Opiate billing

[SommeRiver]

Man! If clinical practice ever fails you I’m sure an insurance carrier would hire you in a heart beat!

Look man, I get it but disagree with it.

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[Ferrismonk]

1. If you want to throw money away, that's up to you. Feel free to bill a 99213 as much as you want.
2. Changing all billing from a 99213 to a 99214 won't get you to baller range, it'll get you to PCP range.
3. I have no qualms about billing a 99214 if the documentation is there and neither should you. I didn't make the rules for billing/payment, I just follow them. If you feel it's an ethics thing, I respect that, but personally I would rather throw in a free SI injection or epidural from time to time for those who need it as my charity work rather than underbill.
4. The insurance carriers are doing everything they can to reduce costs and deny care that we often think is appropriate. I'm not going to voluntarily give them more money for no good reason.
5. DDD is largely used for disks and means pretty much nothing other than "bad stuff". Spondylosis includes the posterior elements and for all practical purposes means facetogenic pain.
6. We have a bazillion BS diagnoses with associated ICD-10 codes, but they exist for a reason. CMS and the other insurances want them, so I give them to play the game. In a utopian world, I could just say facetogenic low back pain and my plan. But instead I need to add FMHx, ROS, PQRS criteria, and a ton of other BS just to get paid. It's the world we live in.

 

[Ducttape]

it is fine to bill primarily level 3s.

in fact, apparently, we should be doing mostly level 3 visits. Level 4 shouldn't be your default for all visits, but if you can justify them with your documentation, go ahead. at roughly $35 difference, it can add up.

billing level 4 is not wrong. neither is billing level 5, but honestly, the only times I have billed a level 5 have been when there is a visible disagreement with the patient that I can specifically document that I spent over 25 minutes "in counselling", for example how using illicit methadone for a paper cut is improper, and that's why I wont prescribe it for them.

remember time based billing can always be done, although somewhere I read that shouldn't be the primary billing determinant...

 

[Pain Applicant1]

you guys are overthinking it.
I bill a level 4 for everything but a f/u in which the patient did great after PT or a procedure, and doesn't need anything from me for a while.

Never had a problem with these level 4s in over a decade of practice.

They go after people billing level 5s. What we do is level 4, 90% of the time in comparison with a 5 min ortho visit which is clearly a level 3.

It's not overthinking it to want to do it right but you're probably right, too many level 4s probably won't trigger an audit although you never know.

 

[Pain Applicant1]

opioid therapy and risk of opioid therapy should qualify for a level 4 visit, if you are reviewing the 5 As...

i think you are making a lot more out of the complexities of billing 99214 and E/M University, the way it is stated, is too confusing.


These visits must meet two of three key components listed below:

	History	Exam	Medical decision making
99213 key components	Expanded problem focused	Expanded problem focused	Low
99214 key components	Detailed	Detailed	Moderate

if you state "chronic severe (8 out of 10) radicular lower back pain without bowel or bladder dysfunction, worse with walking", you have 5-6 elements of HPI in 1 sentence.

see the examples given in this article for moderate complexity for medical decision making.
99213 or 99214? Three Tips for Navigating the Coding Conundrum

btw, "chronic lower back pain" is itself the BS diagnosis. the others are verifiable on imaging and advanced imaging. i would not rely on "back pain" to "justify" opioid prescribing. spondylosis without radiculopathy; degenerative spinal stenosis, lumbar; failed back syndrome; V91.07 (burn due to water skis on fire) are more apropos.

History is easy to get to Detailed but Exam is not, unless you do an extended exam on follow-ups which I'm not sure why it would be necessary on an opioid refill. That leaves medical decision making which is where the confusion is.

 

[Pain Applicant1]

Patient previously seen for low back pain. Comes in for neck pain - new problem, additional work up planned, 4 points. Get x ray, review, decide to get MRI. Probably also reviewed old notes. 4+ points for data review. Given we probably also discussed the low back, that’s multiple chronic problems as well

These points are not cumulative and you're mixing up the different sections. There are no points in the History section and a review of old notes is only 1 point unless you summarize, then it's 2. During an audit, the auditors go through every detail and check off what you've documented. If they find a discrepancy in 10 charts out of 20 they audited, they can extrapolate and request a return of 50% of whatever they have paid you for everything.

