Any ballin’ FM attendings?

[door_to_balloon_knot]

To give some of us hopes/ ideas or to gloat anonymously online, any attendings making $500k+ gross? If so, how and advice to get started would be appreciated.

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[Sardonix]

Why do you need $500,000+ income to give you hope?

 

[Osteoth]

Busy clinic, office ownership, multiple PA/Nurse Prac, ancillaries, good payor mix.

/thread

 

[door_to_balloon_knot]

Why do you need $500,000+ income to give you hope?

A Porsche 911 GT2 RS doesn’t pay for itself duh

 

[Reboa]

Money may not buy happiness but have you ever seen someone frown on a jet ski

 

[simpler2]

Apparently they are even doable with a vow of poverty. The 500k salary isn't necessary!

 

[iforget2]

My FM preceptor's boss is the physician who owns the practice and there's no way he does not clear $500k/year. He regularly sees 40+ patients per day working Monday-Friday and half a day Saturday though.

 

[deleted87716]

I know people in FM who make >$500K. I wouldn't want their schedule, though. I have a life.

 

[VA Hopeful Dr]

I know people in FM who make >$500K. I wouldn't want their schedule, though. I have a life.

Yeah we have a guy that does. Sees 35+ a day and charts 2-3 hours at home after work every day.

Moral of the story: don't have 8 children.

 

[Sardonix]

View attachment 323262
Apparently they are even doable with a vow of poverty. The 500k salary isn't necessary!

What does nephrology have to do with this?

 

[door_to_balloon_knot]

What does nephrology have to do with this?

Excuse me, I think you misspelled pathology.

 

[door_to_balloon_knot]

Yeah we have a guy that does. Sees 35+ a day and charts 2-3 hours at home after work every day.

Moral of the story: don't have 8 children.

Sounds like Utah

 

[VA Hopeful Dr]

Sounds like Utah

Close, he's super Catholic apparently.

 

[deleted87716]

Kids are way cheaper than ex-wives.

 

[robellis]

Ballin isn’t even 500k, go over to the optho forum, they are talking about easily pulling 1.5 mil/year..crazy

 

[Sardonix]

Ballin isn’t even 500k, go over to the optho forum, they are talking about easily pulling 1.5 mil/year..crazy

How's that relevant to FM though?

 

[Keona]

Yeah we have a guy that does. Sees 35+ a day and charts 2-3 hours at home after work every day.

Moral of the story: don't have 8 children.

Does he work that much so he doesn’t have to deal with the kids?

 

[Bacchus]

My FM preceptor's boss is the physician who owns the practice and there's no way he does not clear $500k/year. He regularly sees 40+ patients per day working Monday-Friday and half a day Saturday though.

That’s called assembly line medicine right there.

 

[iforget2]

That’s called assembly line medicine right there.

My preceptor is newer but will probably get there one day because their practice consistently double or triple books time slots and they still accept walk-ins. When looking for an attending job how reasonable is it to negotiate with an employer to capping your day at 20-25 patients/day?

 

[VA Hopeful Dr]

My preceptor is newer but will probably get there one day because their practice consistently double or triple books time slots and they still accept walk-ins. When looking for an attending job how reasonable is it to negotiate with an employer to capping your day at 20-25 patients/day?

Very reasonable, though generally you just want to make sure you have control over your schedule. Then, so long as you're busy enough to cover your expenses and income, they don't much care past that.

 

[deleted997790]

He must see urgent care type visits all day. I have a friend who does this in private practice. No chronic conditions. U can code a 99214 with a sinus infection if ur tricky...or, u can see an uncontrolled diabetic/asthmatic/hypertensive patient and spend forever documenting and counseling the patient and still Bill a 99214...

My FM preceptor's boss is the physician who owns the practice

 

[deleted87716]

He must see urgent care type visits all day. I have a friend who does this in private practice. No chronic conditions. U can code a 99214 with a sinus infection if ur tricky...or, u can see an uncontrolled diabetic/asthmatic/hypertensive patient and spend forever documenting and counseling the patient and still Bill a 99214...

No, counseling "forever" would be at least >40 min. (99215).

