Guest guest Posted February 1, 2006 Report Share Posted February 1, 2006 I think that the guidelines that say the person has to be half dead to use the level 5 visit refer to a single severe problem. Every coding book that I have seen will give you points for multiple new or old problems that are addressed at that visit. For example if you have a return patient who is depressed , obese, diabetic who is also hypertensive and several of those problems are not in control every coding resource that I have seen would let you code that as a 5 assuming that your history or physical support that. Also I have been taught that you may code a return level 5 with just the history and physical at the level 5 if the patient's diagnosis justifies the complete physical. For example all of my diabetics at their annual physical get a complete physical. I feel that diabetes is a disease that affects almost the entire body and a once a year complete physical is medically necessary. Our local medicare carrier will approve these as long as it is only once a year.Larry LIndeman MD If there are two groups out there, and both are wrong, what's to debate? Of course the codes are not intended to be used based on time, but that is why there is a clause to catch a visit where counseling dominated the visit--that is clearly documented in CPT--someone out there realizes that sometimes we can spend a lot of time educating patients, yet not fulfill every "bullet" out there to achieve respectable remuneration. I guess we'll have to agree to disagree, but I take issue with inflammatory statements that accuse physicians of fraud for trying to make a difference--especially when everyone is making subjective arguments. It's like damning for and against checking PSA's. My word! Would you be so quick to hang a man for circumstantial evidence? The only "two camps" I see are--either crank out 30-40 visits and day, or create an idealized comprehensive practice that delivers a service that is clearly recognized as vital yet unattainable in traditional practice. My conscience is clear, and I guess I'm done debating this. A person must follow their own path where their heart leads them. CB > > The 99215/99205 codes are not really intended to be used based on time. > This topic has been debated & debated, but that is the way I understand it > at least. Those codes are to be reserved for the sickest high acuity > patients & not someone that you just happened to spend a lot of counseling > time with. Using those codes on more than a rare occasion is an absolute > guaranteed way to draw the auditing spotlight right down on you. The proper > way to code a long visit is to use a 99214 or 99203/99204 plus an extended > visit code, & that combo actually pays a lot more anyways. I am starting > realizing that there are basically two camps out there: undercoders & > upcoders. Most doctors continue to undercode established visits (ie, every > visit is a 99213) & overcode new visits (ie, every one is either a 992903 or > 99204). > > > > 99205 0r 215 > > It is rare that I would ever bill these codes not based on time. The > only times I have found it reasonable to use these codes by medical > decision making (i.e. risk and other things) was when I recommended > the patient be admitted for hospitalization and they refused! > > To the argument before that "what would I use for a higher code for > chest pain patient if I use a 203/214 on a sore throat," I don't think > that's important-I don't need a higher code for the more complex > patient that takes about the same amount of time. In my way of doing > things, the WORK involved is about the same. And, the beautiful part > is, both involve very thorough, patient-satisfied care which probably > saves money in the long run. > > C. Brown, M.D. > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 Larry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 Larry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 For many patients preventive services are not covered. Also I have had very mixed success at getting insurance companies to honor the modifier 25. For my female patients I will do their pap and breast exam at a separate preventive visit. For my male patients I will also sometimes do a separate preventive visit. At my preventive visits I like to spend a lot of time on counseling on ways to stay healthy. I often wouldn't have time to do this if I'm spending a lot of time on their diabetes. My annual diabetes visits often run up to 45 minutes to an hour as it is. If the majority of the visit is spent on prevention and only a little of it is disease related I will code both for the preventive and a level 2 or 3 visit and hope for the best from the payors.Larry Lindeman MDLarry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 For many patients preventive services are not covered. Also I have had very mixed success at getting insurance companies to honor the modifier 25. For my female patients I