Guest guest Posted January 28, 2006 Report Share Posted January 28, 2006 I rarely code 99203 or 99213’s. And I know my time will probably come to be audited. But, I think its important to be compensated for your work. You are be careful and conscientious, and give your patient excellent care. It shouldn’t be for free. I think its great your friend has already audited your charts and feel you are right on track. We need to value our service, the insurance companies won’t. Don’t let them scare you. T. Ellsworth, MD Family Medicine sdale, AZ Mobile The information contained in this message is confidential and intended solely for the use of the individual or entity named. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution, copying or unauthorized use of this communication is strictly prohibited. If you have received this by error, please notify the sender immediately. From: [mailto: ] On Behalf Of Sue Bidigare MD Sent: Saturday, January 28, 2006 6:16 AM To: Subject: " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2006 Report Share Posted January 28, 2006 I rarely code 99203 or 99213’s. And I know my time will probably come to be audited. But, I think its important to be compensated for your work. You are be careful and conscientious, and give your patient excellent care. It shouldn’t be for free. I think its great your friend has already audited your charts and feel you are right on track. We need to value our service, the insurance companies won’t. Don’t let them scare you. T. Ellsworth, MD Family Medicine sdale, AZ Mobile The information contained in this message is confidential and intended solely for the use of the individual or entity named. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any dissemination, distribution, copying or unauthorized use of this communication is strictly prohibited. If you have received this by error, please notify the sender immediately. From: [mailto: ] On Behalf Of Sue Bidigare MD Sent: Saturday, January 28, 2006 6:16 AM To: Subject: " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2006 Report Share Posted January 28, 2006 Sue: If your documentation supports it, and it sound like it does based on the several audits you've already done, then I would contact the HMO Med Director and discuss it with them. You may also want to have your friend do another audit, just to protect and reassure yourself, but if you haven't been doing anything different, I don't expect that the results will be any different than they were previously. That letter was probably automatically sent out based on stats, and it might be good to present yourself and explain, so you're more than just a breakdown of E/M codes. That being said, they may not care about your justifications, and you may end up being audited anyway, in which case your documentation supports your billing. As for " ticking-off " this company...if they were to really give you a hard time, do you have to continue to contract with them? If you have the option, maybe you could choose to not do business with a company that doesn't want to pay you for the work you are doing? Whatever you do, don't start downcoding to avoid this, because that's what they want you to do. Stand strong and good luck! Debbie J. New Jersey > >Reply-To: >To: < > >Subject: " Overcoding issues " >Date: Sat, 28 Jan 2006 08:16:08 -0500 > >I have been following this group and have learned a lot. I appreciate all >of the advice! I have a question with which I would like some help. > >I recently received a letter from one of our larger HMO's that said my >coding was above average for Family Medicine physicians, comparing their >2004 data to my 2005-as it related to 99214-15's. They said that they are >going to monitor my billing and, if that trend continues, they will be >auditing my records. > >My initial thoughts-I know that many of us previously downcoded to 13's so >as not to have to think or document, or to avoid just such letters. I also >know that the " bell curve " is moving upward because we are now becoming >more proficient in coding, so the published data from even a few years ago >is not accurate now. I am just starting up (1.5 years in this practice). I >only have about 75 patients in my panel for this particular group, and, in >this short time frame, it has been mainly the more " sick " patients that are >coming in. I am getting many chronically ill patients with numerous >problems, from our other ambulatory sites (I am hospital employed), and, >although these pts. are new to me, I have to bill them as established >because all of the sites have the same Tax Id, and these pts are all >considered established. Needing to cover so many issues at the " new " visit >obviously results in many (mostly) 99214's. Realistically, I feel that my >panel is not large enough to have even developed enough data for a " normal " >bell curve, but I could be just rationalizing all of this to support my >data! > >My question-should I be pro active and contact the medical director of this >HMO who sent the letter to discuss this, find out the time frame for their >previous monitoring, and do my own audit of my charting? And if my charting >supports my billing pursue this to " prove " to them I am coding >appropriately (if my charts verify this)? Or should I not worry about it, >just be sure to focus particularly on this group to make sure I do things >appropriately in the future. I hate to just let this go because I feel they >are sending out letters like this just to scare us into downcoding. My best >friend is the compliance officer for a nearby hospital ambulatory care >center, doing all of their auditing, and she also works for a company that >does just such audits nationwide. She has audited my charting previously, >at my request, and tells me I am doing things appropriately. But I hate to > " tick off " this company and their director and forever have the spotlight >on my practice. By the way, I do not have EHR; we use only paper charts >with hand written notes. I have used the StatCoder program on my PDA and >find that, according to that, my coding is appropriate, although some >issues like medical decision making, can be somewhat grey areas. > >Any ideas would be appreciated. > >Sue > _________________________________________________________________ Express yourself instantly with MSN Messenger! Download today - it's FREE! http://messenger.msn.click-url.com/go/onm00200471ave/direct/01/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 28, 2006 Report Share Posted January 28, 2006 Sue: If your documentation supports it, and it sound like it does based on the several audits you've already done, then I would contact the HMO Med Director and discuss it with them. You may also want to have your friend do another audit, just to protect and reassure yourself, but if you haven't been doing anything different, I don't expect that the results will be any different than they were previously. That letter was probably automatically sent out based on stats, and it might be good to present yourself and explain, so you're more than just a breakdown of E/M codes. That being said, they may not care about your justifications, and you may end up being audited anyway, in which case your documentation supports your billing. As for " ticking-off " this company...if they were to really give you a hard time, do you have to continue to contract with them? If you have the option, maybe you could choose to not do business with a company that doesn't want to pay you for the work you are doing? Whatever you do, don't start downcoding to avoid this, because that's what they want you to do. Stand strong and good luck! Debbie J. New Jersey > >Reply-To: >To: < > >Subject: " Overcoding issues " >Date: Sat, 28 Jan 2006 08:16:08 -0500 > >I have been following this group and have learned a lot. I appreciate all >of the advice! I have a question with which I would like some help. > >I recently received a letter from one of our larger HMO's that said my >coding was above average for Family Medicine physicians, comparing their >2004 data to my 2005-as it related to 99214-15's. They said that