 

[Pain Applicant1]

During residency and fellowship, when you guys were kissing the *** of the attendings I was sucking up to the billing staff to learn this stuff. I kept their numbers after I graduated and called them at times. If I worked late, I would call over to the west coast hospitals and ask to speak to the billing department. I would say I was a resident and needed help with billing. I was a resident at one time, just not at their hospital so I wasn't technically lying.

 

[callmeanesthesia]

These points are not cumulative and you're mixing up the different sections. There are no points in the History section and a review of old notes is only 1 point unless you summarize, then it's 2. During an audit, the auditors go through every detail and check off what you've documented. If they find a discrepancy in 10 charts out of 20 they audited, they can extrapolate and request a return of 50% of whatever they have paid you for everything.

That’s just for the complexity score. Comprehensive history is easy enough - the MA fills out all the PMH/SH/FH/ROS and I review the paperwork. If it’s a new problem evaluation they get a comprehensive MSK exam. That alone allows billing level 5 on a follow up since you only need 2/3 (history, physical, complexity) for a follow up. However, since they more generally direct that complexity should be the primary driver of level of service, as I said above, new problem additional workup, and either a high risk score (justifiable if doing certain injections like CESI in my mind - discography is on their list of high risk diagnostic tests) or 4 points for review of data gets you to high complexity as well.

 

[Pain Applicant1]

That’s just for the complexity score. Comprehensive history is easy enough - the MA fills out all the PMH/SH/FH/ROS and I review the paperwork. If it’s a new problem evaluation they get a comprehensive MSK exam. That alone allows billing level 5 on a follow up since you only need 2/3 (history, physical, complexity) for a follow up. However, since they more generally direct that complexity should be the primary driver of level of service, as I said above, new problem additional workup, and either a high risk score (justifiable if doing certain injections like CESI in my mind - discography is on their list of high risk diagnostic tests) or 4 points for review of data gets you to high complexity as well.

I agree with you that H and P for a new problem would suffice for billing a level 4 but the question is billing for an established opioid follow up refill. History is easy enough to reach a level 4 but physical exam would be hard to justify billing a level 4 in an opioid f/u. That leaves Medical Decision Making for which complexity of data reviewed/ordered is just one part. This is where the confusion is. I say this type of visit does not qualify for a level 4 visit. I have given clear reasons for why it does not qualify and have only read conjecture in response.

 

[SommeRiver]

I guess maybe urine on every opiate follow up is another data point but I dont test urine every time.

 

[NOSfan]

Just when you think you have it all figured out.........Don't forget E&M coding changes for 2021

AMA releases 2021 CPT code set

CHICAGO— The first major overhaul in more than 25 years to the codes and guidelines for office and other outpatient evaluation and management (E/M) services was included in today’s release of the 2021 Current Procedural Terminology (CPT®) code set published by the American Medical Association (AMA).

These foundational modifications were designed to make E/M office visit coding and documentation simpler and more flexible, freeing physicians and care teams from clinically irrelevant administrative burdens that led to time-wasting note bloat and box checking. The changes to CPT codes ranging from 99201-99215 are proposed for adoption by the Centers for Medicare and Medicaid Services on Jan. 1, 2021.

The E/M office visit modifications include:

• Eliminating history and physical exam as elements for code selection.
• Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time.
• Promoting payer consistency with more detail added to CPT code descriptors and guidelines.
  “To get the full benefit of the burden relief from the E/M office visit changes, health care organizations need to understand and be ready to use the revised CPT codes and guidelines by Jan. 1, 2021,” said AMA President Susan R. Bailey, M.D. “The AMA is helping physicians and health care organizations prepare now for the transition and offers authoritative resources to anticipate the operational, infrastructural and administrative workflow adjustments that will result from the pending transition.”