If you're billing 99214 for acute sinusitis, it had better not be typical (and your documentation should support it).

 

[deleted997790]

No, counseling "forever" would be at least >40 min. (99215).

If you're billing 99214 for acute sinusitis, it had better not be typical (and your documentation should support it).

I don’t see these kinda patients, but what they do for sinus infection is document sinus infection, cough, fatigue (the last two being symptoms of the first), and order X-ray, in house CBC, give steroid shot, rocephin shot prescribe antibiotics (smh) and schedule one week follow up to assess resolution. It’s crooked, unethical and done frequently around the country (no disrespect to “urgent care” docs). Certain EMR’s calculate complexity off of how many hpi and PE points you check. If you prescribe an antibiotic, it’s automatically atleast a 99213...but a 99214 is ludicrous. I wonder if they get reimbursed for billing out a 99214?

 

[deleted87716]

I don’t see these kinda patients, but what they do for sinus infection is document sinus infection, cough, fatigue (the last two being symptoms of the first), and order X-ray, in house CBC, give steroid shot, rocephin shot prescribe antibiotics (smh) and schedule one week follow up to assess resolution. It’s crooked, unethical and done frequently around the country (no disrespect to “urgent care” docs). Certain EMR’s calculate complexity off of how many hpi and PE points you check. If you prescribe an antibiotic, it’s automatically atleast a 99213...but a 99214 is ludicrous. I wonder if they get reimbursed for billing out a 99214?

If they're audited, they're probably f*cked. Medical necessity matters.

 

[Bacchus]

He must see urgent care type visits all day. I have a friend who does this in private practice. No chronic conditions. U can code a 99214 with a sinus infection if ur tricky...or, u can see an uncontrolled diabetic/asthmatic/hypertensive patient and spend forever documenting and counseling the patient and still Bill a 99214...

This won’t happen after the new year.

 

[Bacchus]

This won’t happen after the new year.

At least you shouldn’t be.

 

[deleted997790]

This won’t happen after the new year.

What changes are being made after the new year?

 

[Bacchus]

What changes are being made after the new year?

Billing. Most acute concerns that are everyday things won’t be a 99214. Granted, there will be a small wRVU increase for each E/M. AMA has a good outline on it.

 

[door_to_balloon_knot]

I don’t see these kinda patients, but what they do for sinus infection is document sinus infection, cough, fatigue (the last two being symptoms of the first), and order X-ray, in house CBC, give steroid shot, rocephin shot prescribe antibiotics (smh) and schedule one week follow up to assess resolution. It’s crooked, unethical and done frequently around the country (no disrespect to “urgent care” docs). Certain EMR’s calculate complexity off of how many hpi and PE points you check. If you prescribe an antibiotic, it’s automatically atleast a 99213...but a 99214 is ludicrous. I wonder if they get reimbursed for billing out a 99214?

Any prescription makes it a 99214 already... what your talking about is closer to a -215

 

[Bacchus]

Any prescription makes it a 99214 already... what your talking about is closer to a -215

You gotta argue unknown outcome, threat to health, etc.

 

[deleted87716]

Any prescription makes it a 99214 already... what your talking about is closer to a -215

Not necessarily.

How to Get All the 99214s You Deserve

 

[Keona]

If they're audited, they're probably f*cked. Medical necessity matters.

I got billed a 99214 for my kids strep throat when I went to an urgent care. An urgent care that i also moonlighted at during residency. Seems so unethical to me. She had a high fever. Took dr less than 2 minutes in room and no other labs needed. I was so mad. I even messaged higher ups and they said the documentation fit. (Her pediatricians office was closed and fever was 104 so I didn’t feel safe waiting until they opened). After that I bought the rapid test kit off Amazon to keep on hand.

 

[door_to_balloon_knot]

Not necessarily.

How to Get All the 99214s You Deserve

Ok hear me out. 9921x implies established patient. For MDM, new diagnosis with no additional work up is 3 points for Problem points. Loss on Data points since your likely not doing labs or imaging. Rx for anything bumps risk to 3 points as well. Need 2/3 points between problem/data/risk. For the above example would be 3/0/3. That’s moderate complexity in MDM no?

