New E and M coding guidelines

[drrosenrosen]

Our compliance department specifically told us that we candouble dip.

1. How is ordering and reviewing a test on the date of the encounter with the patient handled in regard to determining the level of medical decision making?

In the data column, the ordering of each unique test and the reviewing of each unique test are considered separately. An example would be, if a provider ordered an EKG, and later the same day reviewed the results, this would be considered as the ordering of 1 unique test and reviewing of 1 unique test. Additionally, if the provider performed an independent interpretation of the EKG – but was not the billing provider for the interpretation – this would meet the requirements for independent interpretation. Two of the 3 areas – Problems Addressed, Data, and Risk – must support the overall level of MDM. Data alone does not support the overall level.

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[clubdeac]

Wow it’s amazing how many different interpretations are being presented. So much for making things easier. Thanks CMS and AMA

 

[geauxg8rs]

Wow it’s amazing how many different interpretations are being presented. So much for making things easier. Thanks CMS and AMA

I’m from the government and here to help

 

[deleted875186]

Our compliance department specifically told us that we candouble dip.

1. How is ordering and reviewing a test on the date of the encounter with the patient handled in regard to determining the level of medical decision making?

In the data column, the ordering of each unique test and the reviewing of each unique test are considered separately. An example would be, if a provider ordered an EKG, and later the same day reviewed the results, this would be considered as the ordering of 1 unique test and reviewing of 1 unique test. Additionally, if the provider performed an independent interpretation of the EKG – but was not the billing provider for the interpretation – this would meet the requirements for independent interpretation. Two of the 3 areas – Problems Addressed, Data, and Risk – must support the overall level of MDM. Data alone does not support the overall level.

This seems to be completely in disagreement with the actual wording of the guidelines.

in any case, as pain physicians I don’t think we will ever be using the “data” section to be honest. Seems like two illnesses with exacerbation and risk will be the easiest way to consistently document the level visit.

 

[painfree23]

Just bill on time. Keeps it simple. Now the time can be used for writing notes, coordinating care, etc.

 

[gaseous_clay]

Wow it’s amazing how many different interpretations are being presented. So much for making things easier. Thanks CMS and AMA

I attended Palmetto’s (our regional CMS admin contractor) webinar on Thursday and asked them many of these questions. They read their slides word-for-word, ignored me, and answered two rudimentary questions from the audience. They were very clueless.

 

[cowboydoc]

Just bill on time. Keeps it simple. Now the time can be used for writing notes, coordinating care, etc.

The billing for time is far less favorable in the new set up, unless you take a really long time to write notes.

 

[afob100]

The billing for time is far less favorable in the new set up, unless you take a really long time to write notes.

If you have 30 min scheduled new visits, I don't think it's too much of a stretch to say that you spent 45 min including non-face to face time to bill level 4. I guess it just depends on the set up/number of patients per day.

 

[Ducttape]

don't bill on time for a significant portion of patients.

apparently, billing on time puts one more at risk for audit. and much easier to check. if you are seeing 20 patients a day and bill all level 4 visits - then you are working 10 + hours a day.

 

[afob100]

So I read through the AMA guidelines again.

It seems very easy to get to level 4 billing if you decide to perform an injection or prescribe/refill a prescription medication

Example note:
___________________________________________
Assessment/Diagnosis:
1. Lumbar radiculopathy
Problem Complexity: exacerbation/progression of symptoms requiring further care (moderate).

Plan/Risk:
1. Plan for lumbar ESI - risks/benefits of the procedure were discussed. (moderate risk)

OR

1. Prescribed gabapentin - risks/benefits discussed.
______________________________________________________

Just wanted to confirm that both of these will be level 4?

Alternatively, you can list 2 stable chronic problems - ie SI joint pain, Lumbar spondylosis, stable. refilled duloxetine - risks/benefits discussed -> level 4. correct?

 

[mid|ine]

1. Prescribed gabapentin - risks/benefits discussed.
______________________________________________________

Just wanted to confirm that both of these will be level 4?

Alternatively, you can list 2 stable chronic problems - ie SI joint pain, Lumbar spondylosis, stable. refilled duloxetine - risks/benefits discussed -> level 4. correct?

