99214 on procedure days

[lmsanscafe]

Almost all attendings at my institution bill a level 4 follow up as well as for the procedure even if nothing changes. I’ve softly questioned this and I am told that they are still “evaluating”, and tbf if you write a lot in the notes, examine the pt, review meds, labs, imaging, and talk about the procedure, it satisfies criteria. My question for you all is, do you do this? How common is it to do especially in private practice?

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[buddababa]

Almost all attendings at my institution bill a level 4 follow up as well as for the procedure even if nothing changes. I’ve softly questioned this and I am told that they are still “evaluating”, and tbf if you write a lot in the notes, examine the pt, review meds, labs, imaging, and talk about the procedure, it satisfies criteria. My question for you all is, do you do this? How common is it to do especially in private practice?

they do this probably cuz they get paid on collections, so they wanna maximize billing - i dont agree with it. I only bill 99213/99214 if im really doing a lot of "medical evaluation" work; which is very rare. 99.5% of the time im only billing a procedure code. The procedure codes we bill, have built in the work done as you mentioned above.

 

[SSdoc33]

ill do a e/m if something changes with the plan, if i am doing a different or additional injection, if i review an MRI, if the patient doesnt make their clinic f/u and just comes back for the shot, etc.

dont leave money on the table.

e/m pays more than you think it would....

 

[oneforfighting]

ill do a e/m if something changes with the plan, if i am doing a different or additional injection, if i review an MRI, if the patient doesnt make their clinic f/u and just comes back for the shot, etc.

dont leave money on the table.

e/m pays more than you think it would....

Does this apply to the HOPD setting or just office based?

 

[SSdoc33]

Does this apply to the HOPD setting or just office based?

everything.

legitimacy of billing an e/m doesnt depend on SOS

 

[Dr. Ice]

Audit, no interest. The levels are what they are. I’m in no position to back pay a throng because I’m on my own even though I’m with a group. Anything that is “my fault” will really be “my fault”

 

[Ferrismonk]

Many insurances will not allow you to bill an office visit and a procedure on the same visit if they're related to each other. When you try to bill both, many will only pay the cheaper service. If you are able to bill an office visit, and it's about a different issue than the procedure you're doing, and they are willing to pay both, you'll often only get 50% of the second service (usually the more expensive service gets the 50% treatment).

My guess is your attendings are paid based on RVU and the hospital pays them for the RVU documented even if only one code actually gets paid.

 

[bedrock]

Agree with Ferrismonk regarding likely RVU rationale.

For PP, Even if u do deal with a separate issue on procedure day, I was taught by billing to check a 99213, as fluoro guided spine procedure plus 99214 is much more likely to trigger an audit.

 

[BobBarker]

Sure, planned procedure - hey doc, can you ???? =99213-25

 

[Forwho]

Many insurances will not allow you to bill an office visit and a procedure on the same visit if they're related to each other. When you try to bill both, many will only pay the cheaper service. If you are able to bill an office visit, and it's about a different issue than the procedure you're doing, and they are willing to pay both, you'll often only get 50% of the second service (usually the more expensive service gets the 50% treatment).

My guess is your attendings are paid based on RVU and the hospital pays them for the RVU documented even if only one code actually gets paid.

don't hospitals let the physicians know that they're not getting paid appropriately if they're coding inappropriately? or do HOPD docs really just code freely at will without any backlash?

 

[paindoc007]

Once in a while. Not routine.

Pigs get fat, hogs get slaughtered

 

[BobBarker]

@Forwho the coder at the hospital just shrugs her shoulders and deletes the unnecessary office visit codes and moves along with her day. Some places the coders don’t even look at the docs coding and just input the codes as they see fit.

 

[Forwho]

And they get credited the RVUs for the visit code and procedure code? Amazing..

 

[SSdoc33]

And they get credited the RVUs for the visit code and procedure code? Amazing..

happens all the time. ive seen some crazy stuff billed. hospital either doesnt know or doesnt care. in the end, it is indeed fraud, but it rarely if ever comes back to haunt the doc.

 

[Ducttape]

Many insurances will not allow you to bill an office visit and a procedure on the same visit if they're related to each other. When you try to bill both, many will only pay the cheaper service. If you are able to bill an office visit, and it's about a different issue than the procedure you're doing, and they are willing to pay both, you'll often only get 50% of the second service (usually the more expensive service gets the 50% treatment).

