When do you do 99213/99203 visits?

[AmiSansNom]

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While we are on this topic, with the addition of the G2211 modifier starting this year, has this made you downcode any visits? Like something that you were billing a 99215 for (a soft 99215, not a lung cancer on current chemo), do you now bill 99214+G2211 or do you still keep the 99215 plus G2211? @gutonc @osprey099 or any others, would love to hear your thoughts on this.

 

[HemeOncHopeful19]

Why would you downcode a visit?

Do your job, code it correctly, get paid for your work.

 

[osprey099]

While we are on this topic, with the addition of the G2211 modifier starting this year, has this made you downcode any visits? Like something that you were billing a 99215 for (a soft 99215, not a lung cancer on current chemo), do you now bill 99214+G2211 or do you still keep the 99215 plus G2211? @gutonc @osprey099 or any others, would love to hear your thoughts on this.

They are 2 separate things. I code level 4 or 5 based on complexity/time. And then I add G2211 if it's somebody that I see more than once. G2211 just means you are providing continuity of care for that patient. I believe it was designed mainly for PCPs to make more for the amount of continuity they provide. It has been abused by many specialties and I feel like it will get harder to be reimbursed for G2211 in the future. But as of now, I spam it on every patient unless if it's literally someone I see once and I will never see them again (like a NP referral for leukopenia of 3.8).

 

[gutonc]

While we are on this topic, with the addition of the G2211 modifier starting this year, has this made you downcode any visits? Like something that you were billing a 99215 for (a soft 99215, not a lung cancer on current chemo), do you now bill 99214+G2211 or do you still keep the 99215 plus G2211? @gutonc @osprey099 or any others, would love to hear your thoughts on this.

Absolutely not. You code for the work you do. And if it means you're seeing them on an ongoing basis for the issue, you bill the G2211 too.

I suspect that CMS underestimated the amount that this would get used and will likely either pull it back, decrease it's value, or further decrease the conversion rate to compensate for it soon.

 

[randomhemoncpd]

Absolutely not. You code for the work you do. And if it means you're seeing them on an ongoing basis for the issue, you bill the G2211 too.

I suspect that CMS underestimated the amount that this would get used and will likely either pull it back, decrease its value, or further decrease the conversion rate to compensate for it soon.

CMS estimated that most E&M visits would have G2211 in time with variability between specialties so I don’t think it’s unforeseen per se.

 

[checkpointinhibitor]

Doesn't matter level 4 or level 5. Our hospital changes all level 5 to level 4.

 

[gutonc]

Doesn't matter level 4 or level 5. Our hospital changes all level 5 to level 4.

Underbilling is just as much CMS/insurance fraud as overbilling is. If this is truly the case, and you can prove it, you can probably retire on the whistleblower fee you get.

If you're tracking your own coding (which you should be) and getting at least quarterly productivity reports (which you should be) and they don't match up within a reasonable level of variability (5% is my personal "gimme" point, but I could imagine up to 10% being reasonable), it might be time to start asking questions.

 

[HemeOncHopeful19]

Doesn't matter level 4 or level 5. Our hospital changes all level 5 to level 4.

Wow, I'd love to hear more. I've heard of that happening at a place I interviewed last year, but I've never heard of downcoding ALL level 5s

@gutonc I agree it's fraud but what $ do you expect CMS to "recover" from underbilling? I guess they could slap them with a fine. I think the more likely possibility is a class action lawsuit from all the docs working for that hospital for missing RVUs

I'm also curious how you track it, do you just keep an excel sheet or something else?

 

[AmiSansNom]

Can G2211 only be used for Medicare patients or can it be used for patients with other insurances too?

 

[gutonc]

Wow, I'd love to hear more. I've heard of that happening at a place I interviewed last year, but I've never heard of downcoding ALL level 5s

@gutonc I agree it's fraud but what $ do you expect CMS to "recover" from underbilling? I guess they could slap them with a fine. I think the more likely possibility is a class action lawsuit from all the docs working for that hospital for missing RVUs

They "recover" it by filling a massive claim against the hospital (typically in the 8 figure range) for fraud and the whistleblower gets a fraction of it. agree that it may not go anywhere, but something like this may just be the tip of the iceberg.

I'm also curious how you track it, do you just keep an excel sheet or something else?

I rolled my own excel spreadsheet that I update as time goes on. Unfortunately, CMS considers wRVU data proprietary and has been willing to protect it, so there aren't any good spreadsheets or apps out there for you to just grab and run with.