they are >going to monitor my billing and, if that trend continues, they will be >auditing my records. > >My initial thoughts-I know that many of us previously downcoded to 13's so >as not to have to think or document, or to avoid just such letters. I also >know that the " bell curve " is moving upward because we are now becoming >more proficient in coding, so the published data from even a few years ago >is not accurate now. I am just starting up (1.5 years in this practice). I >only have about 75 patients in my panel for this particular group, and, in >this short time frame, it has been mainly the more " sick " patients that are >coming in. I am getting many chronically ill patients with numerous >problems, from our other ambulatory sites (I am hospital employed), and, >although these pts. are new to me, I have to bill them as established >because all of the sites have the same Tax Id, and these pts are all >considered established. Needing to cover so many issues at the " new " visit >obviously results in many (mostly) 99214's. Realistically, I feel that my >panel is not large enough to have even developed enough data for a " normal " >bell curve, but I could be just rationalizing all of this to support my >data! > >My question-should I be pro active and contact the medical director of this >HMO who sent the letter to discuss this, find out the time frame for their >previous monitoring, and do my own audit of my charting? And if my charting >supports my billing pursue this to " prove " to them I am coding >appropriately (if my charts verify this)? Or should I not worry about it, >just be sure to focus particularly on this group to make sure I do things >appropriately in the future. I hate to just let this go because I feel they >are sending out letters like this just to scare us into downcoding. My best >friend is the compliance officer for a nearby hospital ambulatory care >center, doing all of their auditing, and she also works for a company that >does just such audits nationwide. She has audited my charting previously, >at my request, and tells me I am doing things appropriately. But I hate to > " tick off " this company and their director and forever have the spotlight >on my practice. By the way, I do not have EHR; we use only paper charts >with hand written notes. I have used the StatCoder program on my PDA and >find that, according to that, my coding is appropriate, although some >issues like medical decision making, can be somewhat grey areas. > >Any ideas would be appreciated. > >Sue > _________________________________________________________________ Express yourself instantly with MSN Messenger! Download today - it's FREE! http://messenger.msn.click-url.com/go/onm00200471ave/direct/01/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 I received one of those letters 2 years ago from BC/BS and it worried me at first. It was one of those automatically sent ones, my partner at the time also got one and it was identical. He responded, I chose not to. Neither of us ever heard from them again. I use my stat coder e and m and I code appropriately. It is a BELL CURVE for heaven's sake, no matter what we do someone is going to be at either end. I don't care anymore as long as I am doing what is RIGHT. I was the quality improvement officer for one of my hospital duty stations when I was in the Navy. They sent me to all kinds of civilian seminars on auditing and quality improvement. (pretty useful for a physician) Some of them were for insurance company quality people as we were just implementing Tricare midwest at the time. Anyway, I will never forget what one lecturer said at the time, He said "The best way to motivate physicians is by telling them where they are in relation to their peers. It is in their nature to always be in the middle of the bell curve with regards to their practice style. Just telling them they are outliers is the most efficient method of changing their practice" . I used this with great success when discussing antibiotic use in our hospital and now bc/bs and others are using it too. I think many physicians hesitate to use those 04 and 14 codes, even for a little while, just because they got that letter, I know I did. But I KNOW I spend more time with my patients, my patients TELL me so, they say that is why they switched or told their friends to come. I document well and so there. I hope I don't have to go through the hassle of an audit but I am going to continue to code what I do. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 I received one of those letters 2 years ago from BC/BS and it worried me at first. It was one of those automatically sent ones, my partner at the time also got one and it was identical. He responded, I chose not to. Neither of us ever heard from them again. I use my stat coder e and m and I code appropriately. It is a BELL CURVE for heaven's sake, no matter what we do someone is going to be at either end. I don't care anymore as long as I am doing what is RIGHT. I was the quality improvement officer for one of my hospital duty stations when I was in the Navy. They sent me to all kinds of civilian seminars on auditing and quality improvement. (pretty useful for a physician) Some of them were for insurance company quality people as we were just implementing Tricare midwest at the time. Anyway, I will never forget what one lecturer said at the time, He said "The best way to motivate physicians is by telling them where they are in relation to their peers. It is in their nature to always be in the middle of the bell curve with regards to their practice style. Just telling them they are outliers is the most efficient method of changing their practice" . I used this with great success when discussing antibiotic use in our hospital and now bc/bs and others are using it too. I think many physicians hesitate to use those 04 and 14 codes, even for a little while, just because they got that letter, I know I did. But I KNOW I spend more time with my patients, my patients TELL me so, they say that is why they switched or told their friends to come. I document well and so there. I hope I don't have to go through the hassle of an audit but I am going to continue to code what I do. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 " Check out " Getting Paid: Are You Prepared to Defend Your Coding? " published in the June 2005 Family Practice Management, for coding tips, coding resources available through the AAFP and others, as well as a sample letter to use when responding to a health plan audit. " From the AAFP website. This is a good article I found helpful. Just make sure you fully understand what needs to be documented to get a 99214, and keep coding appropriately. Good luck. Joe > >Reply-To: >To: < > >Subject: " Overcoding issues " >Date: Sat, 28 Jan 2006 08:16:08 -0500 > >I have been following this group and have learned a lot. I appreciate all >of the advice! I have a question with which I would like some help. > >I recently received a letter from one of our larger HMO's that said my >coding was above average for Family Medicine physicians, comparing their >2004 data to my 2005-as it related to 99214-15's. They said that they are >going to monitor my billing and, if that trend continues, they will be >auditing my records. > >My initial thoughts-I know that many of us previously downcoded to 13's so >as not to have to think or document, or to avoid just such letters. I also >know that the " bell curve " is moving upward because we are now becoming >more proficient in coding, so the published data from even a few years ago >is not accurate now. I am just starting up (1.5 years in this practice). I >only have about 75 patients in my panel for this particular group, and, in >this short time frame, it has been mainly the more " sick " patients that are >coming in. I am getting many chronically ill patients with numerous >problems, from our other ambulatory sites (I am hospital employed), and, >although these pts. are new to me, I have to bill them as established >because all of the sites have the same Tax Id, and these pts are all >considered established. Needing to