Down-Code Billing issue

[jmj11]

1 hour ago, sas5814 said:

We had a similar issue here in the UC where we were told we were expected to have 75% of our codes as level 4. I asked the VP who told us that to please write it down and sign it so I'd have a copy. That was a year ago and still no signed policy. I wonder why?

Now that sounds fraudulent. A code should reflect reality so, I can't imagine a practice that had the expectation that 75% of patients would have a certain level of complexity before you even see them. 

[sas5814]

It sounded like conspiracy to up-code to me that is why I wanted it in writing. Then he started some song and dance about us being here when everyone else was closed so we are entitled to that extra money. I told him that may effect the amount we get paid at certain visit levels but had no bearing on the level or complexity of the visit. 

I think they think we are all stupid and if they just keep talking we will buy in.

[mgriffiths]

11 minutes ago, sas5814 said:

I think they think we are all stupid and if they just keep talking we will buy in.

unfortunately with the general population that works...it's one of many tactics used by politicians and the media to normalize something previously was considered bad.

[rev ronin]

I routinely code well over 75% of my visits at 99214, whether in sleep, occupational, or family medicine.  It's not hard, based on the risk rules, which dictate the upper limit on E&M coding level:
* Med refills for BP and Cholesterol? 2 stable chronic conditions -> moderate risk => 99214
* Increasing Lisinopril? Med management -> moderate risk => 99214
* New diagnosis of something? Moderate risk... you get the picture.

It is absolutely not OK to upcode.  But the rules are set, published, and well established, such that what might seem to be upcoding is not.  Thus, if the clinic sets up the paperwork so you have a 10-point ROS and PFSHx filled out by the patient each visit, you don't even have to do any exam at all to code for a 99214 on a moderate patient (assuming you have a CC and HPI, obviously).

As a revenue source, it's my job to know coding sufficiently well to maximize the reimbursement for the services I render: the business of medicine acumen helps me justify my salary and that of my support staff.  The question "What's the most revenue I can get paid, ethically and legally?" is a very, very different question from "How can I get the most money from this encounter?"

[mgriffiths]

12 hours ago, rev ronin said:

* Med refills for BP and Cholesterol? 2 stable chronic conditions -> moderate risk => 99214
* Increasing Lisinopril? Med management -> moderate risk => 99214
* New diagnosis of something? Moderate risk... you get the picture.

curious Rev on your thoughts: patient on multiple controlled substances - narcotic and stimulant/sedative/benzodiazepine (take your pick - obviously not ideal combo, but just go with it) coming in for monthly refill.  That would be two chronic conditions, two medications refilled (NOT increased, but either straight refill or decreased) - 99214?

The policy I mentioned in an earlier post was specifically for controlled substance refill visits.  The legality of the practice determining a CPT aside, I feel the above patient is a 99214.  MAYBE a single controlled substance refill would necessitate a 99213 based on only one diagnosis, but if it's a narcotic for back pain + knee pain...that's again two "stable chronic conditions."  Again, I get around the policy very easily, but just curious on your thoughts.

[rev ronin]

4 minutes ago, mgriffiths said:

curious Rev on your thoughts: patient on multiple controlled substances - narcotic and stimulant/sedative/benzodiazepine (take your pick - obviously not ideal combo, but just go with it) coming in for monthly refill.  That would be two chronic conditions, two medications refilled (NOT increased, but either straight refill or decreased) - 99214?

The policy I mentioned in an earlier post was specifically for controlled substance refill visits.  The legality of the practice determining a CPT aside, I feel the above patient is a 99214.  MAYBE a single controlled substance refill would necessitate a 99213 based on only one diagnosis, but if it's a narcotic for back pain + knee pain...that's again two "stable chronic conditions."  Again, I get around the policy very easily, but just curious on your thoughts.

The risk level in a controlled substance refill almost certainly meets 99214.  Even if you don't have two chronic conditions, what's the worst thing that can happen with a controlled substance prescription gone wrong? Addiction or death.  Also look at the data review elements: contract/agreement, PMP, pain inventory, UDS... even if they weren't done each visit, you have to review them each visit just to make sure everything's been done and current, right?

And once the risk level is established, for an established patient you need either H or P at the appropriate level to meet a 99214--again, pretty trivial, really, since you can legitimately incorporate (and count) the patient's per-visit paperwork by reference.

There's two sorts of practitioners in the world: Those who understand this and code almost anything seen by a provider to 99214, and those who don't.  The former stand to lose a bit from the proposed medicare collapse of E&M codes; the latter, perhaps may gain.  But why do you think they're collapsing E&M in the first place? Because they published a set of rules on how to get paid more, and everyone's following them...

[mgriffiths]

That is almost the exact argument I made and was "overruled" - of course one of the docs who was part of the committee that overruled me only bills 99213 - doesn't matter what the patient came in for or how long he spends with the patient.  He is also one of the most productive providers in the clinic - I can't imagine how much money he leaves behind only billing 99213  

[rev ronin]

8 hours ago, mgriffiths said:

That is almost the exact argument I made and was "overruled" - of course one of the docs who was part of the committee that overruled me only bills 99213 - doesn't matter what the patient came in for or how long he spends with the patient.  He is also one of the most productive providers in the clinic - I can't imagine how much money he leaves behind only billing 99213  

His loss, but if you're getting paid for productivity, I'd bill whatever I thought was right: Your SP has no special relationship to overrule your coding decisions.

One of the advantages of ONLY billing 99213 is that he'll never get audited.  I got a nice one page summary from an insurance company comparing my billing habits to other providers in their network.  Guess what? I had more 99214s and less 99213s than their averages!  Message was loud and clear: "Gee, it would certainly be a shame if you got dropped from our network..."

[SCPA]

On 10/26/2018 at 8:53 PM, rev ronin said:

One of the advantages of ONLY billing 99213 is that he'll never get audited.  I got a nice one page summary from an insurance company comparing my billing habits to other providers in their network.  Guess what? I had more 99214s and less 99213s than their averages!  Message was loud and clear: "Gee, it would certainly be a shame if you got dropped from our network..."

   You took this as a scare tactic from insurance, Rev? Like why are you billing higher than most?  Did this change the way you do things (I'm assuming not because you are following the guidelines)?  

[rev ronin]

1 hour ago, SCPA said:

   You took this as a scare tactic from insurance, Rev? Like why are you billing higher than most?  Did this change the way you do things (I'm assuming not because you are following the guidelines)?  

I absolutely did.  Insurance companies are for-profit companies, and anything they can legally do to decrease costs, they will do.

I haven't changed a thing. I still bill at the highest level of service supported by the diagnoses, H&P, etc.

[mgriffiths]

An update...

I gave notice to my current employer regarding my resignation and explained the MANY reasons why I was leaving.  I also voiced my concern regarding the changing of my billing codes without my involvement - and without a certified coding specialist.  The practice administrators response: "I am an expert in billing and if I want to change them I can!"

It is so unfortunate, this has been a great place to work but something changed - without any recent change in administration.

[sas5814]

If you wanted to drive the point home you could make a complaint to CMS and insurers about them changing your codes but then you'd be dragged into the mess with them.