AMA Bulletin

 

[SommeRiver]

1. If you want to throw money away, that's up to you. Feel free to bill a 99213 as much as you want.
2. Changing all billing from a 99213 to a 99214 won't get you to baller range, it'll get you to PCP range.
3. I have no qualms about billing a 99214 if the documentation is there and neither should you. I didn't make the rules for billing/payment, I just follow them. If you feel it's an ethics thing, I respect that, but personally I would rather throw in a free SI injection or epidural from time to time for those who need it as my charity work rather than underbill.
4. The insurance carriers are doing everything they can to reduce costs and deny care that we often think is appropriate. I'm not going to voluntarily give them more money for no good reason.
5. DDD is largely used for disks and means pretty much nothing other than "bad stuff". Spondylosis includes the posterior elements and for all practical purposes means facetogenic pain.
6. We have a bazillion BS diagnoses with associated ICD-10 codes, but they exist for a reason. CMS and the other insurances want them, so I give them to play the game. In a utopian world, I could just say facetogenic low back pain and my plan. But instead I need to add FMHx, ROS, PQRS criteria, and a ton of other BS just to get paid. It's the world we live in.

If all my 3's became 4's there would be a clear difference in monthly billing, and obviously I'm kidding saying that puts me into baller range but if I'm doing 30ish pts per day and all those 3's go up by $35 that is something...

Separating out DDD from spondylosis serves no purpose IMO. The treatment for DDD (normal finding) is nothing other than PT, which you should be doing for all pain pts anyways...I fail to see a reason to separate that considering it is all the same thing.

Practically every human over the age of 40 has that, and a huge chunk of ppl younger than 40 have it.

I personally do not consider that a pain Dx bc it is ubiquitous and IMO a normal and expected finding.

By the way, my VA pts love it when I tell them I don't care about their "degenerative disk."

 

[Pain Applicant1]

That’s just for the complexity score. Comprehensive history is easy enough - the MA fills out all the PMH/SH/FH/ROS and I review the paperwork. If it’s a new problem evaluation they get a comprehensive MSK exam. That alone allows billing level 5 on a follow up since you only need 2/3 (history, physical, complexity) for a follow up. However, since they more generally direct that complexity should be the primary driver of level of service, as I said above, new problem additional workup, and either a high risk score (justifiable if doing certain injections like CESI in my mind - discography is on their list of high risk diagnostic tests) or 4 points for review of data gets you to high complexity as well.

This is confusing enough to people so an attempt to clarify, there is no complexity section. Complexity is part of Section C which is Medical Decision Making. Agree with discography high risk but disagree that CESI is considered high risk. Even elective major surgeries with no risk factors and minor surgeries with risk factors are considered a moderate risk. It would be tough to argue that a CESI is riskier than either one of these. I also don't think it would be easy to get 4 points for review of data. If you know, kindly show me so I can document it and start billing the 99214s.

 

[SommeRiver]

I'm currently reviewing as many free examples as I can online, and Jesus this is such a joke...I may take a paid course at some point.

Maybe I don't take myself serious enough to believe that my spitting one sentence at a pt should qualify as any form of diligence when it comes billing.

If a pt has knee OA that is stable and without issue (but always there and annoying at the age of 83) I can throw one sentence into that note and it counts as my managing multiple problems. More points for me.

I hate this bc I feel dirty for checking boxes and counting up points bc it takes my interaction with my pt and turns it into a gross little game of Gotcha.

 

[Ducttape]

from the opioid refill standpoint, in my opinion, the following exam points would take less than a minute to figure out and could be documented:

psych - personal appearance. well groomed or not. appropriately attired or not. unkempt or foul smelling, especially of alcohol or cigarettes.
Neuro - alert, oriented, awake, responsive, ie "normal", or sleepy, somnolent, slurring of speech, incoherent answers, inappropriate answers, etc.
HEENT - Pupils normal, or fixed, or small, reactive or not, or dilated unexpectedly.
cardiac - document regular rate, rhythm or not.
pulmonary - document breath sounds normal, or "normal".
abdomen - document normal or if distended, firm, quiet, rigid.

and then detailed primary body system, usually musculoskeletal/back.


the included points are to evaluate for side effects from opioid analgesic and are entirely appropriate for patients who are given chronic opioid prescriptions.

and yes, I have seen a patient given ultracet 37.5 twice daily zonked out by her med.