My guess is your attendings are paid based on RVU and the hospital pays them for the RVU documented even if only one code actually gets paid.

in specific, Medicare will not allow this practice.

Agree with Ferrismonk regarding likely RVU rationale.

For PP, Even if u do deal with a separate issue on procedure day, I was taught by billing to check a 99213, as fluoro guided spine procedure plus 99214 is much more likely to trigger an audit.

dont think that thats not going to really do anything. the double billing is what will trigger an audit, unless you can justify the e/m


if the e/m focused entirely on the procedure, then it is part and partial to the procedure. no double dipping.


discussing anything else related to their care should cover the e/m. then bill. for example, review NSAID and discuss side effects, management of risks of these medications. (Z79.1 icd-10). if they have pain elsewhere, set up injection for other body part. use the other body part icd-10 for the e/m.

 

[myrandom2003]

Per my understanding, you cannot bill and E/M code on the day of the procedure if the procedure is a planned procedure.
Need 25 modifier. Many insurance no longer use 25 modifier. Also many procedures have a 0-day global period so anything done that day in relation to the procedure is included so cannot be billed separated.

Now, if the patient shows up, then asks for a med refill, then your choice because that does not have anything to do with the procedure, so use the 25 mod and roll the dice.

If patient shows up, and need to cancel the procedure for anything, then document and bill the E/M for the appropriate level.

 

[specepic]

Classic answer: "it depends"

1. LESI which is planned ahead of time. No e/m typically billed. 62323 only

2. Pt sent for consultation. end up rec'ing USGI hip and we have time to do it. level 4 new pt 99204-25 and bill for USGI as well

3. Pt sent for USGI and while they are here they request opioid RF (we see them for that as well in past). 99214-25 USGI as well

You should only bill for e/m with a procedure if there is a separate service being rendered.

document document document

I almost never bill E and M on fluoro days

 

[SSdoc33]

Classic answer: "it depends"

1. LESI which is planned ahead of time. No e/m typically billed. 62323 only

2. Pt sent for consultation. end up rec'ing USGI hip and we have time to do it. level 4 new pt 99204-25 and bill for USGI as well

3. Pt sent for USGI and while they are here they request opioid RF (we see them for that as well in past). 99214-25 USGI as well

You should only bill for e/m with a procedure if there is a separate service being rendered.

document document document

I almost never bill E and M on fluoro days

you do a hip injection on a patient. they miss their clinic follow up. they show up on your schedule a hear later for a repeat hip injection. i er-evaluate them, bill and e/m AND do the hip injection. i dont know if they need the shot until i do the eval. there is a chance i dont do the shot.

here is another one: i see a new patient in clinic and order an MRI. the next time i see them, it is in the procedure suite, where i review MRI, do an exam and do the ESI. i bill the e/m as well as the ESI. i have gone over this with my billers on multiple occasions, and everything gets paid. just a more efficient way then bringing these folks back to clinic to bill the e/m for everything.

 

[Dr. Ice]

you do a hip injection on a patient. they miss their clinic follow up. they show up on your schedule a hear later for a repeat hip injection. i er-evaluate them, bill and e/m AND do the hip injection. i dont know if they need the shot until i do the eval. there is a chance i dont do the shot.

here is another one: i see a new patient in clinic and order an MRI. the next time i see them, it is in the procedure suite, where i review MRI, do an exam and do the ESI. i bill the e/m as well as the ESI. i have gone over this with my billers on multiple occasions, and everything gets paid. just a more efficient way then bringing these folks back to clinic to bill the e/m for everything.

You’re talking about Medicare patients of course right?

 

[specepic]

you do a hip injection on a patient. they miss their clinic follow up. they show up on your schedule a hear later for a repeat hip injection. i er-evaluate them, bill and e/m AND do the hip injection. i dont know if they need the shot until i do the eval. there is a chance i dont do the shot.

here is another one: i see a new patient in clinic and order an MRI. the next time i see them, it is in the procedure suite, where i review MRI, do an exam and do the ESI. i bill the e/m as well as the ESI. i have gone over this with my billers on multiple occasions, and everything gets paid. just a more efficient way then bringing these folks back to clinic to bill the e/m for everything.

Sounds valid. Being hospital-based, we always have to make the decision about a fluoroscopy injection prior to the appointment so this system would not work for us but it sounds valid the way you are doing it

 

[sdnuser001]

So if a patient coming to clinic for in office procedure needs a gabapentin refill then okay to bill 99213?