will do their pap and breast exam at a separate preventive visit. For my male patients I will also sometimes do a separate preventive visit. At my preventive visits I like to spend a lot of time on counseling on ways to stay healthy. I often wouldn't have time to do this if I'm spending a lot of time on their diabetes. My annual diabetes visits often run up to 45 minutes to an hour as it is. If the majority of the visit is spent on prevention and only a little of it is disease related I will code both for the preventive and a level 2 or 3 visit and hope for the best from the payors.Larry Lindeman MDLarry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 For many patients preventive services are not covered. Also I have had very mixed success at getting insurance companies to honor the modifier 25. For my female patients I will do their pap and breast exam at a separate preventive visit. For my male patients I will also sometimes do a separate preventive visit. At my preventive visits I like to spend a lot of time on counseling on ways to stay healthy. I often wouldn't have time to do this if I'm spending a lot of time on their diabetes. My annual diabetes visits often run up to 45 minutes to an hour as it is. If the majority of the visit is spent on prevention and only a little of it is disease related I will code both for the preventive and a level 2 or 3 visit and hope for the best from the payors.Larry Lindeman MDLarry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 I basically agree. The challenge is getting enough ROS... you need 11+ points. I've started using a form with all the systems listed. At times I have a patient with multiple chronic problems (dm, htn, asthma, AK's, depression) and when I'm seeing them after 4-6 months there are a lot of proper questions to ask ... then I realize I only need to ask one other system, ask if they have xs bleeding/bruising (takes ASA for DM heart risk) and bingo! I've got enough history and the A/P has six different problems with some adjustments or follow up testing needed. That can certainly be 99215. And let's remember, counselling/organizing records, etc for more than 25 or 40 minutes does NOT mean we're chatting! If 20 minutes is spent on " health issues " and then 25 minutes spent on counselling for adjustment disorder (for whatever stress you want to consider) then that is a 99214. Please do not imply that would be " upcoding " because it is not. Tim > I think that the guidelines that say the person has to be half dead to > use the level 5 visit refer to a single severe problem. Every coding > book that I have seen will give you points for multiple new or old > problems that are addressed at that visit. For example if you have a > return patient who is depressed , obese, diabetic who is also > hypertensive and several of those problems are not in control every > coding resource that I have seen would let you code that as a 5 > assuming that your history or physical support that. > Also I have been taught that you may code a return level 5 with just > the history and physical at the level 5 if the patient's diagnosis > justifies the complete physical. For example all of my diabetics at > their annual physical get a complete physical. I feel that diabetes is > a disease that affects almost the entire body and a once a year > complete physical is medically necessary. Our local medicare carrier > will approve these as long as it is only once a year. > Larry LIndeman MD > > > > > >> If there are two groups out there, and both are wrong, what's to >> debate? Of course the codes are not intended to be used based on >> time, but that is why there is a clause to catch a visit where >> counseling dominated the visit--that is clearly documented in >> CPT--someone out there realizes that sometimes we can spend a lot of >> time educating patients, yet not fulfill every " bullet " out there to >> achieve respectable remuneration. >> >> I guess we'll have to agree to disagree, but I take issue with >> inflammatory statements that accuse physicians of fraud for trying to >> make a difference--especially when everyone is making subjective >> arguments. It's like damning for and against checking PSA's. My >> word! Would you be so quick to hang a man for circumstantial >> evidence? >> >> The only " two camps " I see are--either crank out 30-40 visits and day, >> or create an idealized comprehensive practice that delivers a service >> that is clearly recognized as vital yet unattainable in traditional >> practice. My conscience is clear, and I guess I'm done debating this. >> A person must follow their own path where their heart leads them. >> >> CB >> >> >> >> >> > >> > The 99215/99205 codes are not really intended to be used based on >> time. >> > This topic has been debated & debated, but that is the way I >> understand it >> > at least. Those codes are to be reserved for the sickest high >> acuity >> > patients & not someone that you just happened