 

[Ducttape]

If all my 3's became 4's there would be a clear difference in monthly billing, and obviously I'm kidding saying that puts me into baller range but if I'm doing 30ish pts per day and all those 3's go up by $35 that is something...

Separating out DDD from spondylosis serves no purpose IMO. The treatment for DDD (normal finding) is nothing other than PT, which you should be doing for all pain pts anyways...I fail to see a reason to separate that considering it is all the same thing.

Practically every human over the age of 40 has that, and a huge chunk of ppl younger than 40 have it.

I personally do not consider that a pain Dx bc it is ubiquitous and IMO a normal and expected finding.

By the way, my VA pts love it when I tell them I don't care about their "degenerative disk."

by that measure, you probably shouldn't be using that diagnosis to justify chronic opioid therapy...


consider using the diagnosis code of degenerative spinal stenosis, lumbar instead of DDD.
for spondylosis lumbar spine without radiculopathy or myelopathy, I generally use facet arthropathy, lumbar.

 

[deleted131481]

I hate this bc I feel dirty for checking boxes and counting up points bc it takes my interaction with my pt and turns it into a gross little game of Gotcha.

You're not the one who designed the arbitrary payment system, but you have to abide by the rules - so why feel bad about it?

I am sure the insurance companies don't feel dirty when they underpay you relative to your peers, deny procedures, PAs, etc.

 

[SSdoc33]

I'm currently reviewing as many free examples as I can online, and Jesus this is such a joke...I may take a paid course at some point.

Maybe I don't take myself serious enough to believe that my spitting one sentence at a pt should qualify as any form of diligence when it comes billing.

If a pt has knee OA that is stable and without issue (but always there and annoying at the age of 83) I can throw one sentence into that note and it counts as my managing multiple problems. More points for me.

I hate this bc I feel dirty for checking boxes and counting up points bc it takes my interaction with my pt and turns it into a gross little game of Gotcha.

you are right. it IS dirty. but there is enough ambiguity in the language that you can reasonably argue that many things you put in a note can qualify for a higher billing level without having to compromise yourself. do yourself a favor and bill the higher level when in doubt.

 

[Ferrismonk]

from the opioid refill standpoint, in my opinion, the following exam points would take less than a minute to figure out and could be documented:

psych - personal appearance. well groomed or not. appropriately attired or not. unkempt or foul smelling, especially of alcohol or cigarettes.
Neuro - alert, oriented, awake, responsive, ie "normal", or sleepy, somnolent, slurring of speech, incoherent answers, inappropriate answers, etc.
HEENT - Pupils normal, or fixed, or small, reactive or not, or dilated unexpectedly.
cardiac - document regular rate, rhythm or not.
pulmonary - document breath sounds normal, or "normal".
abdomen - document normal or if distended, firm, quiet, rigid.

and then detailed primary body system, usually musculoskeletal/back.


the included points are to evaluate for side effects from opioid analgesic and are entirely appropriate for patients who are given chronic opioid prescriptions.

and yes, I have seen a patient given ultracet 37.5 twice daily zonked out by her med.

I agree it's easy. You can easily do a 12 point physical exam from the door. Since I don't usually lay a stethoscope on my patients unless I have a reason, I use the following basic template and adjust/add as necessary.

General - No acute distress, well groomed, nourished, developed
Psych - Appropriate mood and affect. Normal speech. Alert and orientated. Awake, Engaged, Appropriate insight and judgement
Eyes - Pupils equal and round. Extraocular movements are intact. No scleral icterus.
Ear/Nose/Throat - External ear normal appearance. External nose normal appearance. Oral mucosa moist.
Neck - No visual masses
Respiratory - Unlabored, No audible wheeze/stridor. Normal effort
Cardiovascular - No edema, cyanosis, or clubbing in extremities
Abdomen - Nondistended
Skin - Normal to visual inspection. No visual rashes or lesions.
Gait - Antalgic
Musculoskeletal - Decreased range of motion of Lumbar spine with extension, sidebending, and rotation bilaterally.
Neuro - Sensation intact

I would also state that if you are giving opiate pain medication, you must at LEAST evaluate their general appearance, psych status, eyes, respiratory effort, abdomen, skin, and MSK.

