Billing - Benign Heme

[blackcadillacs]

Very new to attending life and trying to figure out how to bill new benign heme pts, which is currently the majority of my pts. Appreciate any help!

My issue is that I chart review the day before - I feel super uncomfortable doing it the day of, as I currently take forever looking over the chart, looking up guidelines, and also want time to reach out to others for help if I need it. I also pre-write my note the day before. But of course, this means on the day of, I have much less time to show for how long I spent on that patient, even though I spent tons of time the night before.

Any advice on this (besides just 'do it on the day of instead' which as a new attending I feel uncomfortable with)? Does anyone bill level 5 based on complexity for a new benign heme patient? Some pts have more than one problem I'm evaluating and there's tons of labs that I clearly looked through, but I don't know that it fits the bill for high complexity.

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[HemeOncHopeful19]

Hopefully we get some good discussion here from more experienced people the only level 5 visits in my benign Heme have been refractory ITP getting Rituximab.

I have been wondering if somehow reviewing the peripheral smear counts as “Indepedent interpretation of a test performed by another healthcare professional” which might help you capture more. Ditto with anticoagulation patients technically being “intensive therapy requiring monitoring”

 

[MD46]

Hi,

Depends on the type of patient but generally benign heme is a level 4
new/consult.

In my practice i usually bill level 4 for the following:

Mild to moderate anemia (IDA, CKA, Anemia of chronic disease etc)

Low or high wbc count

Low or high Hb

Low or high platelets

Low or high MCV

Elevated PT/PTT/INR

H.o already diagnosed vwd etc

Some straight forward cases of VTE

Level 5 for the following:

If severe or Hb < 8 requiring an iron infusion and or Hb < 7 requiring blood transfusion. I usually will review any endoscopy, us uterus for firboids, fobts etc and add those in the note to justify. If additional things like reactive theombocytosis, low mcv etc you can make your case stronger

Any hemophilia or similar disorder requiring factor support etc

Any ITP requiring immediate intervention

More complex VTE, will always include echo, dopplers, other relevant imaging in notes. Maybe even address smoking, age appropriate cancer screening to justify level 5

There are other things out side above mentioned for level 4-5 new visits but you get the drift


Also if you need to send a new hematological clearance or give instructions for bridging etc. always do a televisit and bill for it.

FYI

Yet to have a denied level 5
Yet to bill anything less than level 4

Hope this helps.
I am little over 5 years out now from fellowship.

All the best

 

[HemeOncHopeful19]

More complex VTE, will always include echo, dopplers, other relevant imaging in notes. Maybe even address smoking, age appropriate cancer screening to justify level 5

This one I’m curious about. I’ve tried to really pay attention to the new MDM charts and I don’t understand how smoking / age appropriate cancer screening would possibly push a level 4 visit to a level 5?

Which of the three complexity categories does that help with? In my mind for a level 5 you need 2 of:

- acute/chronic life threatening condition
- independent review of a test OR discussion with another healthcare provider
- therapy requiring intensive monitoring

 

[MD46]

PE with right heart strain, anything requiring thrombectomy etc potentially.

If you order coumadin with bridge your self and monitor INR or going to monitor INR that should cover it.

When reviewing all the echo, ct scans and dopplers it can be considered a review.

Its case by case not everything qualifies.
If I am spending loads of time digging through chart etc.

I usually will put a statement like > 75mins spent total time in care of patient. Time including but limited to review of outside and inhouse labs, scans, relevant consult notes and other records in patient chart, communicating with referring doctors and involved consultants, going over the plan with the patient and family in detail. ( have macros for these things)

Also inpatient consults for these situations will more likely be a level 5.

Like I said , no level 5 denied yet.

Honestly when you build up more oncology patient referrals and followups, its not even worth your time justifying a level 5 heme consult. You get those elsewhere more frequently.

 

[gutonc]

I look at it like this...if an M3 could answer the question on their own, it's a 99203. If it would take an M4 to do it, it's a 99204. If it actually requires a board certified hem/onc to answer the question, it's a 99205.

Most of mine are 99204s. I can count the number of truly necessary benign heme consults I've seen in the last 11 years on 2 hands and have plenty of fingers left over.

 

[Greonis]

Posting for the first time in a long time to join this thread - I'm community heme/onc, about 3 years in, and still having occasional benign heme billing struggles.

The vast majority of the benign heme consults I see end up as level 4, as I can usually drum up enough "complexity" to justify it (prior labs, medications, scans, etc...). Maybe a level 3 for something silly such as a healthy 30-something year old with "low WBCs" (WBC 3.9, flagged as low on their CBC machine because the lower cutoff of their lab is 4.0, but with otherwise normal differential and completely without symptoms). But the level 5's are where I often feel insecure about overbilling. The rare ones I confidently bill level 5 for are:

-Anemia or thrombocytopenia needing a transfusion/hospital evaluation
-ITP needing therapy immediately
-Hemolytic anemias needing therapy immediately
-Anything needing a bone marrow biopsy
-Any suspected "benign heme emergency"(eg, TMA disorder)

