SNF/NF/AL billing

[thefootfixer]

So I’ve been getting repeated denials and at best minimal/pathetic reimbursements for patients I’ve been seeing at a new SNF we started servicing.

Obviously it’s majority nail care with occasional wounds, lesions etc. Payor mix is the standard mix.

I’ve been billing procedure codes 11721/11720/G0127 along with the proper corresponding q modifier. 11720/G0127 are being accompanied by a 59 modifier.

I am listing diagnosis based on 1. Systemic disease followed by 2. nail disease .

Visit codes are being used for seperate and identifiable diagnosis such as xeroris gangrene, tinea etc. That’s being billed with the visit code and accompanied by a 25 modifier.

What am I doing wrong here? I just got a few reimbursements back for like $10.

Should I be using more visit codes ?

Any advice appreciated.

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[GreenHousePub]

Looks like you are doing everything right, just the reimbursement is absolute garbage. I'd bail out of it.

 

[air bud]

Looks like you are doing everything right, just the reimbursement is absolute garbage. I'd bail out of it.

Can't do that, Ser Practice Owner says it's a good way to build your name within the community.

 

[thefootfixer]

Looks like you are doing everything right, just the reimbursement is absolute garbage. I'd bail out of it.

How are the larger nursing groups doing this? I’m a small office so I obviously don’t have the pull that they do. But I would imagine those groups are servicing similar points of service locations.

 

[heybrother]

How are the larger nursing groups doing this? I’m a small office so I obviously don’t have the pull that they do. But I would imagine those groups are servicing similar points of service locations.

Medicare pays the Medicare "facility" locality fee schedule for your area. If you are getting less than that its because you have a bad fee schedule with the insurance in question ie. they have you on a % of Medicare. If you are paid poorly in facilities, you may be receiving poor reimbursement in your clinic too. One of the actual pillars of podiatry management (not selling creams) is understanding your payors and their reimbursement strategies.

To the best of your ability you should try to never be surprised by what a payor pays. You should already have acquired the fee schedule, figured it out based on past services, etc.

 

[thefootfixer]

Medicare pays the Medicare "facility" locality fee schedule for your area. If you are getting less than that its because you have a bad fee schedule with the insurance in question ie. they have you on a % of Medicare. If you are paid poorly in facilities, you may be receiving poor reimbursement in your clinic too. One of the actual pillars of podiatry management (not selling creams) is understanding your payors and their reimbursement strategies.

To the best of your ability you should try to never be surprised by what a payor pays. You should already have acquired the fee schedule, figured it out based on past services, etc.

So this is actually with a multi specialty group that I’m contracted with. The group themselves, have never had a podiatrist and have never done podiatry billing, so they’re also kinda in limbo when it comes to that…what would you recommend in this case?

 

[dtrack22]

I am listing diagnosis based on 1. Systemic disease followed by 2. nail disease

My understanding was always nail pathology is on the first diagnosis line and the neuropathy or PAD code is second. I have no idea if that actually matters. I don’t see anything wrong with the billing/coding.

It’s possible that some MA plans could be not paying for the service and if there is any Medicaid they generally aren’t paying for it. I would assume your group/clinic would confirm benefits before making you go see these people, so this seems like a long shot too. Medicare should pay, but 11721 is gonna be like $23 when done in a facility. 80% of that if the patient doesn’t have a secondary or if secondary is state insurance. So it’s not like you’re gonna be seeing normal reimbursements even if everyone was Medicare.

 

[icebreaker32]

The pay is not great for nursing homes (facilities pay less than office).....but yah $10 nail debridements are not necessarily uncommon for Medicare HMOs or Medicaid at nursing homes. Hard to make a lot of money without incredible volume, "calluses" on all diabetics and E&Ms on most patients for most visits. By doing all that though you are at a high audit risk.

There must be some way to make money on wounds in nursing homes as some MDs do this at nursing homes (and have kicked many podiatrists out of wound care from facilities). They would not work for pennies. Not sure how they make money other than just volume.....see 20 in a morning with the nursing home treatment nurse, I guess with no overhead.

Home visits and assisted living facilities are probably more profitable if you are dispensing unnecessary DME, and doing lots of unnecessary vascular testing and ultrasound diagnostics on many patients. You can not do these things at a nursing home.

So many jobs are posted for this type work. We need more schools. Maybe they should put the get paid $10 for a back breaking nursing home nail trim picture next to the OR pictures of podiatrists in a surgeon's cap holding a power instrument in marketing for prospective students.

 

[heybrother]

So this is actually with a multi specialty group that I’m contracted with. The group themselves, have never had a podiatrist and have never done podiatry billing, so they’re also kinda in limbo when it comes to that…what would you recommend in this case?

Teasingly, finding better more productive uses for your time.

I'd have your managers/billers/whoever is in charge of this - pull your fee schedule and figure out what the values are. Unfortunately, the values you get are often the reality of the story. Then you'll have to figure out if its worth your time (it won't be).

 

[619]

So I’ve been getting repeated denials and at best minimal/pathetic reimbursements for patients I’ve been seeing at a new SNF we started servicing.