 

[Sig123]

I agree it's easy. You can easily do a 12 point physical exam from the door. Since I don't usually lay a stethoscope on my patients unless I have a reason, I use the following basic template and adjust/add as necessary.

General - No acute distress, well groomed, nourished, developed
Psych - Appropriate mood and affect. Normal speech. Alert and orientated. Awake, Engaged, Appropriate insight and judgement
Eyes - Pupils equal and round. Extraocular movements are intact. No scleral icterus.
Ear/Nose/Throat - External ear normal appearance. External nose normal appearance. Oral mucosa moist.
Neck - No visual masses
Respiratory - Unlabored, No audible wheeze/stridor. Normal effort
Cardiovascular - No edema, cyanosis, or clubbing in extremities
Abdomen - Nondistended
Skin - Normal to visual inspection. No visual rashes or lesions.
Gait - Antalgic
Musculoskeletal - Decreased range of motion of Lumbar spine with extension, sidebending, and rotation bilaterally.
Neuro - Sensation intact

I would also state that if you are giving opiate pain medication, you must at LEAST evaluate their general appearance, psych status, eyes, respiratory effort, abdomen, skin, and MSK.

THIS right here. This is how you do it.

 

[drusso]

I agree it's easy. You can easily do a 12 point physical exam from the door. Since I don't usually lay a stethoscope on my patients unless I have a reason, I use the following basic template and adjust/add as necessary.

General - No acute distress, well groomed, nourished, developed
Psych - Appropriate mood and affect. Normal speech. Alert and orientated. Awake, Engaged, Appropriate insight and judgement
Eyes - Pupils equal and round. Extraocular movements are intact. No scleral icterus.
Ear/Nose/Throat - External ear normal appearance. External nose normal appearance. Oral mucosa moist.
Neck - No visual masses
Respiratory - Unlabored, No audible wheeze/stridor. Normal effort
Cardiovascular - No edema, cyanosis, or clubbing in extremities
Abdomen - Nondistended
Skin - Normal to visual inspection. No visual rashes or lesions.
Gait - Antalgic
Musculoskeletal - Decreased range of motion of Lumbar spine with extension, sidebending, and rotation bilaterally.
Neuro - Sensation intact

I would also state that if you are giving opiate pain medication, you must at LEAST evaluate their general appearance, psych status, eyes, respiratory effort, abdomen, skin, and MSK.

Your forgot "well-perfused" for cardiovascular exam

 

[SommeRiver]

by that measure, you probably shouldn't be using that diagnosis to justify chronic opioid therapy...


consider using the diagnosis code of degenerative spinal stenosis, lumbar instead of DDD.
for spondylosis lumbar spine without radiculopathy or myelopathy, I generally use facet arthropathy, lumbar.

Zero chance you'd ever see my name on an opiate Rx aimed at treating DDD.

 

[lobelsteve]

Different type of opiate billing.

Sarasota pain management doctor, sales rep charged in healthcare fraud and kickback conspiracy

A Sarasota pain management doctor and a sales representative were charged in healthcare fraud and kickback conspiracy

www.abcactionnews.com

 

[Laryngospasm]

that’s nothing compared to the guys in mobile... there’s a whole American greed episode on them. They make that guy look like a choir boy

 

[promethius]

Just checked some of my remittance advices. I noticed that some of my E/M levels were being down-coded by a particular insurance company from 99214 to 99213. The reason for the recoding is that apparently the submitted diagnoses do not support the E/M levels. The insurance company did not even request office notes before the E/M levels were down-coded. Has this happened to anyone else, and is that even legal?

 

[painfree23]

Just checked some of my remittance advices. I noticed that some of my E/M levels were being down-coded by a particular insurance company from 99214 to 99213. The reason for the recoding is that apparently the submitted diagnoses do not support the E/M levels. The insurance company did not even request office notes before the E/M levels were down-coded. Has this happened to anyone else, and is that even legal?