You can't just list 2 stable conditions, you have to make and DOCUMENT some medical decisions regarding them

SI Joint pain - consider SI joint injection in the future
Lumbar spondylosis - stable post RFL, plan repeat RFL >6 months from the past when pain returns

 

[Drd105]

You can't just list 2 stable conditions, you have to make and DOCUMENT some medical decisions regarding them

SI Joint pain - consider SI joint injection in the future
Lumbar spondylosis - stable post RFL, plan repeat RFL >6 months from the past when pain returns

I have been listing the stable conditions, and if no injections are planned I write 'will refill 'xyz med'' under each of them.
Even if the same med covers both of my problems (i.e., knees and low back), I am still addressing both problems in the HPI/exam and determining to proceed with refills.

 

[Drd105]

I attended Palmetto’s (our regional CMS admin contractor) webinar on Thursday and asked them many of these questions. They read their slides word-for-word, ignored me, and answered two rudimentary questions from the audience. They were very clueless.

A week ago I asked my billing person to contact Palmetto for their definition of 'medication management' (because I saw a random youtube video from a coder who said you have to play by the definition of that according to each individual contractor) and she has not heard anything yet. Did they go over that definition in the webinar?

 

[nynydoc]

This is very true. And I use this often. Obesity is never stable.

Take it from someone that is also boarded by the American Board of Obesity Medicine.
Sadly, unless your a primary care IM/FP, surgeon, or a NP/PA, Medicare and some commercials ins do not recognize other specialists to address or treat treat obesity. So I just talk about obesity as a secondary diagnosis. Have passed every internal audit.

Do you find any benefit from being boarded by ABOM? I thought about sitting for those boards

 

[gaseous_clay]

A week ago I asked my billing person to contact Palmetto for their definition of 'medication management' (because I saw a random youtube video from a coder who said you have to play by the definition of that according to each individual contractor) and she has not heard anything yet. Did they go over that definition in the webinar?

 

[gaseous_clay]

A week ago I asked my billing person to contact Palmetto for their definition of 'medication management' (because I saw a random youtube video from a coder who said you have to play by the definition of that according to each individual contractor) and she has not heard anything yet. Did they go over that definition in the webinar?

Of course not. They just read their slides, which were word for word from that chart I posted earlier.

 

[Drd105]

Of course not. They just read their slides, which were word for word from that chart I posted earlier.

LOL to steve! well then, if they won't clarify, I feel even better about my interpretation which includes refilling prescription meds. Our coding 'expert' emailed us that chart on 1/2/21 with: "Remember, medicare guidelines change today." and that is the extent of the internal professional help I have gotten on the matter (hence my immense gratitude for those who have helped me here).

 

[cowboydoc]

I got a message from our coder that my -15 was being down coded to a -14 because the autocoder algorithm said so.

It was a legacy SCI that I still see, an automatic level 5 nearly every 6 month visit. I responded, “Please tell me how to document this visit to meet new guidelines to bill a -15, as this is a level 5 visit if there ever were one.”...crickets!

I documented med changes for spasticity, dermatology consult for failure of multiple topicals, updated MRI to r/o syrinx with Neuro decline, modified bowel program.🤦🏽

In retrospect, I should have just put a time blurb and been generous about how long it took to dictate. In unrelated news, I’m actively working on unloading my legacy SCI patients to more qualified doctors.

 

[Drd105]

I got a message from our coder that my -15 was being down coded to a -14 because the autocoder algorithm said so.

It was a legacy SCI that I still see, an automatic level 5 nearly every 6 month visit. I responded, “Please tell me how to document this visit to meet new guidelines to bill a -15, as this is a level 5 visit if there ever were one.”...crickets!

I documented med changes for spasticity, dermatology consult for failure of multiple topicals, updated MRI to r/o syrinx with Neuro decline, modified bowel program.🤦🏽

In retrospect, I should have just put a time blurb and been generous about how long it took to dictate. In unrelated news, I’m actively working on unloading my legacy SCI patients to more qualified doctors.

there should be a level much higher than 5 for that, thank you.

 

[painfree23]

don't bill on time for a significant portion of patients.

apparently, billing on time puts one more at risk for audit. and much easier to check. if you are seeing 20 patients a day and bill all level 4 visits - then you are working 10 + hours

Working 10 hours a day as a physician doesn’t seem that “red flaggy”

 

[knoxdoc]

Does anyone know if ordering PT counts for anything? When we see a patient and cannot get an MRI due to insurance guidelines, PT is often required and it seems that should count somewhere. Thanks.