My most significant weak point is thrombosis (usually VTE) consult billing. They wind up taking a lot of time to review, and the visits themselves take longer than the typical benign hematology referral. With the amount of data to review (eg, CTA chest, dopplers, echo, history of prior clots, family history, various labs, prior medications, and so forth) I feel like level 5 should be easily doable, but none of them ever come to me with life-threatening issues (if they did have them, they were in the hospital and stabilized there before their office visit with me). And I have a hard time justifying "long-term monitoring" for anticoagulation, unless they are a rare patient taking warfarin and in need of INR checks. So I usually just end up making anticoagulation therapy/duration recommendations and occasionally thrombophilia labs/followup clot imaging, which all feels very "level 4" to me. Hence, that's what I usually bill for, unless I can get away with time-based billing, which is rare. But if some of you are successfully billing level 5 for those thrombosis consults based on complexity, then perhaps I need to up my coding.

 

[blackcadillacs]

Thanks for the excellent advice about complexity/MDM everyone!

Is it okay to bill level 5 based on time for benign heme? I was so slow seeing patients my first week that I easily spent an hour on seeing them + charting + looking stuff up. Some of them I even spent over 74 minutes. Epic also tracks how much time you spend in the chart, so it did check out with the tracked amount of time.

 

[gutonc]

Thanks for the excellent advice about complexity/MDM everyone!

Is it okay to bill level 5 based on time for benign heme? I was so slow seeing patients my first week that I easily spent an hour on seeing them + charting + looking stuff up. Some of them I even spent over 74 minutes. Epic also tracks how much time you spend in the chart, so it did check out with the tracked amount of time.

Time is time. Doesn't matter what you're using it on, normocytic anemia or metastatic sarcoma, time bills the same.

 

[Mehena]

Thank you for all your input. I'm also a new attending, and your advice has been very helpful,consistent with the levels I bill for. Initially, the billing compliance person suggested I should bill more level 3 codes, possibly comparing me to PCPs rather than oncologists. However, now EPIC shows that my coding is consistent with other oncologists in my practice. I didn't find their initial guidance very helpful.

In the field of medicine, we often encounter various cliches and repeated phrases, and one of them is "financial toxicity," especially in the context of cancer care. I didn't go to medical school and accumulate student loans to become a charity worker, but I am acutely aware of the financial burdens faced by people on fixed incomes and those on the lower economic rungs, as my own family has experienced such challenges.

It appears that I may either be practicing in a population with limited financial resources or in a setting where the value of healthcare is not fully appreciated, or perhaps both. For example, I have breast cancer patients whom I see every four to six months. They come to the clinic with expensive purses, discussing upcoming vacations or plans for fancy dinners (although this may be an exaggeration, as I don't always have time to inquire about these details). However, they also express dissatisfaction with copayments that amount to the price of a meal, and some seem to expect a free visit.
How can I reconcile these disparities and prevent iatrogenic bankruptcy while ensuring fair compensation for my efforts? Is this a problem worth considering and getting involved in?

 

[gutonc]

Thank you for all your input. I'm also a new attending, and your advice has been very helpful,consistent with the levels I bill for. Initially, the billing compliance person suggested I should bill more level 3 codes, possibly comparing me to PCPs rather than oncologists. However, now EPIC shows that my coding is consistent with other oncologists in my practice. I didn't find their initial guidance very helpful.

I've only ever asked coders one question: "Does my documentation support my billing?". If the answer is yes (and it always has been), I move on with my life. If you can justify your billing, you're in the clear and nothing else matters. Your job is not to make sure your coders get their annual bonus.

In the field of medicine, we often encounter various cliches and repeated phrases, and one of them is "financial toxicity," especially in the context of cancer care. I didn't go to medical school and accumulate student loans to become a charity worker, but I am acutely aware of the financial burdens faced by people on fixed incomes and those on the lower economic rungs, as my own family has experienced such challenges.

It appears that I may either be practicing in a population with limited financial resources or in a setting where the value of healthcare is not fully appreciated, or perhaps both. For example, I have breast cancer patients whom I see every four to six months. They come to the clinic with expensive purses, discussing upcoming vacations or plans for fancy dinners (although this may be an exaggeration, as I don't always have time to inquire about these details). However, they also express dissatisfaction with copayments that amount to the price of a meal, and some seem to expect a free visit.
How can I reconcile these disparities and prevent iatrogenic bankruptcy while ensuring fair compensation for my efforts? Is this a problem worth considering and getting involved in?

This is so far outside the confines of this discussion I'm not sure we should even continue it here. But it's a great question, just not one that you, or I, or anyone who doesn't fully control both houses of Congress, the Supreme Court and the Executive branch could even start to make a dent in. You're basically asking, how can I, @Mehena, fix our broken healthcare system in the US. The short answer is that you can't. The longer answer is that it will take a lot of people like you a long time to make a dent in it, but I hope you give it a shot.

Also, entitled people are entitled. You're not going to fix that ever. My current position is in a "rural" area (it's rural the same way that Jackson Hole, WY is rural) where ~1/4-1/3 of the population is phenomenally wealthy and the rest are small business owners, service industry and agricultural workers. The latter group doesn't complain about anything and sets up payment plans. The former group complains about everything and sets up lawsuits. Welcome to America.