cover so many issues at the " new " visit >obviously results in many (mostly) 99214's. Realistically, I feel that my >panel is not large enough to have even developed enough data for a " normal " >bell curve, but I could be just rationalizing all of this to support my >data! > >My question-should I be pro active and contact the medical director of this >HMO who sent the letter to discuss this, find out the time frame for their >previous monitoring, and do my own audit of my charting? And if my charting >supports my billing pursue this to " prove " to them I am coding >appropriately (if my charts verify this)? Or should I not worry about it, >just be sure to focus particularly on this group to make sure I do things >appropriately in the future. I hate to just let this go because I feel they >are sending out letters like this just to scare us into downcoding. My best >friend is the compliance officer for a nearby hospital ambulatory care >center, doing all of their auditing, and she also works for a company that >does just such audits nationwide. She has audited my charting previously, >at my request, and tells me I am doing things appropriately. But I hate to > " tick off " this company and their director and forever have the spotlight >on my practice. By the way, I do not have EHR; we use only paper charts >with hand written notes. I have used the StatCoder program on my PDA and >find that, according to that, my coding is appropriate, although some >issues like medical decision making, can be somewhat grey areas. > >Any ideas would be appreciated. > >Sue > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 " Check out " Getting Paid: Are You Prepared to Defend Your Coding? " published in the June 2005 Family Practice Management, for coding tips, coding resources available through the AAFP and others, as well as a sample letter to use when responding to a health plan audit. " From the AAFP website. This is a good article I found helpful. Just make sure you fully understand what needs to be documented to get a 99214, and keep coding appropriately. Good luck. Joe > >Reply-To: >To: < > >Subject: " Overcoding issues " >Date: Sat, 28 Jan 2006 08:16:08 -0500 > >I have been following this group and have learned a lot. I appreciate all >of the advice! I have a question with which I would like some help. > >I recently received a letter from one of our larger HMO's that said my >coding was above average for Family Medicine physicians, comparing their >2004 data to my 2005-as it related to 99214-15's. They said that they are >going to monitor my billing and, if that trend continues, they will be >auditing my records. > >My initial thoughts-I know that many of us previously downcoded to 13's so >as not to have to think or document, or to avoid just such letters. I also >know that the " bell curve " is moving upward because we are now becoming >more proficient in coding, so the published data from even a few years ago >is not accurate now. I am just starting up (1.5 years in this practice). I >only have about 75 patients in my panel for this particular group, and, in >this short time frame, it has been mainly the more " sick " patients that are >coming in. I am getting many chronically ill patients with numerous >problems, from our other ambulatory sites (I am hospital employed), and, >although these pts. are new to me, I have to bill them as established >because all of the sites have the same Tax Id, and these pts are all >considered established. Needing to cover so many issues at the " new " visit >obviously results in many (mostly) 99214's. Realistically, I feel that my >panel is not large enough to have even developed enough data for a " normal " >bell curve, but I could be just rationalizing all of this to support my >data! > >My question-should I be pro active and contact the medical director of this >HMO who sent the letter to discuss this, find out the time frame for their >previous monitoring, and do my own audit of my charting? And if my charting >supports my billing pursue this to " prove " to them I am coding >appropriately (if my charts verify this)? Or should I not worry about it, >just be sure to focus particularly on this group to make sure I do things >appropriately in the future. I hate to just let this go because I feel they >are sending out letters like this just to scare us into downcoding. My best >friend is the compliance officer for a nearby hospital ambulatory care >center, doing all of their auditing, and she also works for a company that >does just such audits nationwide. She has audited my charting previously, >at my request, and tells me I am doing things appropriately. But I hate to > " tick off " this company and their director and forever have the spotlight >on my practice. By the way, I do not have EHR; we use only paper charts >with hand written notes. I have used the StatCoder program on my PDA and >find that, according to that, my coding is appropriate, although some >issues like medical decision making, can be somewhat grey areas. > >Any ideas would be appreciated. > >Sue > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 Hi Sue, When I got one of those letters from Anthem, I immediately wrote and invited them to come review charts and my code habits. I never heard another word from them. I figured it would be easier to “entertain” them early, when I had a small panel, than later when I was really busy. Just my 2 cents, Annie " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 29, 2006 Report Share Posted January 29, 2006 Hi Sue, When I got one of those letters from Anthem, I immediately wrote and invited them to come review charts and my code habits. I never heard another word from them. I figured it would be easier to “entertain” them early, when I had a small panel, than later when I was really busy. Just my 2 cents, Annie " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 30, 2006 Report Share Posted January 30, 2006 Yes, I heard that the companies are really not even interested anymore in “auditing” charts because they know that, with EMR’s, the charts will almost certainly meet all the criteria for the chosen E/M code. Instead, they are now just saying certain doctors are coding too high, period. Hopefully they will not just drop your contract when it runs out, because I’ve heard others that have had that dangled over their heads as a “threat”. " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 30, 2006 Report Share Posted January 30, 2006 So if you rarely code 99203/99213 does that mean that you never code 992201-99202 or 99212? That sounds more like a mountain peak than a bell curve. " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 30, 2006 Report Share Posted January 30, 2006 So if you rarely code 99203/99213 does that mean that you never code 992201-99202 or 99212? That sounds more like a mountain peak than a bell curve. " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 30, 2006 Report Share Posted January 30, 2006 I don’t see how we can ever expect a bell curve out of a 5 point scale that really only has 2 “usable codes”. In my simple minded way of looking at things” (sticking to established patients for this discussion) 99211 can’t happen in my office, as I have no nurse or other staff, it the patient sees anybody, they see me, and seeing the MD makes it at least a 99212. For me to code a 99212 the patient did not need to come in anyway, and I generally head those off with phone triage. An example would be a simple sunburn that somebody thought I would give them Lortab for: I walk in, say “Use sunscreen and this won’t happen” and “No you can’t have 60 lortab for it. Take some ibuprofen and get some Solarcaine spray.” (this has only ever happened once, and it was one of only a handful of times I have ever coded a 99212. Lets skip 99213 and 99214 for a sec and go to 99215. I have only ever coded that a very few times also. I know some people code it based on time, but even though it is not unusual for me to meet the time criteria, I always get hung on the level of risk. The way I read the guidelines, there should be substantial risk associated with the