 

[door_to_balloon_knot]

Does anyone know if ordering PT counts for anything? When we see a patient and cannot get an MRI due to insurance guidelines, PT is often required and it seems that should count somewhere. Thanks.

Counts the same as OTC med recommendations - low risk in MDM.

 

[BobBarker]

I billed a level 5 f/u today.

weaned opioids, changed drug
Rx narcan
Symproic sample and rx
Ordered cervical MRI
Referred for bil UE emg - cervical radic vs cubical tunnel
UDS
Checked pmp

 

[buddababa]

I billed a level 5 f/u today.

weaned opioids, changed drug
Rx narcan
Symproic sample and rx
Ordered cervical MRI
Referred for bil UE emg - cervical radic vs cubical tunnel
UDS
Checked pmp

Interesting. Per my hospital billing department that’s a level 4. Level 5 basically means there unstable in the sense that they’re withdrawing or have angina and you need to transfer to ER.
Also, isn’t billing more level 5 a risk for audit?

 

[door_to_balloon_knot]

Interesting. Per my hospital billing department that’s a level 4. Level 5 basically means there unstable in the sense that they’re withdrawing or have angina and you need to transfer to ER.
Also, isn’t billing more level 5 a risk for audit?

I would agree with level 5. Level 5 for complexity of problem depending on how it’s worded but certainly severe chronic pain could be argued to be a threat to bodily function. Level 4 for data with the tests and labs ordered. Level 5 risk for intensive drug monitoring for toxicity.

 

[deleted875186]

Interesting. Per my hospital billing department that’s a level 4. Level 5 basically means there unstable in the sense that they’re withdrawing or have angina and you need to transfer to ER.
Also, isn’t billing more level 5 a risk for audit?

I think the risk is billing many level 5 visits.

I’d like to think that since these guidelines are somewhat subjective, that any level 5 like the one listed above would be reasonable.

 

[clubdeac]

I would agree with level 5. Level 5 for complexity of problem depending on how it’s worded but certainly severe chronic pain could be argued to be a threat to bodily function. Level 4 for data with the tests and labs ordered. Level 5 risk for intensive drug monitoring for toxicity.

Using the old rules this would be level 5 for complexity or number of problems but that doesn’t appear to be true anymore under the new rules. My understanding is that under the new rules level 5 is near impossible in our field

 

[door_to_balloon_knot]

Using the old rules this would be level 5 for complexity or number of problems but that doesn’t appear to be true anymore under the new rules. My understanding is that under the new rules level 5 is near impossible in our field

What I have written is in accordance with 2021 guidelines from CMS. I truly believe it would pass muster. Or your billers need to be better.

Here’s the cheat sheet card:

Google Image Result for https://namas.co/wp-content/uploads/2020/06/MDM-table-2.png

images.app.goo.gl

Edit: also if I’m wrong please point it out, serious. We’re all here to learn.

 

[Agast]

My approach to not getting audited:

 

[Drd105]

If you have moderate/4 for the problem category (ignoring data) and the ONLY plan is to do a hip inj, would you go with moderate/4 for the risk or low/3 for the risk? or would you base that vs comorbidities like DM/risk of hyperglycemia?

I feel like if the only plan is TPIs (anywhere that is not near the lungs/neck vessels) would be low/3, and I consider spine injections to be mod/4 risk but joints are a little bit of a gray area.

 

[deleted875186]

If you have moderate/4 for the problem category (ignoring data) and the ONLY plan is to do a hip inj, would you go with moderate/4 for the risk or low/3 for the risk? or would you base that vs comorbidities like DM/risk of hyperglycemia?

I feel like if the only plan is TPIs (anywhere that is not near the lungs/neck vessels) would be low/3, and I consider spine injections to be mod/4 risk but joints are a little bit of a gray area.

I personally would say level 4 for a hip joint injection.

 

[ateria radicularis magna]

Sorry if already covered... but why does the risk of a procedure planned/discussed during an ov change the coding of the ov? Please talk to me like I’m in 4th grade so I can understand. I don’t get it. I feel like I’m missing something.

 

[deleted875186]

Sorry if already covered... but why does the risk of a procedure planned/discussed during an ov change the coding of the ov? Please talk to me like I’m in 4th grade so I can understand. I don’t get it. I feel like I’m missing something.