It can be as simple as just tracking each CPT code that you generate and compare that to your monthly/quarterly report. That's where I started. But I've since added a bunch of other things including tracking my total monthly and quarterly wRVU and productivity bonus earned (we get paid a portion of our productivity bonus quarterly with a true-up at end of year) as well as my delta to goals montly, quarterly and annually, all of which are updated immediately with each encounter I record.

 

[checkpointinhibitor]

@gutonc mind sharing an empty sheet?

 

[gutonc]

They "recover" it by filling a massive claim against the hospital (typically in the 8 figure range) for fraud and the whistleblower gets a fraction of it. agree that it may not go anywhere, but something like this may just be the tip of the iceberg.

I rolled my own excel spreadsheet that I update as time goes on. Unfortunately, CMS considers wRVU data proprietary and has been willing to protect it, so there aren't any good spreadsheets or apps out there for you to just grab and run with.

It can be as simple as just tracking each CPT code that you generate and compare that to your monthly/quarterly report. That's where I started. But I've since added a bunch of other things including tracking my total monthly and quarterly wRVU and productivity bonus earned (we get paid a portion of our productivity bonus quarterly with a true-up at end of year) as well as my delta to goals montly, quarterly and annually, all of which are updated immediately with each encounter I record.

@gutonc mind sharing an empty sheet?

I do mind, for the bolded reason above.

 

[checkpointinhibitor]

I do mind, for the bolded reason above.

Thank you ! I will try to create my own. Appreciate your candidness though.

 

[gutonc]

Thank you ! I will try to create my own. Appreciate your candidness though.

It's not that hard, it's just annoying unless you're a spreadsheet wizard, which I am not. I started it with the bare bones and have added on to it as time has gone on.

 

[faelivrin]

Noob here, but how does one add a modifier like G2211 on Epic?

 

[gutonc]

Noob here, but how does one add a modifier like G2211 on Epic?

Once you add an LOS, you can use the "Add E/M Code" function to include G2211. Then you're going to wrench that into your favorites so you've got it as a button you can click in <1s for the rest of your career.

 

[guildsman]

I did a deep dive and in general for 99214/ 99215, even for chemotherapy and Stage IV patients, this is how ASCO officially interprets the guidelines:

" Example: A moderate E/M code (99214) would be reported if: A patient presented with a new progression of bone metastasis while under treatment for breast cancer (moderate problems addressed). The physician reviewed the most recent CT scan (low level of data reviewed). It is determined the patient will have a change in chemotherapy due to the progression. (moderate/high level of risk dependent on the chemotherapy plan)."

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I am not sure what the threshold is then for high risk of mortality or morbidity for a chemotherapy regimen or disease state. So, this opens a can worms whether metastatic pancreatic cancer on FOLFIRINOX is more high risk / higher therapeutic monitoring index than metastatic prostate cancer progressed on ADT on chemotherapy now. Both to me are 1) High risk conditions with high risk of morbidity / mortality. 2) Both chemotherapy regimens are high risk and carry therapeutic intense monitoring parameters. But reading ASCO's documents it would almost seem 992215 is only for ER / Hospitalization, which is also an improbable interpretation, as we would then equate a health maintenance visit for HTN/DM II and labs to treating someone with Carbo-Pem-Pem with metastatic NSCLC with multiple complications.

 

[osprey099]

I did a deep dive and in general for 99214/ 99215, even for chemotherapy and Stage IV patients, this is how ASCO officially interprets the guidelines:

" Example: A moderate E/M code (99214) would be reported if: A patient presented with a new progression of bone metastasis while under treatment for breast cancer (moderate problems addressed). The physician reviewed the most recent CT scan (low level of data reviewed). It is determined the patient will have a change in chemotherapy due to the progression. (moderate/high level of risk dependent on the chemotherapy plan)."

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I am not sure what the threshold is then for high risk of mortality or morbidity for a chemotherapy regimen or disease state. So, this opens a can worms whether metastatic pancreatic cancer on FOLFIRINOX is more high risk / higher therapeutic monitoring index than metastatic prostate cancer progressed on ADT on chemotherapy now. Both to me are 1) High risk conditions with high risk of morbidity / mortality. 2) Both chemotherapy regimens are high risk and carry therapeutic intense monitoring parameters. But reading ASCO's documents it would almost seem 992215 is only for ER / Hospitalization, which is also an improbable interpretation, as we would then equate a health maintenance visit for HTN/DM II and labs to treating someone with Carbo-Pem-Pem with metastatic NSCLC with multiple complications.