conditions being assessed and treated, and that just isn’t the case most of the time. I often joke that to code a 5 I have to do a complete history, complete physical, and then the patient has to die in my office and I have to do the autopsy on my desk. It was funnier when I had a desk big enough to use for that purpose, which I don’t any more. Now back to 99213 and 99214. I code a three for a single problem, low risk visit for which I prescribe anything: Strep throat, bronchitis, ankle sprain (that they walked in on), or for refills on one or two or sometimes even three straight forward stable things like controlled hypertension, allergies and osteopenia, IF there are no new tests and no new complaints. OK, that leaves 99214 for EVERYTHING else (leaving preventive, consult etc out of the picture for this discussion). So, how in the world can a bell curve ever come out of that? A 99214 covers everything from yearly labs and 6 month refills on DM, HTN, & osteoporosis (H & P, blood and urine tests, DEXA (and usually mammogram) on a 66 year old to the 80 year olds on 20 medications whose A & P ends up with 13 or 14 diagnoses by the time I cover everything. A few of those 80 year olds slip over into 99215, but most of them are so stable that the risk is hard to call high. I don’t know what the answer to the problem is, but I do know that this system is leaning toward payment being one-size-fits-all, to the detriment of my bottom line and to the detriment of the patients in practices that operate on the “drive the cattle thru the chute as fast as possible” model. Annie " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 30, 2006 Report Share Posted January 30, 2006 I see what you are saying with the established codes. Yes, the vast majority are either 99213 or 99214. Still I do have a few each of 99212 & 99215, so it will at least be a distribution if not a true “bell”. But in regards to the new visit codes, I definitely use the full bell. I only rarely use a 99205 but routinely use 99201, 99202, 99203, 99204. Basically, I think most doctors still undercode established visits & overcode new visits. By the way, I agree completely about your interpretation of the 99215 code. It is not meant to be used for a visit that you spent an hour on counseling or for multiple stable problems (that would be the extended visit codes, etc). " Overcoding issues " I have been following this group and have learned a lot. I appreciate all of the advice! I have a question with which I would like some help. I recently received a letter from one of our larger HMO's that said my coding was above average for Family Medicine physicians, comparing their 2004 data to my 2005-as it related to 99214-15's. They said that they are going to monitor my billing and, if that trend continues, they will be auditing my records. My initial thoughts-I know that many of us previously downcoded to 13's so as not to have to think or document, or to avoid just such letters. I also know that the " bell curve " is moving upward because we are now becoming more proficient in coding, so the published data from even a few years ago is not accurate now. I am just starting up (1.5 years in this practice). I only have about 75 patients in my panel for this particular group, and, in this short time frame, it has been mainly the more " sick " patients that are coming in. I am getting many chronically ill patients with numerous problems, from our other ambulatory sites (I am hospital employed), and, although these pts. are new to me, I have to bill them as established because all of the sites have the same Tax Id, and these pts are all considered established. Needing to cover so many issues at the " new " visit obviously results in many (mostly) 99214's. Realistically, I feel that my panel is not large enough to have even developed enough data for a " normal " bell curve, but I could be just rationalizing all of this to support my data! My question-should I be pro active and contact the medical director of this HMO who sent the letter to discuss this, find out the time frame for their previous monitoring, and do my own audit of my charting? And if my charting supports my billing pursue this to " prove " to them I am coding appropriately (if my charts verify this)? Or should I not worry about it, just be sure to focus particularly on this group to make sure I do things appropriately in the future. I hate to just let this go because I feel they are sending out letters like this just to scare us into downcoding. My best friend is the compliance officer for a nearby hospital ambulatory care center, doing all of their auditing, and she also works for a company that does just such audits nationwide. She has audited my charting previously, at my request, and tells me I am doing things appropriately. But I hate to " tick off " this company and their director and forever have the spotlight on my practice. By the way, I do not have EHR; we use only paper charts with hand written notes. I have used the StatCoder program on my PDA and find that, according to that, my coding is appropriate, although some issues like medical decision making, can be somewhat grey areas. Any ideas would be appreciated. Sue Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 No, no, no. Just because you document all of those things does not justify a 99203 for a sore throat. That is crazy & will only leave us with a label of “upcoders”. If that were so easy then all doctors would simply have to fill in all components every time and, presto!,it is a 99204. It does not work that way. RE: " Overcoding issues " I rarely code 99203 or 99213’s. And I know my time will probably come to be audited. But, I think its important to be compensated for your work. You are be careful and conscientious, and give your patient excellent care. It shouldn’t be for free. I think its great your friend has already audited your charts and feel you are right on track. We need to value our service, the insurance companies won’t. Don’t let them scare you. Family Medicine , " on the web. · To unsubscribe from this group, send an email to: -unsubscribe · Your use of Yahoo! Groups is subject to the Yahoo! Terms of Service. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 The key topic that most here seem to be forgetting though is that of medical necessity. Documenting a complete PE on a new sore throat is great care & makes the patient feel like you were " thorough " but it would not be considered medically necessary based on an ICD-9 code of 462. So, an outside chart auditor can always override your documentation & say that it was still not considered medically necessary by the prevailing standard of care in the community. If that were not the case, then coding would be full of fraud as any visit could be documented to meet a 99215/99205 & no one except the patient & doctor would know what actually took place. " Overcoding issues " >> >> >>I have been following this group and have learned a lot. I appreciate all >>of the advice! I have a question with which I would like some help. >> >> >>I recently received a letter from one of our larger HMO's that said my >>coding was above average for Family Medicine physicians, comparing their >>2004 data to my 2005-as it related to 99214-15's. They said that they are >>going to monitor my billing and, if that trend continues, they will be >>auditing my records. >> >> >>My initial thoughts-I know that many of us previously downcoded to 13's >>so as not to have to think or document, or to avoid just such letters. I >>also know that the " bell curve " is moving upward because we are now >>becoming more proficient in coding, so the published data from even a few >>years ago is not accurate now. I am just starting up (1.5 years in this >>practice). I only have about 75 patients in my panel for this particular >>group, and, in this short time frame, it has been mainly the more " sick " >>patients that are coming in. I am getting many chronically ill patients >>with numerous problems, from our other ambulatory sites (I am hospital >>employed), and, although these pts. are new to me, I have to