How do you know when associates are getting screwed

[air bud]

Let's start with this. Also posting to memes but this is related to the conversation.

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[619]

New patient comes in with complain of bilateral heel pain for 3 months. You do your usual workup magic and diagnose patient with bilateral plantar fasciitis. You take B/L x-ray and give B/L steroid injection and also dispense DME. Is this an obvious e/m 99204 (level 4 visit)?
Asking because it is bilateral or do some folks still bill a 99203 because they are afraid of an audit.

 

[PMG03470]

New patient comes in with complain of bilateral heel pain for 3 months. You do your usual workup magic and diagnose patient with bilateral plantar fasciitis. You take B/L x-ray and give B/L steroid injection and also dispense DME. Is this an obvious e/m 99204 (level 4 visit)?
Asking because it is bilateral or do some folks still bill a 99203 because they are afraid of an audit.

I would like to know what people do as well. Some people I talk to do 99204, however my past employer said basically never bill anything ending in a 4 unless it is a diabetic train wreck with a limb threatening wound/gangrene

 

[wakaflocka88]

New patient comes in with complain of bilateral heel pain for 3 months. You do your usual workup magic and diagnose patient with bilateral plantar fasciitis. You take B/L x-ray and give B/L steroid injection and also dispense DME. Is this an obvious e/m 99204 (level 4 visit)?
Asking because it is bilateral or do some folks still bill a 99203 because they are afraid of an audit.

I bill quite a few level 4s. Recently had an audit from the billers in my MSG and no issues. The billers say I should be billing more level 4s

 

[shadesofgrey]

I also am routinely harassed by the billing department to bill more level 4's.

 

[heybrother]

New patient comes in with complain of bilateral heel pain for 3 months. You do your usual workup magic and diagnose patient with bilateral plantar fasciitis. You take B/L x-ray and give B/L steroid injection and also dispense DME. Is this an obvious e/m 99204 (level 4 visit)?
Asking because it is bilateral or do some folks still bill a 99203 because they are afraid of an audit.

What problem complexity are you selecting out of the 1st column. That really is the answer to this. If you think this is a "new undiagnosed problem with uncertain progression" then I guess you've got a 4 with prescription drug management.

 

[619]

What problem complexity are you selecting out of the 1st column. That really is the answer to this. If you think this is a "new undiagnosed problem with uncertain progression" then I guess you've got a 4 with prescription drug management.

Basically most things we see fall under this category. Examples are heel pain, ingrown toenail, warts, ulcers, ankle sprain, bunion, hammertoes, neuroma etc. I can't think of anything that does not have an uncertain progression maybe except routine nail care and callus.
With the new E/M changes, podiatry should be billing more level 4 in general.

 

[heybrother]

Basically most things we see fall under this category. Examples are heel pain, ingrown toenail, warts, ulcers, ankle sprain, bunion, hammertoes, neuroma etc. I can't think of anything that does not have an uncertain progression maybe except routine nail care and callus.
With the new E/M changes, podiatry should be billing more level 4 in general.

 

[Weirdy]

View attachment 360935

High risk of morbidity- not exactly plantar fasciitis even if it is a new undiagnosed problem?

Is there a severity scale to billing an EM4?

 

[dtrack22]

I would like to know what people do as well. Some people I talk to do 99204, however my past employer said basically never bill anything ending in a 4 unless it is a diabetic train wreck with a limb threatening wound/gangrene

Your past employer sounds like an older podiatrist…

I had to fight with an in house biller for a podiatrist about level 4s and that was before the new e/m criteria

The big thing with the above example given is the “uncertain prognosis” (not uncertain progression).

“Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.”

Vs

“Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast. “

Which one better described plantar fasciitis when you did not document anything else in your plan as a differential diagnosis? You will get paid if you bill a level 4, but “uncertain prognosis” does not mean, “I’m not sure if it will get better or not.” It means, there are possible conditions that you have considered that have significant morbidity or increased mortality risks. Someone go ahead and make the case that new presentation plantar fasciitis (before you have made the decision to perform surgery) really fits that criteria…

A pigmented skin lesion or even a wart (I had one that was squamous cell recently) is a better example of pathology that would fit the uncertain prognosis problem point criteria than plantar fasciitis

 

[air bud]

New patient comes in with complain of bilateral heel pain for 3 months. You do your usual workup magic and diagnose patient with bilateral plantar fasciitis. You take B/L x-ray and give B/L steroid injection and also dispense DME. Is this an obvious e/m 99204 (level 4 visit)?
Asking because it is bilateral or do some folks still bill a 99203 because they are afraid of an audit.