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf

Look at the table, you code the visit based on the highest level reached by 2 of the three “elements”. The last element is titled “risk of complications, morbidity, or mortality associated with treatment of the patient”. Examples provided by AMA in their description is given below. Ou don’t need to necessarily diagnose the patient with something dangerous or high risk with these guidelines, or do a high risk treatment, just the act of considering these things leads to a higher medical decision making. For example, working up a simple problem seen every day could require a high level of medical decision making to come to the correct diagnosis and exclude more dangerous things. So if you considered doing a riskier treatment for a patient, say consider an injection or surgery, but discuss with patient, and then ultimately choose a course of PT, yoj get credit for moderate level.

the subjective part is deciding what treatment is moderate level. From the examples AMA gives, sounds like prescribing a Med, doing any procedure, etc, is mod level.


Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
• Prescription drug management
• Decision regarding minor surgery with
identified patient or procedure risk
factors
• Decision regarding elective major
surgery without identified patient or
procedure risk factors
• Diagnosis or treatment significantly
limited by social determinants of health

 

[Kissmyabjj]

PN&R and Sports Med guy here who also does basic lumbar fluoro.

I schedule chronic spine pain initial evals for 1 hour. I spend a lot of time on education, reviewing their images, discussing the procedure I am going to perform (when I am considering one) and teaching activity modifications during the visit. If it’s someone with good kinesthetic awareness or with only 1-2 easy-to-learn rehab issues, I usually won’t send them to PT. Instead I will teach them the appropriate exercises myself, and send them a personalized HEP.

So the change has been great for me. Before I was having to bill 90% of these visits as level fours, and maybe 10% as level fives. Now I can effectively bill all of them as level fives. I just keep track of my time in the room. Since you can’t use the history and physical examination components anymore to bump up the billing level, There’s really no incentive for me to try to squeeze in two 30-minute evals per hour that I used to be able to bill as a level 4, but now usually have to bill as a level 3 based up MDM criteria alone.

 

[deleted875186]

PN&R and Sports Med guy here who also does basic lumbar fluoro.

I schedule chronic spine pain initial evals for 1 hour. I spend a lot of time on education, reviewing their images, discussing the procedure I am going to perform (when I am considering one) and teaching activity modifications during the visit. If it’s someone with good kinesthetic awareness or with only 1-2 easy-to-learn rehab issues, I usually won’t send them to PT. Instead I will teach them the appropriate exercises myself, and send them a personalized HEP.

So the change has been great for me. Before I was having to bill 90% of these visits as level fours, and maybe 10% as level fives. Now I can effectively bill all of them as level fives. I just keep track of my time in the room. Since you can’t use the history and physical examination components anymore to bump up the billing level, There’s really no incentive for me to try to squeeze in two 30-minute evals per hour that I used to be able to bill as a level 4, but now usually have to bill as a level 3 based up MDM criteria alone.

Seems like you should be able to get to a level 4 for the 30 min evals too.

almost always will review theee pieces of data for a new visit, and as long as they have two chronic illnesses yojr good.

back pain and sciatica-> lumbar spondylosis, lumbar radic -> review external notes from PCP, review X-ray, review MRI, level 4

 

[Yo GabbaPentin]

Sorry if I missed this. But did any billing rules change for private insurance?

 

[Laryngospasm]

I billed a level 99215 today too.. 45 min spent on reviewing imaging, discussing weight loss, planning ESi and discussing surgery. Also don’t forget charting and discussing patient with nurse. They keep us fighting over peanuts and we are so henpecked we are afraid to Bill what we deserve. Oh medicine.. what a crap show you have become. Meanwhile. My plumber” that’ll be 300$ to unclog the drain.. “ after 20 min of work.

 

[NJPAIN]

I billed a level 99215 today too.. 45 min spent on reviewing imaging, discussing weight loss, planning ESi and discussing surgery. Also don’t forget charting and discussing patient with nurse. They keep us fighting over peanuts and we are so henpecked we are afraid to Bill what we deserve. Oh medicine.. what a crap show you have become. Meanwhile. My plumber” that’ll be 300$ to unclog the drain.. “ after 20 min of work.

Exactly. But you have been demoralized enough to accept LESS than what your plumber received to unclog a drain to stick a needle in someone's neck. Sad. Very sad.