bill them as >> established because all of the sites have the same Tax Id, and these >>pts are all considered established. Needing to cover so many issues at >>the " new " visit obviously results in many (mostly) 99214's. >>Realistically, I feel that my panel is not large enough to have even >>developed enough data for a " normal " bell curve, but I could be just >>rationalizing all of this to support my data! >> >> >>My question-should I be pro active and contact the medical director of >>this HMO who sent the letter to discuss this, find out the time frame for >>their previous monitoring, and do my own audit of my charting? And if my >>charting supports my billing pursue this to " prove " to them I am coding >>appropriately (if my charts verify this)? Or should I not worry about it, >>just be sure to focus particularly on this group to make sure I do things >>appropriately in the future. I hate to just let this go because I feel >>they are sending out letters like this just to scare us into downcoding. >>My best friend is the compliance officer for a nearby hospital >>ambulatory care center, doing all of their auditing, and she also works >>for a company that does just such audits nationwide. She has audited my >>charting previously, at my request, and tells me I am doing things >>appropriately. But I hate to " tick off " this company and their director >>and forever have the spotlight on my practice. By the way, I do not have >>EHR; we use only paper charts with hand written notes. I have used the >>StatCoder program on my PDA and find that, according to that, my coding >>is appropriate, although some issues like medical decision making, can be >>somewhat grey areas. >> >> >>Any ideas would be appreciated. >> >> >>Sue >> >> >> >> >> >>YAHOO! GROUPS LINKS >> >> Visit your group " " on the web. >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 A good representative example: I just saw a 17 yo female as a new patient this AM. CC was sore throat of 3 days duration, getting slightly worse. Absolutely no other complaints, on no meds, otherwise healthy. Rapid strep test done, RX written. Gave patient education handout from MDconsult on pharyngitis. Code: 99202. For me to try to document a head to toe exam to make that a 99203 or higher would be fraud in my book. Sure, my history/ROS may be there but not the MDM or necessity. " Overcoding issues " >> >> >>I have been following this group and have learned a lot. I appreciate all >>of the advice! I have a question with which I would like some help. >> >> >>I recently received a letter from one of our larger HMO's that said my >>coding was above average for Family Medicine physicians, comparing their >>2004 data to my 2005-as it related to 99214-15's. They said that they are >>going to monitor my billing and, if that trend continues, they will be >>auditing my records. >> >> >>My initial thoughts-I know that many of us previously downcoded to 13's >>so as not to have to think or document, or to avoid just such letters. I >>also know that the " bell curve " is moving upward because we are now >>becoming more proficient in coding, so the published data from even a few >>years ago is not accurate now. I am just starting up (1.5 years in this >>practice). I only have about 75 patients in my panel for this particular >>group, and, in this short time frame, it has been mainly the more " sick " >>patients that are coming in. I am getting many chronically ill patients >>with numerous problems, from our other ambulatory sites (I am hospital >>employed), and, although these pts. are new to me, I have to bill them as >> established because all of the sites have the same Tax Id, and these >>pts are all considered established. Needing to cover so many issues at >>the " new " visit obviously results in many (mostly) 99214's. >>Realistically, I feel that my panel is not large enough to have even >>developed enough data for a " normal " bell curve, but I could be just >>rationalizing all of this to support my data! >> >> >>My question-should I be pro active and contact the medical director of >>this HMO who sent the letter to discuss this, find out the time frame for >>their previous monitoring, and do my own audit of my charting? And if my >>charting supports my billing pursue this to " prove " to them I am coding >>appropriately (if my charts verify this)? Or should I not worry about it, >>just be sure to focus particularly on this group to make sure I do things >>appropriately in the future. I hate to just let this go because I feel >>they are sending out letters like this just to scare us into downcoding. >>My best friend is the compliance officer for a nearby hospital >>ambulatory care center, doing all of their auditing, and she also works >>for a company that does just such audits nationwide. She has audited my >>charting previously, at my request, and tells me I am doing things >>appropriately. But I hate to " tick off " this company and their director >>and forever have the spotlight on my practice. By the way, I do not have >>EHR; we use only paper charts with hand written notes. I have used the >>StatCoder program on my PDA and find that, according to that, my coding >>is appropriate, although some issues like medical decision making, can be >>somewhat grey areas. >> >> >>Any ideas would be appreciated. >> >> >>Sue >> >> >> >> >> >>YAHOO! GROUPS LINKS >> >> Visit your group " " on the web. >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 A good representative example: I just saw a 17 yo female as a new patient this AM. CC was sore throat of 3 days duration, getting slightly worse. Absolutely no other complaints, on no meds, otherwise healthy. Rapid strep test done, RX written. Gave patient education handout from MDconsult on pharyngitis. Code: 99202. For me to try to document a head to toe exam to make that a 99203 or higher would be fraud in my book. Sure, my history/ROS may be there but not the MDM or necessity. " Overcoding issues " >> >> >>I have been following this group and have learned a lot. I appreciate all >>of the advice! I have a question with which I would like some help. >> >> >>I recently received a letter from one of our larger HMO's that said my >>coding was above average for Family Medicine physicians, comparing their >>2004 data to my 2005-as it related to 99214-15's. They said that they are >>going to monitor my billing and, if that trend continues, they will be >>auditing my records. >> >> >>My initial thoughts-I know that many of us previously downcoded to 13's >>so as not to have to think or document, or to avoid just such letters. I >>also know that the " bell curve " is moving upward because we are now >>becoming more proficient in coding, so the published data from even a few >>years ago is not accurate now. I am just starting up (1.5 years in this >>practice). I only have about 75 patients in my panel for this particular >>group, and, in this short time frame, it has been mainly the more " sick " >>patients that are coming in. I am getting many chronically ill patients >>with numerous problems, from our other ambulatory sites (I am hospital >>employed), and, although these pts. are new to me, I have to bill them as >> established because all of the sites have the same Tax Id, and these >>pts are all considered established. Needing to cover so many issues at >>the " new " visit obviously results in many (mostly) 99214's. >>Realistically, I feel that my panel is not large enough to have even >>developed enough data for a " normal " bell curve, but I could be just >>rationalizing all of this to support my data! >> >> >>My question-should I be pro active and contact the medical director of >>this HMO who sent the letter to discuss this, find out the time frame for >>their previous monitoring, and do my own audit of my charting? And if my >>charting supports my billing pursue this to " prove " to them I am coding >>appropriately (if my charts verify this)? Or should I not worry about it, >>just be sure to focus particularly on this group to make sure I do things >>appropriately in the future. I hate to just let this go because I feel >>they are