I am not convinced this a 4 if unilateral based on your description....and I like to think of myself as aggressive.

 

[air bud]

Uncertain progression is like is this mass going to be cancer? Your heel pain has a few ways it can go.

 

[air bud]

Your past employer sounds like an older podiatrist…

I had to fight with an in house biller for a podiatrist about level 4s and that was before the new e/m criteria

The big thing with the above example given is the “uncertain prognosis” (not uncertain progression).

“Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected.”

Vs

“Undiagnosed new problem with uncertain prognosis: A problem in the differential diagnosis that represents a condition likely to result in a high risk of morbidity without treatment. An example may be a lump in the breast. “

Which one better described plantar fasciitis when you did not document anything else in your plan as a differential diagnosis? You will get paid if you bill a level 4, but “uncertain prognosis” does not mean, “I’m not sure if it will get better or not.” It means, there are possible conditions that you have considered that have significant morbidity or increased mortality risks. Someone go ahead and make the case that new presentation plantar fasciitis (before you have made the decision to perform surgery) really fits that criteria…

A pigmented skin lesion or even a wart (I had one that was squamous cell recently) is a better example of pathology that would fit the uncertain prognosis prob

Didnt read this before posting so my answer agrees with dtrack.

lem point criteria than plantar fasciitis

 

[619]

Uncertain progression is like is this mass going to be cancer? Your heel pain has a few ways it can go.

Heel pain could be bone tumor of the calcaneus. Rare but can happen.

 

[heybrother]

Heel pain could be bone tumor of the calcaneus. Rare but can happen.

Yes, but you would be doing a totally different work-up and you wouldn't be injecting them. Are you going to put something in your note saying - oh, there's a low chance this could be a bone tumor. Are you going to suggest it to the patient and freak them out when you know that isn't what it is?

There's an obsession on this forum for calling things something more than it is - a higher level code or a 25 when the whole point of these things is they are to be earned by your work-up and MDM.

 

[dtrack22]

Heel pain could be bone tumor of the calcaneus. Rare but can happen.

So how did you address this differential diagnosis in your treatment plan? Did you just acknowledge it? Or if your concern is that this legitimately could be a tumor, did you order advanced imaging?

 

[HaimFeldman]

To put this thread somewhat back on topic, if you're an associate getting screwed over in a private practice, and you're on your way out the door, every new patient is a 99202 and every follow up is a 99212 and there are no in-office procedure codes.

 

[619]

To put this thread somewhat back on topic, if you're an associate getting screwed over in a private practice, and you're on your way out the door, every new patient is a 99202 and every follow up is a 99212 and there are no in-office procedure codes.

Savage 100% hahahaha.

Especially when you are not close in hitting any bonus threshold. Might as well sink the ship while you are under.

 

[PatchAdamsFan]

I bill a fair amount of level 4 E/M codes, some based on MDM guidelines and some on time-based requirements. Don't forget about the time component. It is either/or, not both. When billing on time, I personally find it pretty easy hitting 30 min level 4 E/M on a f/u non-straightforward patient based on what is actually included in the time component -

Time inclusions (has to be done the day of encounter, no more of the >50% has to be face-to-face nonsense):
- preparing to see the patient (eg, review of tests/imaging, other provider notes)
- obtaining and/or reviewing separately obtained history
- performing a medically appropriate examination and/or evaluation
- counseling and educating the patient/family/caregiver
- ordering medications, tests, or procedures
- referring and communicating with other health care professionals (when not separately reported)
- documenting clinical information in the electronic or other health record (I.e. writing your note)
- independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
- care coordination (not separately reported)

 

[air bud]

So how did you address this differential diagnosis in your treatment plan? Did you just acknowledge it? Or if your concern is that this legitimately could be a tumor, did you order advanced imaging?

Just like other times when you use the description in your plan then by that account you should be saying in your plan this is an uncertain diagnosis and doing appropriate workup. Just like when I say we discussed medication management when putting somebody on a steroid. Those are words exactly from the CMS description. And these are the foundation upon which you Bill a higher code so do the same for an uncertain prognosis

the best way to avoid problems with billing is to think out loud on paper so there is no misunderstanding of what you were trying to do

 

[Shiyuan]

I have a template that I use that includes total time spent (prepping, reviewing vitals/labs, face time w/ pt, note writing, etc.). From what my biller tells me the medical decision making matches me billing level 4s (and once in a GREAT while level 5s). No issues thus far.