Obviously it’s majority nail care with occasional wounds, lesions etc. Payor mix is the standard mix.

I’ve been billing procedure codes 11721/11720/G0127 along with the proper corresponding q modifier. 11720/G0127 are being accompanied by a 59 modifier.

I am listing diagnosis based on 1. Systemic disease followed by 2. nail disease .

Visit codes are being used for seperate and identifiable diagnosis such as xeroris gangrene, tinea etc. That’s being billed with the visit code and accompanied by a 25 modifier.

What am I doing wrong here? I just got a few reimbursements back for like $10.

Should I be using more visit codes ?

Any advice appreciated.

If you are working for a MSG group (or even a crappy podiatry associate job), your time is 1000% better marketing yourself and meeting PCPs for referrals than doing SNF/nursing home work. $10 sounds about right for reimbursement. Even if you fight and it doubles to $20, still not worth your time. One referral for heel pain from your local PCP is worth more than see 20 patients at a SNF/nursing home. And once you treat that heel pain, that PCP will send you even more pathologies.

Building an ideal podiatry practice should not be complicated. You don't have to see patients in the SNF/nursing home or take free ER call at the hospital. Those are old and outdated ideas. You are better off even making tik-tok videos.

 

[619]

To the best of your ability you should try to never be surprised by what a payor pays. You should already have acquired the fee schedule, figured it out based on past services, etc.

Most folks don't look at the EOB and actually see what each insurance reimburses and what they deny. I am 2 years into owning my practice and I still look at each EOB because things change every year and every month. Medicare can be constant and predictable but private insurance is a whole different game. There are multitudes of insurance and sub-plans even within the same insurance. You can 5 different patients with the same BCBS on the surface but with different sub-plans underneath.
It's a game with winners and losers and insurance companies are the obvious winners and guess who the losers are? Doctors

 

[thefootfixer]

The pay is not great for nursing homes (facilities pay less than office).....but yah $10 nail debridements are not necessarily uncommon for Medicare HMOs or Medicaid at nursing homes. Hard to make a lot of money without incredible volume, "calluses" on all diabetics and E&Ms on most patients for most visits. By doing all that though you are at a high audit risk.

There must be some way to make money on wounds in nursing homes as some MDs do this at nursing homes (and have kicked many podiatrists out of wound care from facilities). They would not work for pennies. Not sure how they make money other than just volume.....see 20 in a morning with the nursing home treatment nurse, I guess with no overhead.

Home visits and assisted living facilities are probably more profitable if you are dispensing unnecessary DME, and doing lots of unnecessary vascular testing and ultrasound diagnostics on many patients. You can not do these things at a nursing home.

So many jobs are posted for this type work. We need more schools. Maybe they should put the get paid $10 for a back breaking nursing home nail trim picture next to the OR pictures of podiatrists in a surgeon's cap holding a power instrument in marketing for prospective students.

Being so, I’m still confused at how some of the docs that work for the larger 360care etc type groups make $500-$600 per day for NH work. I would imagine this is pay based off collections . I briefly looked into that stuff after residency and even got as far as getting a contract but backed out last minute.

$10 can’t be the norm. At least it’s insane to accept it as such

 

[Pronation]

Podiatry, le hidden gem. Best kept secret in cosmetolo... I mean, medicine. Aging population, wow, such need. Save lives.

 

[wakaflocka88]

Being so, I’m still confused at how some of the docs that work for the larger 360care etc type groups make $500-$600 per day for NH work. I would imagine this is pay based off collections . I briefly looked into that stuff after residency and even got as far as getting a contract but backed out last minute.

$10 can’t be the norm. At least it’s insane to accept it as such

My friend, I promise you a day off spent with your family is worth far more than the $500 you are breaking your back for. Heck, go to BWW or Hooters and enjoy some wings and playoff baseball.

 

[icebreaker32]

Being so, I’m still confused at how some of the docs that work for the larger 360care etc type groups make $500-$600 per day for NH work. I would imagine this is pay based off collections . I briefly looked into that stuff after residency and even got as far as getting a contract but backed out last minute.

$10 can’t be the norm. At least it’s insane to accept it as such

The norm no. You will have some very poor insurance mixed in with the mediocre. Probably Medicaid and Humana mixed in etc. You will probably get some $0 also for one reason or another. You will probably just see all 40 patients on you list regardless of insurance mix. Mix in new patients, lots of "calluses" on diabetics and E&M on existing patients...must treat that xerosis etc. and you can bump up the average amount. Get greedy and do lots of "toenail avulsions" and get audited or worse real quick.

Doing all this even with your denials and shockingly low amounts mixed in even and even if you average less than $50 per patient when you see 25-50 patients a day it is often better than associate pay and helps you when starting an office.

Almost a rite of passage when opening your office for a couple years. Some ABFAS presidents have even done it (many won't admit it). Doing it for a couple years for one day a week in facilities that are reasonably run is one thing. Doing it all day everyday day is another thing.

 

[air bud]

Edit - actual picture of at least 1 of the residency directors in question.

2nd edit - haven't looked this up but I think maybe it is supposed to be "whom"