sending out letters like this just to scare us into downcoding. >>My best friend is the compliance officer for a nearby hospital >>ambulatory care center, doing all of their auditing, and she also works >>for a company that does just such audits nationwide. She has audited my >>charting previously, at my request, and tells me I am doing things >>appropriately. But I hate to " tick off " this company and their director >>and forever have the spotlight on my practice. By the way, I do not have >>EHR; we use only paper charts with hand written notes. I have used the >>StatCoder program on my PDA and find that, according to that, my coding >>is appropriate, although some issues like medical decision making, can be >>somewhat grey areas. >> >> >>Any ideas would be appreciated. >> >> >>Sue >> >> >> >> >> >>YAHOO! GROUPS LINKS >> >> Visit your group " " on the web. >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 Which is why this system is so dysfunctional and leans heavily toward benefiting insurance companies. If you don’t document enough, it never happened. If you document more than the typical care in the community, you’re overcoding. And yet, we all would agree that most primary care docs are not coding appropriately with the majority of those codes being lower than they should be (so the standard is messed up), leaving those of us “outliers” set up for insurance fraud charges when we might actually be coding appropriately. So why not go back to a system where the doctor and patient (who were actually in the room) decide on what the appropriate code/charge should be? If every code is a 99215 (for the sake of taking the argument to the absurd), have the insurance company send a survey to the patient asking if indeed they got 40 minutes of face-to-face time with the doctor addressing all their complex medical issues. If patient rating scales on surveys are accurate, then they should be able to either confirm or deny the visit code. In the meantime, all we can do is guess as to what the insurance company determines to be “medically necessary” for billing purposes and leave our truly medically necessary judgments in the exam room. (Sorry if I seem bitter, but this is perhaps the most frustrating part of practicing medicine) " Overcoding issues " >> >> >>I have been following this group and have learned a lot. I appreciate all >>of the advice! I have a question with which I would like some help. >> >> >>I recently received a letter from one of our larger HMO's that said my >>coding was above average for Family Medicine physicians, comparing their >>2004 data to my 2005-as it related to 99214-15's. They said that they are >>going to monitor my billing and, if that trend continues, they will be >>auditing my records. >> >> >>My initial thoughts-I know that many of us previously downcoded to 13's >>so as not to have to think or document, or to avoid just such letters. I >>also know that the " bell curve " is moving upward because we are now >>becoming more proficient in coding, so the published data from even a few >>years ago is not accurate now. I am just starting up (1.5 years in this >>practice). I only have about 75 patients in my panel for this particular >>group, and, in this short time frame, it has been mainly the more " sick " >>patients that are coming in. I am getting many chronically ill patients >>with numerous problems, from our other ambulatory sites (I am hospital >>employed), and, although these pts. are new to me, I have to bill them as >> established because all of the sites have the same Tax Id, and these >>pts are all considered established. Needing to cover so many issues at >>the " new " visit obviously results in many (mostly) 99214's. >>Realistically, I feel that my panel is not large enough to have even >>developed enough data for a " normal " bell curve, but I could be just >>rationalizing all of this to support my data! >> >> >>My question-should I be pro active and contact the medical director of >>this HMO who sent the letter to discuss this, find out the time frame for >>their previous monitoring, and do my own audit of my charting? And if my >>charting supports my billing pursue this to " prove " to them I am coding >>appropriately (if my charts verify this)? Or should I not worry about it, >>just be sure to focus particularly on this group to make sure I do things >>appropriately in the future. I hate to just let this go because I feel >>they are sending out letters like this just to scare us into downcoding. >>My best friend is the compliance officer for a nearby hospital >>ambulatory care center, doing all of their auditing, and she also works >>for a company that does just such audits nationwide. She has audited my >>charting previously, at my request, and tells me I am doing things >>appropriately. But I hate to " tick off " this company and their director >>and forever have the spotlight on my practice. By the way, I do not have >>EHR; we use only paper charts with hand written notes. I have used the >>StatCoder program on my PDA and find that, according to that, my coding >>is appropriate, although some issues like medical decision making, can be >>somewhat grey areas. >> >> >>Any ideas would be appreciated. >> >> >>Sue >> >> >> >> >> >>YAHOO! GROUPS LINKS >> >> Visit your group " " on the web. >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 Yes, all true & good points. " Overcoding issues " >> >> >>I have been following this group and have learned a lot. I appreciate all >>of the advice! I have a question with which I would like some help. >> >> >>I recently received a letter from one of our larger HMO's that said my >>coding was above average for Family Medicine physicians, comparing their >>2004 data to my 2005-as it related to 99214-15's. They said that they are >>going to monitor my billing and, if that trend continues, they will be >>auditing my records. >> >> >>My initial thoughts-I know that many of us previously downcoded to 13's >>so as not to have to think or document, or to avoid just such letters. I >>also know that the " bell curve " is moving upward because we are now >>becoming more proficient in coding, so the published data from even a few >>years ago is not accurate now. I am just starting up (1.5 years in this >>practice). I only have about 75 patients in my panel for this particular >>group, and, in this short time frame, it has been mainly the more " sick " >>patients that are coming in. I am getting many chronically ill patients >>with numerous problems, from our other ambulatory sites (I am hospital >>employed), and, although these pts. are new to me, I have to bill them as >> established because all of the sites have the same Tax Id, and these >>pts are all considered established. Needing to cover so many issues at >>the " new " visit obviously results in many (mostly) 99214's. >>Realistically, I feel that my panel is not large enough to have even >>developed enough data for a " normal " bell curve, but I could be just >>rationalizing all of this to support my data! >> >> >>My question-should I be pro active and contact the medical director of >>this HMO who sent the letter to discuss this, find out the time frame for >>their previous monitoring, and do my own audit of my charting? And if my >>charting supports my billing pursue this to " prove " to them I am coding >>appropriately (if my charts verify this)? Or should I not worry about it, >>just be sure to focus particularly on this group to make sure I do things >>appropriately in the future. I hate to just let this go because I feel >>they are sending out letters like this just to scare us into downcoding. >>My best friend is the compliance officer for a nearby hospital >>ambulatory care center, doing all of their auditing, and she also works >>for a company that does just such audits nationwide. She has audited my >>charting previously, at my request, and tells me I am doing things >>appropriately. But I hate to " tick off " this company and their director >>and forever have the spotlight on my practice. By the way, I do not have >>EHR; we use only paper charts with hand written notes. I