 

[bloxxeeey]

Where do people learn billing, I feel like it's the one thing attendings don't want to talk about or discuss in residency. I also

20 patients per day, 4 days per week, 48 weeks out of the year, $130 PPV…$499k in collections. If overhead is 40% you’re grossing $300k. If overhead is 50%, $250k.

$100 per patient (or encounter, really) is low.

Realistically is it possible to get $130 per visit. It seems like visits alone mostly add up to less than $100. It almost seems abnormal for us to bill more than $100 for a visit unless its a new visit with x-rays etc.

 

[AttackNME]

Where do people learn billing, I feel like it's the one thing attendings don't want to talk about or discuss in residency. I also

Realistically is it possible to get $130 per visit. It seems like visits alone mostly add up to less than $100. It almost seems abnormal for us to bill more than $100 for a visit unless its a new visit with x-rays etc.

Easy. Everyone in my group is at least 150, the limb salvage ones are 200+ per patient

 

[619]

Realistically is it possible to get $130 per visit. It seems like visits alone mostly add up to less than $100. It almost seems abnormal for us to bill more than $100 for a visit unless its a new visit with x-rays etc.

New patient for heel pain! X-ray, injection and DME is wayyyyy over $130. Sure if you build your practice around nail care then $130 is a far reach.

 

[AttackNME]

Where do people learn billing, I feel like it's the one thing attendings don't want to talk about or discuss in residency.

Being in private practice, I do have residents that scrub with me and sometimes spend time in my office. I try to teach them billing and coding and all the rules of the modifiers. Usually they don’t remember, and no one bothers to study this stuff. Most residents just push it under the rug and hope they’ll just figure it out after residency.

 

[Redsting]

It’s a 4 part series. Enjoy.

1. He's in the OR, you know he is serious
2. At least he isn't wearing a stethoscope
3. He is very proud to have hired "dozens" of podiatrists

 

[HaimFeldman]

1. He's in the OR, you know he is serious
2. At least he isn't wearing a stethoscope
3. He is very proud to have hired "dozens" of podiatrists

At least one every year he's been in practice!

 

[NatCh]

Where do people learn billing, I feel like it's the one thing attendings don't want to talk about or discuss in residency. I also

Realistically is it possible to get $130 per visit. It seems like visits alone mostly add up to less than $100. It almost seems abnormal for us to bill more than $100 for a visit unless its a new visit with x-rays etc.

I can see how you'd be lacking training on billing and coding. I'm not sure how much of it would even make sense until you start doing it though. If someone told you, "For that ingrown toenail procedure bill a 99203-25, 11750-TA, and A4550, all paired to ICD10 L60.0 you'd probably be wondering WTH did he just say? We kind of learn as we go.

It's quite realistic to collect more than $130 per visit. The last time I checked I think I average over $200 per encounter. It comes with being a procedure-heavy profession versus a counseling-heavy profession like primary care.

 

[Greylo's Anatomy]

I can see how you'd be lacking training on billing and coding. I'm not sure how much of it would even make sense until you start doing it though. If someone told you, "For that ingrown toenail procedure bill a 99203-25, 11750-TA, and A4550, all paired to ICD10 L60.0 you'd probably be wondering WTH did he just say? We kind of learn as we go.

It's quite realistic to collect more than $130 per visit. The last time I checked I think I average over $200 per encounter. It comes with being a procedure-heavy profession versus a counseling-heavy profession like primary care.

Yep, that's the field I'm going into, haven't taken a coding class yet, and the bolded looks like gibberish an angry comic book character would yell.

 

[Boba Foot]

I can see how you'd be lacking training on billing and coding. I'm not sure how much of it would even make sense until you start doing it though. If someone told you, "For that ingrown toenail procedure bill a 99203-25, 11750-TA, and A4550, all paired to ICD10 L60.0 you'd probably be wondering WTH did he just say? We kind of learn as we go.

It's quite realistic to collect more than $130 per visit. The last time I checked I think I average over $200 per encounter. It comes with being a procedure-heavy profession versus a counseling-heavy profession like primary care.

What's this A4550 business?

 

[Pronation]

What's this A4550 business?

90% of insurances will deny dressing supplies. But hey, if it’s already auto populated in the template…