All chemotherapy visits = 99215
Hormonal therapies (ADT, AI) = 99214
Benign heme requiring intervention (IV iron) = 99214
Benign heme not requiring intervention = 99213

 

[guildsman]

All chemotherapy visits = 99215
Hormonal therapies (ADT, AI) = 99214
Benign heme requiring intervention (IV iron) = 99214
Benign heme not requiring intervention = 99213

I think ASCO is arguing that they would interpret some chemotherapy visits to be 99214. Probably stable patients. But surprising example they provide is progression of serious chronic illness and change of chemotherapy, which I would think would be 99215. I am not sure how they are adjudicating these distinctions.

 

[osprey099]

I think ASCO is arguing that they would interpret some chemotherapy visits to be 99214. Probably stable patients. But surprising example they provide is progression of serious chronic illness and change of chemotherapy, which I would think would be 99215. I am not sure how they are adjudicating these distinctions.

I have not yet had any issues with billing and I have been following what I wrote above

 

[gutonc]

I think ASCO is arguing that they would interpret some chemotherapy visits to be 99214. Probably stable patients. But surprising example they provide is progression of serious chronic illness and change of chemotherapy, which I would think would be 99215. I am not sure how they are adjudicating these distinctions.

I have not yet had any issues with billing and I have been following what I wrote above

I see it both ways TBH. I agree that the vast majority of chemo patients can easily qualify for 99215 and I bill as such. OTOH, I think there are a reasonable subset of chemo patients (<10% or so) that I have a hard time billing more than a 99214 on, and I will bill those as I feel appropriate. I imagine I could bump most of those up to a 99215 if I tried, but it's usually not worth the trouble.

 

[solidonc2020]

I see it both ways TBH. I agree that the vast majority of chemo patients can easily qualify for 99215 and I bill as such. OTOH, I think there are a reasonable subset of chemo patients (<10% or so) that I have a hard time billing more than a 99214 on, and I will bill those as I feel appropriate. I imagine I could bump most of those up to a 99215 if I tried, but it's usually not worth the trouble.

I'm confused by this. My understanding is MDM is considered level 5 (and thus a 99215) if you have 1) an acute or chronic illness that poses a threat to life or bodily function and 2) high risk for complications which includes drug therapy requiring intensive monitoring for toxicity. I would think all cancer patients on chemotherapy should qualify for these two categories unless I'm missing something.

Is it the "intensive monitoring" ambiguity that is the determinant? Seems to me it would be malpractice to not "intensely monitor" for chemotherapy toxicity.

 

[gutonc]

I'm confused by this. My understanding is MDM is considered level 5 (and thus a 99215) if you have 1) an acute or chronic illness that poses a threat to life or bodily function and 2) high risk for complications which includes drug therapy requiring intensive monitoring for toxicity. I would think all cancer patients on chemotherapy should qualify for these two categories unless I'm missing something.

Is it the "intensive monitoring" ambiguity that is the determinant? Seems to me it would be malpractice to not "intensely monitor" for chemotherapy toxicity.

That's the judgement call aspect of it. I think you can easily make an argument either way, and billing these a 99215 is pretty much not an issue. I just have a hard time justifying it personally when somebody is sailing through treatment with stone cold normal labs, no side effects and no questions. These are typically adjuvant cases, often lung. But that's just me. You could totally bill 99215 on these and be in the clear from a CMS standpoint.

 

[checkpointinhibitor]

As gutonc mentioned, there is ambiguity aspect to it. Our stupid coders downcode everything (even hospice discussions from disease progression) but that is another issue.
To be fair - code whatever you can but have backing documentation to support your claim. For e.g. I code 99214 for all adjuvants, myeloma (in CR), NSCLC in CR but on maintenance. Because I interpret that as - "stable/chronic disease" and not life threatening in the immediate/intermediate term. But in those cases if you review the scan (high MDM) then it will be level 5 despite moderate complexity based on Dx. Hope this helps.
The goal is to not be an outlier in front of CMS and invite problems.

 

[HemeOncHopeful19]

As gutonc mentioned, there is ambiguity aspect to it. Our stupid coders downcode everything (even hospice discussions from disease progression) but that is another issue.
To be fair - code whatever you can but have backing documentation to support your claim. For e.g. I code 99214 for all adjuvants, myeloma (in CR), NSCLC in CR but on maintenance. Because I interpret that as - "stable/chronic disease" and not life threatening in the immediate/intermediate term. But in those cases if you review the scan (high MDM) then it will be level 5 despite moderate complexity based on Dx. Hope this helps.
The goal is to not be an outlier in front of CMS and invite problems.