have used the >>StatCoder program on my PDA and find that, according to that, my coding >>is appropriate, although some issues like medical decision making, can be >>somewhat grey areas. >> >> >>Any ideas would be appreciated. >> >> >>Sue >> >> >> >> >> >>YAHOO! GROUPS LINKS >> >> Visit your group " " on the web. >> >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted January 31, 2006 Report Share Posted January 31, 2006 You all have reminded me (as if I needed reminding) why I decided not to contract with insurance or Medicare! I still need to deal with arbitrary and illogical definitions of medical necessity when I order meds and tests for my insurance and Medicare patients, but at least I get paid and can stay in business. Rancho Mirage --- Brock DO wrote: > The key topic that most here seem to be forgetting > though is that of medical > necessity. Documenting a complete PE on a new sore > throat is great care & > makes the patient feel like you were " thorough " but > it would not be > considered medically necessary based on an ICD-9 > code of 462. So, an > outside chart auditor can always override your > documentation & say that it > was still not considered medically necessary by the > prevailing standard of > care in the community. If that were not the case, > then coding would be full > of fraud as any visit could be documented to meet a > 99215/99205 & no one > except the patient & doctor would know what actually > took place. > > > > RE: " Overcoding > issues " > >> > >> > >>I don't see how we can ever expect a bell curve > out of a 5 point scale > >>that really only has 2 " usable codes " . In my > simple minded way of > >>looking at things " (sticking to established > patients for this discussion) > > >>99211 can't happen in my office, as I have no > nurse or other staff, it > >>the patient sees anybody, they see me, and seeing > the MD makes it at > >>least a 99212. For me to code a 99212 the > patient did not need to come > >>in anyway, and I generally head those off with > phone triage. An example > >>would be a simple sunburn that somebody thought I > would give them Lortab > >>for: I walk in, say " Use sunscreen and this won't > happen " and " No you > >>can't have 60 lortab for it. Take some ibuprofen > and get some Solarcaine > > >>spray. " (this has only ever happened once, and it > was one of only a > >>handful of times I have ever coded a 99212. Lets > skip 99213 and 99214 > >>for a sec and go to 99215. I have only ever coded > that a very few times > >>also. I know some people code it based on time, > but even though it is > >>not unusual for me to meet the time criteria, I > always get hung on the > >>level of risk. The way I read the guidelines, > there should be > >>substantial risk associated with the conditions > being assessed and > >>treated, and that just isn't the case most of the > time. I often joke > >>that to code a 5 I have to do a complete history, > complete physical, and > >>then the patient has to die in my office and I > have to do the autopsy on > >>my desk. It was funnier when I had a desk big > enough to use for that > >>purpose, which I don't any more. > >> > >> > >>Now back to 99213 and 99214. I code a three for a > single problem, low > >>risk visit for which I prescribe anything: Strep > throat, bronchitis, > >>ankle sprain (that they walked in on), or for > refills on one or two or > >>sometimes even three straight forward stable > things like controlled > >>hypertension, allergies and osteopenia, IF there > are no new tests and no > >>new complaints. OK, that leaves 99214 for > EVERYTHING else (leaving > >>preventive, consult etc out of the picture for > this discussion). So, > >>how in the world can a bell curve ever come out > of that? A 99214 covers > >>everything from yearly labs and 6 month refills > on DM, HTN, & > >>osteoporosis (H & P, blood and urine tests, DEXA > (and usually mammogram) on > > >>a 66 year old to the 80 year olds on 20 > medications whose A & P ends up > >>with 13 or 14 diagnoses by the time I cover > everything. A few of those > >>80 year olds slip over into 99215, but most of > them are so stable that > >>the risk is hard to call high. > >> > >> > >>I don't know what the answer to the problem is, > but I do know that this > >>system is leaning toward payment being > one-size-fits-all, to the > >>detriment of my bottom line and to the detriment > of the patients in > === message truncated === __________________________________________________ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 On the contrary, I would not be in business for long if I did not take insurances where I'm at. Also, I'm sure I can make more money by taking insurances than cash only, hassles and all. > > > Date: 2006/01/31 Tue PM 06:42:01 EST > To: > Subject: RE: " Overcoding issues " > > You all have reminded me (as if I needed reminding) > why I decided not to contract with insurance or > Medicare! I still need to deal with arbitrary and > illogical definitions of medical necessity when I > order meds and tests for my insurance and Medicare > patients, but at least I get paid and can stay in > business. > > > Rancho Mirage > > --- Brock DO wrote: > > > The key topic that most here seem to be forgetting > > though is that of medical > > necessity. Documenting a complete PE on a new sore > > throat is great care & > > makes the patient feel like you were " thorough " but > > it would not be > > considered medically necessary based on an ICD-9 > > code of 462. So, an > > outside chart auditor can always override your > > documentation & say that it > > was still not considered medically necessary by the > > prevailing standard of > > care in the community. If that were not the case, > > then coding would be full > > of fraud as any visit could be documented to meet a > > 99215/99205 & no one > > except the patient & doctor would know what actually > > took place. > > > > > > > > RE: " Overcoding > > issues " > > >> > > >> > > >>I don't see how we can ever expect a bell curve > > out of a 5 point scale > > >>that really only has 2 " usable codes " . In my > > simple minded way of > > >>looking at things " (sticking to established > > patients for this discussion) > > > > >>99211 can't happen in my office, as I have no > > nurse or other staff, it > > >>the patient sees anybody, they see me, and seeing > > the MD makes it at > > >>least a 99212. For me to code a 99212 the > > patient did not need to come > > >>in anyway, and I generally head those off with > > phone triage. An example > > >>would be a simple sunburn that somebody thought I > > would give them Lortab > > >>for: I walk in, say " Use sunscreen and this won't > > happen " and " No you > > >>can't have 60 lortab for it. Take some ibuprofen > > and get some Solarcaine > > > > >>spray. " (this has only ever happened once, and it > > was one of only a > > >>handful of times I have ever coded a 99212. Lets > > skip 99213 and 99214 > > >>for a sec and go to 99215. I have only ever coded > > that a very few times > > >>also. I know some people code it based on time, > > but even though it is > > >>not unusual for me to meet the time criteria, I > > always get hung on the > > >>level of risk. The way I read the guidelines, > > there should be > > >>substantial risk associated with the conditions > > being assessed and > > >>treated, and that just isn't the case most of the > > time. I often joke > > >>that to code a 5 I have to do a complete history, > > complete physical, and > > >>then the patient has to die in my office and I > > have to do the autopsy on > > >>my desk. It was funnier when I had a desk big > > enough to use for that > > >>purpose, which I don't any more. > > >> > > >> > > >>Now back to 99213 and 99214. I code a three for a > > single problem, low > > >>risk visit for which I prescribe anything: Strep > > throat, bronchitis, > > >>ankle sprain (that they walked in on), or for > > refills on one or two or > > >>sometimes even three straight forward stable > > things like controlled > > >>hypertension, allergies and osteopenia, IF there > > are no new tests and no > > >>new