Wow. This seems illegal

 

[Ferrismonk]

Just checked some of my remittance advices. I noticed that some of my E/M levels were being down-coded by a particular insurance company from 99214 to 99213. The reason for the recoding is that apparently the submitted diagnoses do not support the E/M levels. The insurance company did not even request office notes before the E/M levels were down-coded. Has this happened to anyone else, and is that even legal?

Wow. This seems illegal

My guess is that they figured you won't fight it or that enough people won't fight it that they'll recoup any legal costs for those that do by those who won't fight it.

 

[lobelsteve]

Check your insurance contract...It surely allows them to arbitrarily do whatever they want.

 

[Ferrismonk]

On a flip-side, I was softly reprimanded recently because an internal billing audit of my charts suggests that they meet 99215 criteria and I was only billing a 99214. They don't want to bill a 99215 because "That's really meant for the really complicated cases" and it may trigger an audit. They also don't want me to just bill the 99214 because that is technically incorrect billing. I've been asked to "Remove a few physical exam findings" to lower to a 99214 level.

The world has gone crazy, especially in medicine.

 

[Pain Applicant1]

Just checked some of my remittance advices. I noticed that some of my E/M levels were being down-coded by a particular insurance company from 99214 to 99213. The reason for the recoding is that apparently the submitted diagnoses do not support the E/M levels. The insurance company did not even request office notes before the E/M levels were down-coded. Has this happened to anyone else, and is that even legal?

IF THEY reviewed your notes I would say you've been down-coded because your notes do not fulfill 99214 criteria. The difference between 99213 and 99214 is not ambiguous as others have mentioned here and there are clear guidelines delineating the two. It's not illegal for the payer to down-code you but on the contrary. it is illegal for you to up-code a claim.

It is also illegal to down-code a claim which is why the billing company is asking the doctor to change the Physical Exam, which ironically in and of itself can also be considered illegal.

I recommend contacting the payer and inquiring about it or requesting your biller to do so. I would be interested in their response if you'd be willing to post it. You can frequently get denied claims overturned if you just fulfill whatever is missing in the claim.

 

[promethius]

Just checked some of my remittance advices. I noticed that some of my E/M levels were being down-coded by a particular insurance company from 99214 to 99213. The reason for the recoding is that apparently the submitted diagnoses do not support the E/M levels. The insurance company did not even request office notes before the E/M levels were down-coded. Has this happened to anyone else, and is that even legal?

Hey so just wanted to follow-up on this post. I disputed the downcoding of my E/M levels by submitting my office notes for review, and the E&M levels were adjusted back up on review to what I had been billing for those office visits.

I recently got a notice from another insurance company that they will be implementing a new policy soon for "leveling of care," where they will be using an automated algorithm to evaluate each diagnosis code billed with historical claims to determine if the level of E&M service billed is appropriate.

Sounds like the use of this automated algorithm will lead to significant downcoding of E/M levels unless you have been billing 99213s on all of your follow-ups. I noticed that 90% of my downcoded claims have been converted to 99213s based just on my diagnosis codes. Of course, I could submit all of my affected office notes for review, but it's tedious and takes time away from patient care. Anyone else notice this downcoding trend lately by insurance companies? Seems like only 2 of the insurance companies I am contracted with have or will be using this automated algorithm, but I suspect more will follow due to their desire to limit overcoding and "save money." I would pay attention to your reimbursements for this change, as the use of this automated algorithm may become more prevalent.

 

[painfree23]

Hey so just wanted to follow-up on this post. I disputed the downcoding of my E/M levels by submitting my office notes for review, and the E&M levels were adjusted back up on review to what I had been billing for those office visits.

I recently got a notice from another insurance company that they will be implementing a new policy soon for "leveling of care," where they will be using an automated algorithm to evaluate each diagnosis code billed with historical claims to determine if the level of E&M service billed is appropriate.

