Testosterone Clinic Billing

[WanderlustPA]

I've been working at a testosterone clinic for a while, and I'm questioning their billing practices. I'm trying to find another job anyway, but I'm wondering what you guys think of this.

They're billing all visits at least a 99213. 90% of the visits are just the patient coming in for their weekly injection. Before I started, I assumed this would be a 99212. Even with me seeing the patient, it's a simple, quick visit. They are now wanting to add a FULL HPI to the notes, with all the elements. I've objected to this, saying that I refuse to put something in the note that isn't being done. Which is probably what everyone else is doing. So instead we're going to actually cover all of this stuff on EVERY visit. I don't think the patients will like this, as they are just there to get their shot and get out. I also feel that it borders on being unethical, as there isn't even a medical necessity for us to see the patient every single week. Let's be honest, they can get a testosterone Rx from their PCP (which I prescribed a lot in family practice), and do the shots at home without any weekly oversight. Just come in for labs every 3-4 months to monitor T levels, Hct, PSA, estradiol, etc.

A friend of mine is an office manager in Internal Medicine, and he says if they are just there for an injection, there should be no E&M at all, just the injection code. I feel that instead of doing what is appropriate and then billing for that, they are targeting a 99213 code, and then doing what they have to do to meet that code.

Overall I just think this is kind of a shady business, and I think there's probably a day coming where insurance companies are going to refuse to pay for a 99213 for a simple injection visit, even if the coding requirements are met, it just isn't medically necessary. It's costing the patient way more than it needs to, and it's costing the insurance company way more than it needs to. I don't feel good about it, and besides I want to get back to REAL medicine anyway. This was just the first job I could get after being laid-off from my previous job (yes, believe it or not, I was laid-off as a PA!).

[coloradopa]

8 hours ago, WanderlustPA said:

I've been working at a testosterone clinic for a while, and I'm questioning their billing practices. I'm trying to find another job anyway, but I'm wondering what you guys think of this.

They're billing all visits at least a 99213. 90% of the visits are just the patient coming in for their weekly injection. Before I started, I assumed this would be a 99212. Even with me seeing the patient, it's a simple, quick visit. They are now wanting to add a FULL HPI to the notes, with all the elements. I've objected to this, saying that I refuse to put something in the note that isn't being done. Which is probably what everyone else is doing. So instead we're going to actually cover all of this stuff on EVERY visit. I don't think the patients will like this, as they are just there to get their shot and get out. I also feel that it borders on being unethical, as there isn't even a medical necessity for us to see the patient every single week. Let's be honest, they can get a testosterone Rx from their PCP (which I prescribed a lot in family practice), and do the shots at home without any weekly oversight. Just come in for labs every 3-4 months to monitor T levels, Hct, PSA, estradiol, etc.

A friend of mine is an office manager in Internal Medicine, and he says if they are just there for an injection, there should be no E&M at all, just the injection code. I feel that instead of doing what is appropriate and then billing for that, they are targeting a 99213 code, and then doing what they have to do to meet that code.

Overall I just think this is kind of a shady business, and I think there's probably a day coming where insurance companies are going to refuse to pay for a 99213 for a simple injection visit, even if the coding requirements are met, it just isn't medically necessary. It's costing the patient way more than it needs to, and it's costing the insurance company way more than it needs to. I don't feel good about it, and besides I want to get back to REAL medicine anyway. This was just the first job I could get after being laid-off from my previous job (yes, believe it or not, I was laid-off as a PA!).

First the disclaimer, you are responsible for your coding nothing here constitutes legal advice. 

There are two issues. One is do you need an office visit for the injection and the other is what is the appropriate code. 

For issue one it depends on medical necessity. The various medicare guidelines recommend testing testosterone levels then reassessing every 3-6 months as well as testing HCT every 3-6 months. Testosterone has a number of significant side effects and complications. If the treatment plan requires assessing the patient for side effects and complications prior to each injection then you probably have medical necessity. If you are just seeing the patient to increase the billing then you are not. The key is are you mitigating risk/adding value. 

For issue two it looks like 99213 would be appropriate. The HPI is unnecessary and not required for a 99213. For 99213 you need 2 of 3 of History, Exam and Medical decision making. For history you need and expanded problem focused history which is 1-3 HPI elements and one ROS. For exam you needs six bullets for one or more organ systems. For MDM you need 2 of 3 off problem points, data points or risk. Generally most coders believe that you can't get a higher level unless MDM supports that level (higher levels of History and exam don't trump lower levels of MDM). So if you ignore history you need six exam bullets (VS, appearance, CV, Pulm. Abdomen and extremities for example). Then you need MDM. If you have the chronic problem you are dealing with (low testosterone) and one other chronic problem you are good. Two data points (such as labs or xrays would be rare). For MDM prescription drug mangement is actually medium risk and would qualify for a level four. However given the lack of problems level 3 (99213) is appropriate. 

Hope this helps. 

[rev ronin]

Actually, two chronic but stable medical problems would be a Moderate risk and support a 99214.

I question the provider visit with every injection as medically necessary. Since it's a controlled substance, I would definitely see them every 3 months at a minimum, but not every 2 weeks.  I routinely charge 99214s for just about every repeat visit, because that's what can be supported by the elements and medical risk.

[BruceBanner]

Fraudulent billing. There is no medical reason to have a person back in your office for an E&M once a week for what is a fairly straightforward diagnosis. An office I used to work at did injections for some patients and it was billed as a nurse visit injection (not sure the code). Provider doesn't even see them. 

At most your office should be seeing them every 3 months, but 6 months is the norm. Then you can do your H&P, exam, etc. But anything you are coding for on those weekly visits is made up. Are you doing the injection? Or other staff? As I'm sure you know by now, retail testosterone clinics are a very shady business. The new trend is online men's clinics. They charge a flat fee for "membership", fee for labs, dont bill insurance, use only compounded meds, prescribe high doses and "ancillaries" like HCG and aromatase inhibitors, etc. 

Not putting you down at all. You needed a job. I almost worked for one! 

But that is fraudulent billing. 

[WanderlustPA]

On 2/4/2019 at 2:25 PM, BruceBanner said:

Fraudulent billing. There is no medical reason to have a person back in your office for an E&M once a week for what is a fairly straightforward diagnosis. An office I used to work at did injections for some patients and it was billed as a nurse visit injection (not sure the code). Provider doesn't even see them. 

At most your office should be seeing them every 3 months, but 6 months is the norm. Then you can do your H&P, exam, etc. But anything you are coding for on those weekly visits is made up. Are you doing the injection? Or other staff? As I'm sure you know by now, retail testosterone clinics are a very shady business. The new trend is online men's clinics. They charge a flat fee for "membership", fee for labs, dont bill insurance, use only compounded meds, prescribe high doses and "ancillaries" like HCG and aromatase inhibitors, etc. 

Not putting you down at all. You needed a job. I almost worked for one! 

But that is fraudulent billing. 

This is how I feel. I'm actively looking for another job, and have a few interviews this week. I honestly hadn't planned on being there as long as I have, but just got comfortable, and stopped putting a lot of effort into searching for a new job.

I think the time is about up for these types of clinics. One of the other employee providers, not an owner, was saying that BCBS is now only allowing an office visit code to be used once a month for hypogonadism. I'm not surprised, and I bet that the others aren't too far behind. I see this business tanking in the next 3-5 years, perhaps even sooner. 

At any rate, they finally listened to my concerns and have hired a 3rd party billing company to review our notes.

[BruceBanner]

Yeah, I see the ones that bill insurance going belly up and transitioning to the retail model, which may flood the market enough to get the DEA involved and start shutting them down.