up visits down to 20min. That would likely be a better use of your time. With that being said I’m not sure what would trigger an audit but if you can back it up with your time devoted to each patient then you should pass the audit fine

 

[cowboydoc]

Sounds like a great way to get audited, but also if the schedule justifies the time, would not think it’s difficult to pass the audit.

 

[BobBarker]

Do you really want to see so few patients?I saw 46 on Thursday. One trial and one two level kypho are included in that number.

 

[mdo1738]

If you are indeed meeting criteria for a level 5, why would you care about an audit? I couldn’t imagine underbilling to a level 4 because I was worried about that. Of course I also couldn’t imagine spending even 1/3 that much time on most of my follow ups.

 

[Scottie_Dog]

Do you really want to see so few patients?I saw 46 on Thursday. One trial and one two level kypho are included in that number.

How on earth do you see 46 patients in a day? Assuming you work a typical 8 hour day that works out to about 10 minutes per patient. How are you reviewing their record, looking at their images/explaining the findings, doing an exam, discussing risks/benefits of procedures and doing a note in 10 minutes?

Sounds like you are incredibly efficient. Teach me your ways?

I cap out at about 20 patients per day and that’s pushing it. 46 with my current set up is impossible

 

[BobBarker]

I started at 7:30 and ended at 4 without taking lunch. No scribe. I use a lot of macros and templates. Some of the 46 were a follow up visit only, some planned procedure, some visit and injection. Did several rfa’s.

 

[powermd]

I started at 7:30 and ended at 4 without taking lunch. No scribe. I use a lot of macros and templates. Some of the 46 were a follow up visit only, some planned procedure, some visit and injection. Did several rfa’s.

Walk us through the process.

I'm solo now with one part time office assistant- seeing 20 patients per day like this is rough.

In my old practice where we had good billers and prior-auth staff, a fully staffed check in desk, NPs seeing patients and sending back for injections, RTs running the fluoro rooms, and scribes assisting the docs- I had literally nothing to do that wasn't essential- it was STILL a hard-ass day seeing 35-40. from 8-4 with 1 hr lunch. I would sometimes do a kypho in the early AM and four RFs.

 

[BobBarker]

I don’t want to hijack the thread so bad but I will I guess.

I got there at 7am. Made sure everything was ready for the trial which swas scheduled to start at 7:30am. We probably started that procedure at 7:40am. I was done before the 8am patients were ready. 8am double book is helpful to get things started as people come in a little early/late routinely. We typically have 3 medical assistants but today we only had two. Total of 83 patients seen. So the other doc saw 37. We did some add on injections, a couple same day auths. If the medical assistants got behind, I grabbed the patient from the waiting room and saw them before the medical assistant. I was ahead of them most of the day. We had another staff member help with fluoro for a few of the cases. I did some of the add on cases by myself with the foot pedal so they could keep rooming patients. . One was a cervical epidural. I just changed gloves after I put it in CLO.

I spent plenty of time with the patients and showed multiple fishing pictures. Usually, I spend the first couple minutes talking about the weather, sports, fishing depending on the patients interests. Ask how their trip was, ask where their daughter is today, whatever. Then get down to clinical stuff. I can look at the patient, talk/listen while typing a note. So that is helpful.

But I am also fast and efficient. This was my day at the surgery center yesterday. I was done at 1:00.

 

[powermd]

Holy crap, you are doing full SCS implants, Intracept, and MILD in 30 min slots???

 

[BobBarker]

I got a little behind but caught up with injections and IPG exchange.

Single level vertiflex is less than 15 minutes. My implant was 24 minutes skin to skin. The revision was on a lady who had a lot of posterior fat and had to close 3 layers on her midline. Took 45 minutes.

 

[BobBarker]

Got behind on intracept and the revision. Everything else was done well within 30 minutes. Two rooms though.

 

[powermd]

Got behind on intracept and the revision. Everything else was done well within 30 minutes. Two rooms though.

This is a proper ASC though, so you had a lot of help rooming the patient, positioning, anesthesia present, etc, right? When you were done you just walk away, staff clean up, take patient to recovery..

 

[BobBarker]

Yes

 

[bedrock]

Holy crap, you are doing full SCS implants, Intracept, and MILD in 30 min slots???

My thoughts exactly. Bob is a machine

 

[clubdeac]

Having 2 procedure rooms is a game changer. Who does your consents

 

[MitchLevi]

Bob is impressive. Also has actual skills too, which isn’t always the case no matter your volume.

 

[Ready_User_1]

Got behind on intracept and the revision. Everything else was done well within 30 minutes. Two rooms though.

Can you walk me though how you approach BVNA for S1?

 

[BobBarker]

I do my own consents. I do the first two patients before the first case and then do the next one between cases so I can stay one ahead.


I’m no bvna S1 expert. This lady was 84 so pretty easy to navigate through her osteoporotic bone. I did a 7min at L5 and had S1 placed by the time that burn was over then did 15min at S1.

 

[gaspasser127]

I got a little behind but caught up with injections and IPG exchange.

Single level vertiflex is less than 15 minutes. My implant was 24 minutes skin to skin. The revision was on a lady who had a lot of posterior fat and had to close 3 layers on her midline. Took 45 minutes.

I’m jealous of the 24 min skin to skin SCS perm. Any tips?

The quickest I’ve ever had was approx. 30 min (with using fixates). On average a straight forward SCS perm is about 35-40 min for me.

I’ve thought about how I can be quicker. I’m probably 60 cases into my career (finishing my 3rd year after fellowship) and I went to a high volume fellowship where I did around 40 SCS perms.

Making the pocket and making the paramedian incision with appropriate exposure takes me about 4 min.

Getting needles inserted, placed appropriately, getting LOR in lateral, and placing leads at their final location is 7 min on average.

I think anchoring is what may be killing me. Probably takes me 7-10 minutes total.

I use the Touhys to tunnel to the pocket.

Irrigate. Ensure hemostasis (probably a little bovieing here or there as necessary)

Closing takes me a while too. Both incisions probably close to 15 min.

Any areas where I could make up some time? I want to minimize using fixates. I only use them when I do Boston cases.

 

[BobBarker]

I think 35-40 minutes is excellent and you will only continue to improve as you are quite early in your career.

I use ticron or ethibond pops to anchor. Doesn’t take very long but is slower than fixate.