Sounds like the use of this automated algorithm will lead to significant downcoding of E/M levels unless you have been billing 99213s on all of your follow-ups. I noticed that 90% of my downcoded claims have been converted to 99213s based just on my diagnosis codes. Of course, I could submit all of my affected office notes for review, but it's tedious and takes time away from patient care. Anyone else notice this downcoding trend lately by insurance companies? Seems like only 2 of the insurance companies I am contracted with have or will be using this automated algorithm, but I suspect more will follow due to their desire to limit overcoding and "save money." I would pay attention to your reimbursements for this change, as the use of this automated algorithm may become more prevalent.

See 20 patients a day and bill on time with mixes of 3s and 4s. How can they automate out of that?

 

[Ferrismonk]

Hey so just wanted to follow-up on this post. I disputed the downcoding of my E/M levels by submitting my office notes for review, and the E&M levels were adjusted back up on review to what I had been billing for those office visits.

I recently got a notice from another insurance company that they will be implementing a new policy soon for "leveling of care," where they will be using an automated algorithm to evaluate each diagnosis code billed with historical claims to determine if the level of E&M service billed is appropriate.

Sounds like the use of this automated algorithm will lead to significant downcoding of E/M levels unless you have been billing 99213s on all of your follow-ups. I noticed that 90% of my downcoded claims have been converted to 99213s based just on my diagnosis codes. Of course, I could submit all of my affected office notes for review, but it's tedious and takes time away from patient care. Anyone else notice this downcoding trend lately by insurance companies? Seems like only 2 of the insurance companies I am contracted with have or will be using this automated algorithm, but I suspect more will follow due to their desire to limit overcoding and "save money." I would pay attention to your reimbursements for this change, as the use of this automated algorithm may become more prevalent.

This is what they are hoping. Increase the PITA factor for you, less in-person review time for them.

 

[IAmTheOne1]

For 2021, the level of MDM for office/outpatient E/Ms continues to be based on 2 out of 3 elements:

1) Problems Addressed
2) Data Reviewed and Analyzed
3) Risk

In terms of problems addressed, a level four visit requires:

1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;
-or-
2 or more stable chronic illnesses;

and a level 5 visit requires:

1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
-or-
1 acute or chronic illness or injury that poses a threat to life or bodily function

In terms of Risk:

A level four visit, for example:

• Prescription drug management

A level five visit, for example:

• Drug therapy requiring intensive monitoring for toxicity

So if a patient is on chronic opioid therapy, it seems like a level four visit is very easy to meet. The question is does prescription opioid management with evaluation for toxicity qualify for a level 5 visit? Probably not - guessing that's more for drugs that have a narrow therapeutic window and require continuous blood level monitoring.

But even for problems addressed qualifying for a level 5 doesn't seem that much of a stretch - a patient that has known radiculopathy with severe exacerbation of symptoms or even a patient that has had lumbar RFA in the past and the pain begins to return in a severe nature. Is that a level 5? If radiculopathy limits your ability to walk, is that a threat to bodily function?

 

[painfree23]

For 2021, the level of MDM for office/outpatient E/Ms continues to be based on 2 out of 3 elements:

1) Problems Addressed
2) Data Reviewed and Analyzed
3) Risk

In terms of problems addressed, a level four visit requires:

1 or more chronic illnesses with exacerbation, progression, or side effects of treatment;
-or-
2 or more stable chronic illnesses;

and a level 5 visit requires:

1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
-or-
1 acute or chronic illness or injury that poses a threat to life or bodily function

In terms of Risk:

A level four visit, for example:

• Prescription drug management

A level five visit, for example:

• Drug therapy requiring intensive monitoring for toxicity

So if a patient is on chronic opioid therapy, it seems like a level four visit is very easy to meet. The question is does prescription opioid management with evaluation for toxicity qualify for a level 5 visit? Probably not - guessing that's more for drugs that have a narrow therapeutic window and require continuous blood level monitoring.

But even for problems addressed qualifying for a level 5 doesn't seem that much of a stretch - a patient that has known radiculopathy with severe exacerbation of symptoms or even a patient that has had lumbar RFA in the past and the pain begins to return in a severe nature. Is that a level 5? If radiculopathy limits your ability to walk, is that a threat to bodily function?

So ur charging a level 4 every month?