The goal should be to get paid what you are owed by your employer who is making literal millions off the chemo you are ordering. Their billers have a different motivation entirely.

Reviewing a scan does not bump up complexity unless you’re talking about doing an independent interpretation which I’d say is more questionable than almost anything else. You need either independent interpretation or discussion with an external professional for that checkbox.

IMO drug therapy requiring intensive monitoring is by far the easiest criteria to meet because “intensive monitoring” is defined as monitoring for toxicity by a lab test at least quarterly (so basically everything we do outside of ADT or AIs).

The biggest decision point for billing a level 4 vs a level 5 is whether the patient has an illness that poses a threat to life or bodily injury. I would argue if you’re treating lung cancer or Myeloma with chemotherapy, even adjuvantly, then there better damn well be a risk to patient’s life if you DIDN’T give chemotherapy but I can see the argument otherwise and whether the time course matters.

 

[checkpointinhibitor]

The goal should be to get paid what you are owed by your employer who is making literal millions off the chemo you are ordering. Their billers have a different motivation entirely.

Reviewing a scan does not bump up complexity unless you’re talking about doing an independent interpretation which I’d say is more questionable than almost anything else. You need either independent interpretation or discussion with an external professional for that checkbox.

IMO drug therapy requiring intensive monitoring is by far the easiest criteria to meet because “intensive monitoring” is defined as monitoring for toxicity by a lab test at least quarterly (so basically everything we do outside of ADT or AIs).

The biggest decision point for billing a level 4 vs a level 5 is whether the patient has an illness that poses a threat to life or bodily injury. I would argue if you’re treating lung cancer or Myeloma with chemotherapy, even adjuvantly, then there better damn well be a risk to patient’s life if you DIDN’T give chemotherapy but I can see the argument otherwise and whether the time course matters.

I don’t disagree with you buddy. But our coders are malignant. The institution does not care about proper billing as their revenue is generated from chemo and scans and tests we order. 2 oncologists in our group left the practice due to this nonsense and old folks don’t simply care.

Scan review is independent interpretation, don’t care for the radiology report, they should match my findings not otherwise. I don’t trust half of the radiologists in our institute to call cancer progression. So truly it’s independent interpretation.

How can you defend myeloma in VGPR on maintenance Dara + Len (for e.g.). Super stable, no s/e. I would argue that it is NOT an imminently life threatening condition as even if you stop treatment, the patient will NOT die for several years.

As long as no one audits, things are rosy. It’s when you are under the lens, you need to be astute.

 

[GFP]

Newbie attending here and appreciate all the discussion on coding, which I really wish we received more training on!

I had thought that anyone on active treatment (or high-risk therapy) would be a 99215, but my institution requires a coding justification checklist in our notes which basically says 99215 visits require independent imaging interpretation or discussion with another specialty (among others), which is similar to the MDM coding elements table that I'm sure many have seen. I find this too strict as what if a patient is receiving carbo/etop/atezo for SCLC but we are managing several treatment side effects such as irAE, cytopenias, nausea, fatigue etc? I would think this would be highly complex (level 99215) but since there was no imaging to be independently reviewed or discussion with a consultant, I believe I would not be justified in billing this as 99215 (I would do 99214 instead?). I've heard of people adding a blurb on "intensive therapy requiring monitoring..." in the notes but that still doesn't meet MDM criteria for 99215 (two of three complexity elements). Thoughts on this?

 

[gutonc]

Newbie attending here and appreciate all the discussion on coding, which I really wish we received more training on!

I had thought that anyone on active treatment (or high-risk therapy) would be a 99215, but my institution requires a coding justification checklist in our notes which basically says 99215 visits require independent imaging interpretation or discussion with another specialty (among others), which is similar to the MDM coding elements table that I'm sure many have seen. I find this too strict as what if a patient is receiving carbo/etop/atezo for SCLC but we are managing several treatment side effects such as irAE, cytopenias, nausea, fatigue etc? I would think this would be highly complex (level 99215) but since there was no imaging to be independently reviewed or discussion with a consultant, I believe I would not be justified in billing this as 99215 (I would do 99214 instead?). I've heard of people adding a blurb on "intensive therapy requiring monitoring..." in the notes but that still doesn't meet MDM criteria for 99215 (two of three complexity elements). Thoughts on this?

The way I try to simplify it for myself (and which was simplified for me by our coders in my first job when I started...that was over a decade ago though so the rules have changed a bit since then) is:
1. anybody not on treatment and asymptomatic is a 99213.
2. Anybody on treatment and asymptomatic from the disease or the treatment is a 99214.
3. Anybody on treatment (or not) with 2 or more symptoms/side effects from disease or treatment is a 99215.