 

[deleted87716]

Ok hear me out. 9921x implies established patient. For MDM, new diagnosis with no additional work up is 3 points for Problem points. Loss on Data points since your likely not doing labs or imaging. Rx for anything bumps risk to 3 points as well. Need 2/3 points between problem/data/risk. For the above example would be 3/0/3. That’s moderate complexity in MDM no?

Depends. I'm assuming you read the article...?

 

[VA Hopeful Dr]

No, counseling "forever" would be at least >40 min. (99215).

If you're billing 99214 for acute sinusitis, it had better not be typical (and your documentation should support it).

You're not billing your sinus infections as 99214s?

 

[deleted87716]

You're not billing your sinus infections as 99214s?

No.

Unless I can somehow tag some unrelated **** onto the visit, or I think it could be something more complicated than a simple sinusitis and document accordingly (rare).

 

[deleted997790]

Wow all these above replies make me so nervous. There’s so much non-medical crap we have to keep up with.

 

[deleted87716]

Wow all these above replies make me so nervous. There’s so much non-medical crap we have to keep up with.

Compared to the real medicine, it's easy peasy.

 

[VA Hopeful Dr]

No.

Unless I can somehow tag some unrelated **** onto the visit, or I think it could be something more complicated than a simple sinusitis and document accordingly (rare).

I should have included prescriptions I suppose. If I diagnose a sinus infection and prescribe an antibiotic it's getting level 4 from me.

 

[deleted87716]

I should have included prescriptions I suppose. If I diagnose a sinus infection and prescribe an antibiotic it's getting level 4 from me.

Not here. 99213 vs. 99214: Three tips for spotting the difference

A single acute (probably self-limited) problem with no lab review, imaging, or follow up just doesn't pass the smell test for 99214, regardless of prescription drug management, IMO.

 

[Bacchus]

Not here. 99213 vs. 99214: Three tips for spotting the difference

A single acute (probably self-limited) problem with no lab review, imaging, or follow up just doesn't pass the smell test for 99214, regardless of prescription drug management, IMO.

Only of our guys says if he has to access the PDMP it’s a 4.

What would you code a rhus dermatitis as when it requires PO steroid taper? The counseling on the steroid complications would make you bump to a 4 in addition to the RX management, no? This is a 214 for me.

Regardless, the new EM is going to make all these single issues 213s.

 

[Bacchus]

I got billed a 99214 for my kids strep throat when I went to an urgent care. An urgent care that i also moonlighted at during residency. Seems so unethical to me. She had a high fever. Took dr less than 2 minutes in room and no other labs needed. I was so mad. I even messaged higher ups and they said the documentation fit. (Her pediatricians office was closed and fever was 104 so I didn’t feel safe waiting until they opened). After that I bought the rapid test kit off Amazon to keep on hand.

1) Was testing done?
2) With a fever of 104 I’d argue unknown diagnosis with possible poor outcome leads to a 214 “seriousness.”
3) Were you paying out of pocket?

I always review my EOBs, but I never mind paying if there’s no concern. We all gotta eat.

 

[deleted997790]

Antibiotics, lab review and X-ray review on a sinus infection still isn’t a 99214 I thought? Antibiotics or prescription medications is a 99213 at the least, but complexity matters. If I have a stable hypertensive and refill his meds and tell him return in 3-6 months, that’s not high complexity (it’s low). It’s a chronic condition, but stable and took 2 minutes. A sinus infection being prescribed antibiotics is not high complexity - this is def low complexity, but because of the antibiotics it’s gonna be a 99213. Complexity is king with coding (I thought atleast ... what I was taught in residency in 2014)

 

[Dr. Wexler]

I got billed a 99214 for my kids strep throat when I went to an urgent care. An urgent care that i also moonlighted at during residency. Seems so unethical to me. She had a high fever. Took dr less than 2 minutes in room and no other labs needed. I was so mad. I even messaged higher ups and they said the documentation fit. (Her pediatricians office was closed and fever was 104 so I didn’t feel safe waiting until they opened). After that I bought the rapid test kit off Amazon to keep on hand.