 

[GlowInTheDark]

I should hang a sign in fluoro suite: “if you talk about anything else except this injection, you will be billed”

 

[cowboydoc]

So if a patient coming to clinic for in office procedure needs a gabapentin refill then okay to bill 99213?

I’m not sure that involves any medical decision making.

 

[RoloTomassi]

I’m not sure that involves any medical decision making.

Sure it does, to fill or not too fill. Falls under prescription drug management= mod complexity

 

[specepic]

So if a patient coming to clinic for in office procedure needs a gabapentin refill then okay to bill 99213?

Yes, and especially if you discuss dosing, safety, SE's, precautions, next steps

 

[Ducttape]

So if a patient coming to clinic for in office procedure needs a gabapentin refill then okay to bill 99213?

if you discuss gabapentin and review benefits, adverse side effects, potential interactions with medications, etc., then yes.

if its "hey doc, im running out of gabapentin tomorrow, can you call me in a refill?" "sure. ready for the poke?" then probably not.

 

[sloh]

if its "hey doc, im running out of gabapentin tomorrow, can you call me in a refill?" "sure. ready for the poke?" then probably not.

"hey doc, im running out of gabapentin tomorrow, can you call me in a refill?"

"sure. let me reiterate the side effects, benefits, and potential interactions with you again. ready for the poke?" then probably yes

Don't leave money on the table!

 

[PainAnonymous]

While waiting for my attending for bilateral pudendal block my patient stated he had new neck pain. Did a physical, discussed the onset, duration, treatments. Ordered an MRI.

Attending showed up and I did the block and billed for both that and a 99214. They were proud.

 

[MitchLevi]

While waiting for my attending for bilateral pudendal block my patient stated he had new neck pain. Did a physical, discussed the onset, duration, treatments. Ordered an MRI.

Attending showed up and I did the block and billed for both that and a 99214. They were proud.

Have them do PT before the MRI so (1) you don't get a denial, and (2) your PT dept stays busy.

 

[PainAnonymous]

Have them do PT before the MRI so (1) you don't get a denial, and (2) your PT dept stays busy.

Already with our PT team =)

 

[Ducttape]

While waiting for my attending for bilateral pudendal block my patient stated he had new neck pain. Did a physical, discussed the onset, duration, treatments. Ordered an MRI.

Attending showed up and I did the block and billed for both that and a 99214. They were proud.

great! make sure you document.

now, you will get 50% reimbursement for either the procedure or the office visit, but it is more than either one alone.



good job... as long as you did not not slow down the procedure room....

 

[Baron Samedi]

While waiting for my attending for bilateral pudendal block my patient stated he had new neck pain. Did a physical, discussed the onset, duration, treatments. Ordered an MRI.

Attending showed up and I did the block and billed for both that and a 99214. They were proud.

Someone correct me if I'm wrong, but I believe that the 99214 would get a -25 modifier in that scenario.

 

[drrosenrosen]

99214 should have a -25 modifier for sure. What I often see in practice when I use this modifier, is that one code or the other doesn't get paid. Sometimes they'll not pay the procedure code and just pay the cheaper 99214. So I often don't bother with adding an EM-25 code, no matter how appropriate it may be

 

[paindoc007]

One of the few good things with a wrvu system. Somebodies problem. Ain’t mine

99214 should have a -25 modifier for sure. What I often see in practice when I use this modifier, is that one code or the other doesn't get paid. Sometimes they'll not pay the procedure code and just pay the cheaper 99214. So I often don't bother with adding an EM-25 code, no matter how appropriate it may be

 

[PainAnonymous]

99214 should have a -25 modifier for sure. What I often see in practice when I use this modifier, is that one code or the other doesn't get paid. Sometimes they'll not pay the procedure code and just pay the cheaper 99214. So I often don't bother with adding an EM-25 code, no matter how appropriate it may be

So do you not do the 99214 all together? To not risk it being the paid visit Vs injection?

 

[GatorCHOMPions]

Wait, do some HOPD docs get the full total RVUs for both procedure and office codes on the same visit?

 

[Ducttape]

what they bill, what they get paid, and what Medicare allows and will ultimately agree with may not be be the same.

 

[MitchLevi]

How does the payment flesh out in these?

You'll be paid 50% for one of these codes correct?

Full payment on the lowest billing code and 50% on the highest code?

Is that correct?