80-90% of my treatment patients are 99215. 80-90% of my non-treatment patients are 99213. The rest are 99214 or new patients.

I code appropriately but also make sure that I get paid for my work without being a 3 SD billing outlier.

 

[ONC2023]

Two RVU questions:

1) I understand different jobs attach a different dollar value to an RVU. However, am I correct in saying that a 99215 visit is always the exact same wRVUs regardless of location/job?

2) We normally use 2.2 or 2.4 (with G2211) as an estimated average wRVU when doing job salary calculations (e.g., 18 patients a day * 4 days a week * 2.2 RVU * 46 weeks * $90 = $655,000). I'm curious how we get to 2.2/2.4 if a 99215 is 2.8 wRVUs and most visits are 99215? Can a practice arbitrarily keep your RVUs per visit at the lower number (before the 2021 CMS increase), or are they only allowed to change the dollar/RVU and not the RVU itself?

Thank you.

 

[checkpointinhibitor]

Two RVU questions:

1) I understand different jobs attach a different dollar value to an RVU. However, am I correct in saying that a 99215 visit is always the exact same wRVUs regardless of location/job?

2) We normally use 2.2 or 2.4 (with G2211) as an estimated average wRVU when doing job salary calculations (e.g., 18 patients a day * 4 days a week * 2.2 RVU * 46 weeks * $90 = $655,000). I'm curious how we get to 2.2/2.4 if a 99215 is 2.8 wRVUs and most visits are 99215? Can a practice arbitrarily keep your RVUs per visit at the lower number (before the 2021 CMS increase), or are they only allowed to change the dollar/RVU and not the RVU itself?

Thank you.

RVUs are stable. The conversion factor $/wRVU is dependent on facility. Bigger cities have lower CF and smaller areas have higher CF. Typical in midwest is 95-105 $/wRVU. Slightly lower on the coasts. Academic and PP are different ballgame.

 

[gutonc]

Two RVU questions:

1) I understand different jobs attach a different dollar value to an RVU. However, am I correct in saying that a 99215 visit is always the exact same wRVUs regardless of location/job?


2) We normally use 2.2 or 2.4 (with G2211) as an estimated average wRVU when doing job salary calculations (e.g., 18 patients a day * 4 days a week * 2.2 RVU * 46 weeks * $90 = $655,000). I'm curious how we get to 2.2/2.4 if a 99215 is 2.8 wRVUs and most visits are 99215? Can a practice arbitrarily keep your RVUs per visit at the lower number (before the 2021 CMS increase), or are they only allowed to change the dollar/RVU and not the RVU itself?

Thank you.

TBH, my average wRVU/encounter (I track my own) has been creeping up this year (2.4 the first half of the year, closer to 2.7 the 2nd half of the year). But that's just my practice. Not everyone is going to be pulling 80+% 99215s and there are days when I barely crack 2. I'm know that MGMA (and AMGA and AAMC and others) report a median wRVU and the last time I was in a position to have access to that data, it was 2. I suspect it's 2.4+ now.

The point of picking a number is to have a fair comparison between different comp systems. For any production based comp system, the answer to "how much will I make?" is going to be "it depends". And it will also change over time. The issue is being able to compare apples to apples when you're being offered jackfruit and kumquats.

 

[ONC2023]

Thank you both. This is really useful.

For anyone who is aware of how these things work behind the scenes, do some places keep the old pre-2021 wRVU value? Had one private group tell me that they’re still at that (ie, 99215 = 2.1), and I’m trying to understand if that’s odd.

 

[gutonc]

Thank you both. This is really useful.

For anyone who is aware of how these things work behind the scenes, do some places keep the old pre-2021 wRVU value? Had one private group tell me that they’re still at that (ie, 99215 = 2.1), and I’m trying to understand if that’s odd.

Yes. Some places do. Or will take a few years to catch up and even then aren't "current".

 

[ONC2023]

Thank you. I was about to ask why you would stick with a CMS schedule that gives you less RVUs, but the practice told me that if RVU/visit increases then you have to lower $/RVU for fair market purposes. This partially makes sense to me.

 

[gutonc]

Thank you. I was about to ask why you would stick with a CMS schedule that gives you less RVUs, but the practice told me that if RVU/visit increases then you have to lower $/RVU for fair market purposes. This partially makes sense to me.

Except that if everyone in the market goes to the new numbers, the FMV goes up.

Unless you're top 1% for pay, people throwing FMV at you are trying to pay you less. Full stop.