How do you think this New Problem with Systemic Symptoms that required Prescription Management should be billed?

Some 99214s take 2 minutes. Some 99213s take 10+ minutes. It is messed up IMHO but it is not my system and so I don't feel bad about it. Patients can complain to their insurance companies. Current contracts require me to bill following the CMS rules.

 

[Bacchus]

Antibiotics, lab review and X-ray review on a sinus infection still isn’t a 99214 I thought? Antibiotics or prescription medications is a 99213 at the least, but complexity matters. If I have a stable hypertensive and refill his meds and tell him return in 3-6 months, that’s not high complexity (it’s low). It’s a chronic condition, but stable and took 2 minutes. A sinus infection being prescribed antibiotics is not high complexity - this is def low complexity, but because of the antibiotics it’s gonna be a 99213. Complexity is king with coding (I thought atleast ... what I was taught in residency in 2014)

You suggest a level 2. If you were a doc that “fell under my review” (I’m the ‘lead’ at our office) I’d question your sanity. Please tell me you aren’t billing level 2s. Haha.

That would be akin to seeing you walk through the parking lot with a bad posture and I tell you to straighten up.

 

[deleted87716]

Only of our guys says if he has to access the PDMP it’s a 4.

What would you code a rhus dermatitis as when it requires PO steroid taper? The counseling on the steroid complications would make you bump to a 4 in addition to the RX management, no? This is a 214 for me.

Depends on the patient. If they're diabetic, you'd have to consider the transient hyperglycemia that would go along with the steroids, so that would bump it to a 99214 (be sure to code for the diabetes and specify your concerns in your A&P as well).

Regardless, the new EM is going to make all these single issues 213s.

I don't think so. Complexity matters. More importantly, your ability to document complexity matters.

 

[deleted87716]

You suggest a level 2. If you were a doc that “fell under my review” (I’m the ‘lead’ at our office) I’d question your sanity. Please tell me you aren’t billing level 2s. Haha.

That would be akin to seeing you walk through the parking lot with a bad posture and I tell you to straighten up.

Pretty much. I can almost always find something else to bill for to bump it to a 99213. "Hey, how long have you had that mole?" Kidding...sort of.

 

[Bacchus]

To add something fruitful to this, here goes.

Caveat, I’m single without kids. Since the pandemic started, despite the market issues and initial productivity issues, I’ve seen a significant increase in net worth. The arrest of student loan payments (and the $0/mo still counting towards PSLF) was a god send. Combined with my discretionary spending each month being 1/3 to 1/2 what it normally is, I had a very good year. Still got bonuses. Got my productivity downfall payment given back to me (Thanks employer and the CARES Act putting our network into the black). None of this is to gloat, but to reassure you during the midst of a pandemic, if financially smart you can still grow. I’m not going to give numbers re: growth, but everything will be ok.

 

[Bacchus]

Depends on the patient. If they're diabetic, you'd have to consider the transient hyperglycemia that would go along with the steroids, so that would bump it to a 99214 (be sure to code for the diabetes and specify your concerns in your A&P as well).



I don't think so. Complexity matters. More importantly, your ability to document complexity matters.

First quote: this is the idea I got from our compliance presentation. Of course he’s presenting the rules as that division interpreted them.

Another interesting interpretation was the rule of 3 DX may not hold if you aren’t actively managing one. Eg: Parkinson disease controlled on sinemet TID, continue with Neuro.

 

[deleted87716]

First quote: this is the idea I got from our compliance presentation. Of course he’s presenting the rules as that division interpreted them.

Another interesting interpretation was the rule of 3 DX may not hold if you aren’t actively managing one. Eg: Parkinson disease controlled on sinemet TID, continue with Neuro.

It depends whether the fact that the patient has Parkinson's and is on Sinemet matters to anything else you're doing. It's all in how you document it. Actually, it always has been. I'm not sure why the new guidelines make it seem like this is different.

It's also largely irrelevant in practical terms, as anyone with Parkinson's probably has at least three other conditions that you're actively managing. So, 99214's are still easy, assuming you document properly. Many people today do not.