to spend a lot of >> counseling >> > time with. Using those codes on more than a rare occasion is an >> absolute >> > guaranteed way to draw the auditing spotlight right down on you. >> The proper >> > way to code a long visit is to use a 99214 or 99203/99204 plus an >> extended >> > visit code, & that combo actually pays a lot more anyways. I am >> starting >> > realizing that there are basically two camps out there: >> undercoders & >> > upcoders. Most doctors continue to undercode established visits >> (ie, every >> > visit is a 99213) & overcode new visits (ie, every one is either a >> 992903 or >> > 99204). >> > >> > >> > >> > 99205 0r 215 >> > >> > It is rare that I would ever bill these codes not based on time. >> The >> > only times I have found it reasonable to use these codes by medical >> decision making (i.e. risk and other things) was when I recommended >> the patient be admitted for hospitalization and they refused! >> > >> > To the argument before that " what would I use for a higher code for >> chest pain patient if I use a 203/214 on a sore throat, " I don't >> think >> > that's important-I don't need a higher code for the more complex >> patient that takes about the same amount of time. In my way of >> doing >> > things, the WORK involved is about the same. And, the beautiful >> part >> > is, both involve very thorough, patient-satisfied care which >> probably >> > saves money in the long run. >> > >> > C. Brown, M.D. >> > >> > >> > >> > >> > >> > >> > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 Several of my payors deny the 25 modifier on the first pass and then pay it with when called directly on it. I think their software bumps it out automatically, which saves them a bunch of money. I'm stubborn and keep calling, and I think paying someone to phone and/or resubmit those claims pays off. For many patients preventive services are not covered. Also I have had very mixed success at getting insurance companies to honor the modifier 25. For my female patients I will do their pap and breast exam at a separate preventive visit. For my male patients I will also sometimes do a separate preventive visit. At my preventive visits I like to spend a lot of time on counseling on ways to stay healthy. I often wouldn't have time to do this if I'm spending a lot of time on their diabetes. My annual diabetes visits often run up to 45 minutes to an hour as it is. If the majority of the visit is spent on prevention and only a little of it is disease related I will code both for the preventive and a level 2 or 3 visit and hope for the best from the payors.Larry Lindeman MDLarry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 2, 2006 Report Share Posted February 2, 2006 Several of my payors deny the 25 modifier on the first pass and then pay it with when called directly on it. I think their software bumps it out automatically, which saves them a bunch of money. I'm stubborn and keep calling, and I think paying someone to phone and/or resubmit those claims pays off. For many patients preventive services are not covered. Also I have had very mixed success at getting insurance companies to honor the modifier 25. For my female patients I will do their pap and breast exam at a separate preventive visit. For my male patients I will also sometimes do a separate preventive visit. At my preventive visits I like to spend a lot of time on counseling on ways to stay healthy. I often wouldn't have time to do this if I'm spending a lot of time on their diabetes. My annual diabetes visits often run up to 45 minutes to an hour as it is. If the majority of the visit is spent on prevention and only a little of it is disease related I will code both for the preventive and a level 2 or 3 visit and hope for the best from the payors.Larry Lindeman MDLarry, Just wondered-why would you not code a preventive visit for the complete physical, and also code for the appropriate E & M level too? For an established pt. with DM (and probably HTN, increased Cholesterol) you can usually code either a 99213 or 4, depending on the situation. Sue 99205 0r 215> > It is rare that I would ever bill these codes not based on time. The> only times I have found it reasonable to use these codes by medical> decision making (i.e. risk and other things) was when I recommended> the patient be admitted for hospitalization and they refused!> > To the argument before that "what would I use for a higher code for> chest pain patient if I use a 203/214 on a sore throat," I don't think> that's important-I don't need a higher code for the more complex> patient that takes about the same amount of time. In my way of doing> things, the WORK involved is about the same. And, the beautiful part> is, both involve very thorough, patient-satisfied care which probably> saves money in the long run.> > C. Brown, M.D.> > > > > > > Quote Link to comment Share on other sites More sharing options...
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