complaints. OK, that leaves 99214 for > > EVERYTHING else (leaving > > >>preventive, consult etc out of the picture for > > this discussion). So, > > >>how in the world can a bell curve ever come out > > of that? A 99214 covers > > >>everything from yearly labs and 6 month refills > > on DM, HTN, & > > >>osteoporosis (H & P, blood and urine tests, DEXA > > (and usually mammogram) on > > > > >>a 66 year old to the 80 year olds on 20 > > medications whose A & P ends up > > >>with 13 or 14 diagnoses by the time I cover > > everything. A few of those > > >>80 year olds slip over into 99215, but most of > > them are so stable that > > >>the risk is hard to call high. > > >> > > >> > > >>I don't know what the answer to the problem is, > > but I do know that this > > >>system is leaning toward payment being > > one-size-fits-all, to the > > >>detriment of my bottom line and to the detriment > > of the patients in > > > === message truncated === > > > __________________________________________________ > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Annie, I agree that 99213 and 99214 are basically the only relevant codes (but I was afraid to admit this. ) I LOVE your 99215 criteria: " I often joke >>that to code a 5 I have to do a complete history, complete physical, and >>then the patient has to die in my office and I have to do the autopsy on >>my desk. It was funnier when I had a desk big enough to use for that >>purpose, which I don't any more. " Gwen --- " Brady, MD " wrote: > Which is why this system is so dysfunctional and > leans heavily toward > benefiting insurance companies. If you don't > document enough, it never > happened. If you document more than the typical care > in the community, > you're overcoding. And yet, we all would agree that > most primary care > docs are not coding appropriately with the majority > of those codes being > lower than they should be (so the standard is messed > up), leaving those > of us " outliers " set up for insurance fraud charges > when we might > actually be coding appropriately. So why not go back > to a system where > the doctor and patient (who were actually in the > room) decide on what > the appropriate code/charge should be? If every code > is a 99215 (for the > sake of taking the argument to the absurd), have the > insurance company > send a survey to the patient asking if indeed they > got 40 minutes of > face-to-face time with the doctor addressing all > their complex medical > issues. If patient rating scales on surveys are > accurate, then they > should be able to either confirm or deny the visit > code. In the > meantime, all we can do is guess as to what the > insurance company > determines to be " medically necessary " for billing > purposes and leave > our truly medically necessary judgments in the exam > room. > > (Sorry if I seem bitter, but this is perhaps the > most frustrating part > of practicing medicine) > > RE: " Overcoding > issues " > >> > >> > >>I don't see how we can ever expect a bell curve > out of a 5 point > scale > >>that really only has 2 " usable codes " . In my > simple minded way of > >>looking at things " (sticking to established > patients for this > discussion) > > >>99211 can't happen in my office, as I have no > nurse === message truncated === Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 Your example of a 17yo female with a sore throat could have easily been a 99203. Here's why: Hx - You've got the chief complaint; HPI only needs 1-3 elements, which you have; you only need pertinent ROS - such as fever, ear pain, other URI symptoms (which presumably you asked about - since you've state " no other complaints " ) PE - you don't need a head-to-toe exam for a Level 3 visit, you just need at least 6 elements: ears, nose, throat, Lymph nodes, heart, lungs are 6 (but you could also easily justify abdominal exam as mono is on the differential, esp in this age group and splenomegaly would be pertinent) Decision-making: Checking a throat culture and deciding whether or not to use antibiotics justifies " low " decision-making. All that I've described is pertinent and justifiable, so coding for a 99203 would not be fraudulent, nor unnecessary. Debbie New Jersey > >Reply-To: >To: < > >Subject: RE: " Overcoding issues " >Date: Tue, 31 Jan 2006 11:15:07 -0500 > >A good representative example: I just saw a 17 yo female as a new patient >this AM. CC was sore throat of 3 days duration, getting slightly worse. >Absolutely no other complaints, on no meds, otherwise healthy. Rapid strep >test done, RX written. Gave patient education handout from MDconsult on >pharyngitis. Code: 99202. For me to try to document a head to toe exam to >make that a 99203 or higher would be fraud in my book. Sure, my >history/ROS >may be there but not the MDM or necessity. > > > > " Overcoding issues " > >> > >> > >>I have been following this group and have learned a lot. I appreciate >all > > >>of the advice! I have a question with which I would like some help. > >> > >> > >>I recently received a letter from one of our larger HMO's that said my > >>coding was above average for Family Medicine physicians, comparing >their > >>2004 data to my 2005-as it related to 99214-15's. They said that they >are > > >>going to monitor my billing and, if that trend continues, they will be > >>auditing my records. > >> > >> > >>My initial thoughts-I know that many of us previously downcoded to 13's > >>so as not to have to think or document, or to avoid just such letters. >I > >>also know that the " bell curve " is moving upward because we are now > >>becoming more proficient in coding, so the published data from even a >few > > >>years ago is not accurate now. I am just starting up (1.5 years in this > >>practice). I only have about 75 patients in my panel for this >particular > >>group, and, in this short time frame, it has been mainly the more > " sick " > >>patients that are coming in. I am getting many chronically ill patients > >>with numerous problems, from our other ambulatory sites (I am hospital > >>employed), and, although these pts. are new to me, I have to bill them >as > > >> established because all of the sites have the same Tax Id, and these > >>pts are all considered established. Needing to cover so many issues at > >>the " new " visit obviously results in many (mostly) 99214's. > >>Realistically, I feel that my panel is not large enough to have even > >>developed enough data for a " normal " bell curve, but I could be just > >>rationalizing all of this to support my data! > >> > >> > >>My question-should I be pro active and contact the medical director of > >>this HMO who sent the letter to discuss this, find out the time frame >for > > >>their previous monitoring, and do my own audit of my charting? And if >my > >>charting supports my billing pursue this to " prove " to them I am coding > >>appropriately (if my charts verify this)? Or should I not worry about >it, > > >>just be sure to focus particularly on this group to make sure I do >things > > >>appropriately in the future. I hate to just let this go because I feel > >>they are sending out letters like this just to scare us into >downcoding. > >>My best friend is the compliance officer for a nearby hospital > >>ambulatory care center, doing all of their auditing, and she also works > >>for a company that does just such audits nationwide. She has audited my > >>charting previously, at my request, and tells me I am doing things > >>appropriately. But I hate to " tick off " this company and their director > >>and forever have the spotlight on my practice. By the way, I do not >have > >>EHR; we use only paper charts with hand written notes. I have used the > >>StatCoder program on my PDA and find that, according to that, my coding > >>is appropriate, although some issues like medical decision making, can >be > > >>somewhat grey areas. > >> > >> > >>Any ideas would be appreciated. > >> > >> > >>Sue > >> > >> > >> > >> > >> > >>YAHOO! GROUPS LINKS > >> > >> Visit your group " " on the web. > >> > >> Quote Link to comment Share on other sites More sharing options...
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