 

[Ducttape]

I don’t think your examples qualify for level 5 visits.

Yes for level 4s for chronic opioid management. You have 2 chronic stable diseases - the primary pain generator that is confirmable on imaging and the use of opioid medication, along with prescription

 

[IAmTheOne1]

I don’t think your examples qualify for level 5 visits.

Yes for level 4s for chronic opioid management. You have 2 chronic stable diseases - the primary pain generator that is confirmable on imaging and the use of opioid medication, along with prescription

It would seem logical that chronic opioid management shouldn’t be a level 5.

But this is directly from cms.gov

Parenteral controlled substance is classified as high risk straight from CMS.

What to make of this?

 

[deleted131481]

It would seem logical that chronic opioid management shouldn’t be a level 5.

But this is directly from cms.gov

View attachment 332248
Parenteral controlled substance is classified as high risk straight from CMS.

What to make of this?

Sounds like everyone is getting Butrans patch.

 

[drusso]

It would seem logical that chronic opioid management shouldn’t be a level 5.

But this is directly from cms.gov

View attachment 332248
Parenteral controlled substance is classified as high risk straight from CMS.

What to make of this?

If you've been following the news lately, you'd appreciate that NOTHING is more personally or professionally risky than managing controlled substances for chronic pain. It might even cost you your life or license.

 

[painfree23]

It would seem logical that chronic opioid management shouldn’t be a level 5.

But this is directly from cms.gov

View attachment 332248
Parenteral controlled substance is classified as high risk straight from CMS.

What to make of this?

None of the “presenting problems” match that of the monthly visits for med refills tho?

 

[Laryngospasm]

Parenteral means non oral. I think the one next to the one you circled about intensive monitoring could be argued due to all the hoops we jump through but could also be argued against.

 

[Ducttape]

there is a partial list of meds that require intensive monitoring from CMS. these are meds like TCAs for elderly. it does not include opioids.

I couldn't find the CMS link - this is from Palmetto GBA.

Palmetto GBA - JM Part B - Management Options: Drug Therapy Requiring Intensive Monitoring for Toxicity

The table of risk lists drug therapy requiring intensive monitoring for toxicity as a high risk management option.

www.palmettogba.com

a coding site suggested that a standing order for a blood test was a requirement for a medication to be determined that requires intensive monitoring.

 

[IAmTheOne1]

Yeah it seems like level 4 is definitely indicated for patients on chronic opioids - as mentioned above it is one of the riskiest things we do professionally directly related to the risk of patients abusing/misusing them.

 

[painfree23]

Yeah it seems like level 4 is definitely indicated for patients on chronic opioids - as mentioned above it is one of the riskiest things we do professionally directly related to the risk of patients abusing/misusing them.

So level 4 for monthly visits? 12 a year?

 

[Laryngospasm]

Why not? We are so beat down we feel bad getting paid appropriately for something that is very risky and honestly even level 4 is underpaid for it in my opinion.

 

[Ferrismonk]

So level 4 for monthly visits? 12 a year?

Absolutely.

 

[SommeRiver]

It would seem logical that chronic opioid management shouldn’t be a level 5.

But this is directly from cms.gov

View attachment 332248
Parenteral controlled substance is classified as high risk straight from CMS.

What to make of this?

That's not PO opiates.

I don't see monthly. I do Q2M or Q3M for opiates (usually 3).

 

[Ducttape]

So level 4 for monthly visits? 12 a year?

follow up every month may be overkill. but has to be at least every 3 months.

perhaps the best plan is to continue to do what you are doing now. determine your concern of risk - risk to the patient and your assessment of safe care - and base your decision on how often to follow up based on that determination.

 

[Laryngospasm]

I think the regional preferences for this vary quite a bit. I know in some areas 1 month is the norm while other are comfortable with 2 or 3. Personally I never do any thing to the minimum standards and a lot can change in three months. You can notice changes in patients hygiene, dress, weight and all kinds of other signs that would lead you to stop opioids or refer to MAT.

 

[painfree23]

That's not PO opiates.

I don't see monthly. I do Q2M or Q3M for opiates (usually 3).

How do u handle refills?