RE: appt length

[Guest guest]

My MA and I know our patients very well,

having only 400 of them. Usually we know they have several issues, and my

standard OV time is 45-60 minutes, sometimes 30 if we know most things are

under control. This is one of the main reasons that I want to maintain

control over our schedule – everyone thinks they would only need 30

minutes, but they often don’t realize the depth of

education/understanding I strive for. I do have the occasional surprise,

and I either forge on if it’s time to strike when the metal is hot, or

have them come back another time to address the issue. I do have low volume,

obviously.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From: [mailto: ] On Behalf Of Brock DO

Sent: Thursday, September 21, 2006

10:29 AM

To:

Subject: RE:

coding

Scheduling-wise, how do you handle that practice style? In

other words, sometimes you think a patient is just coming for “med

refills” & you end up in that 45+ minute discussion because they are

totally out of control with their metabolic syndrome, etc. Are you

perhaps low enough volume that you can afford to just schedule every patient

for 45 minutes – 1 hour? Or do you just do the best you can &

run behind sometimes? For me, I would rarely allot 45 minutes for an

established pt & so if that long of an appt happened often I would be

hopelessly behind. How do you tweak these uncertainties of chief

complaint vs the actual reason for coming?

-----Original

Message-----

From:

[mailto: ]

On Behalf Of Eads

Sent: Thursday, September 21, 2006

11:10 AM

To:

Subject: RE:

coding

Usually several things are being fine tuned (med dose, replacing a

med, etc) during these visits. I spend a lot of time educating my pts,

and they are fairly sophisticated and appreciate the thoroughness and ability

to address all of their issues (ie, whole person care) at one visit. It

is because of this, in my opinion, that I have scored well by my pts reports in

the IMP study when it comes to providing good information and pt confidence.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO

80863

From:

[mailto: ]

On Behalf Of Brock DO

Sent: Thursday, September 21, 2006

9:55 AM

To:

Subject: RE:

coding

If you have truly spent 45 minutes face to face with a complex

patient as you described, and over half of the time was in counseling/coordination,

then sure you can choose a 99214 + extended or a 99215. But the key is

that there has to be a component of medical decision making & medical

necessity to justify you having spent that much time (ie, sugars & BP out

of control, PPI not helping GERD, etc). Otherwise, any doc could just

make a notation of time spent & code it & be done. Still, if any

one practice is coding much more than ~ 5% 99215 visits you can expect to be

forever flagged & scrutinized because payors will continually want to know

“why do this doctor’s patients repeatedly require so much more time

& complexity versus the majority of other doctors?” I also have

a few patients like you describe but it is very rare that ALL of those issues

are unstable all at once, and even then it is very rare for me to spend 45

minutes face to face, though it sure does feel like it had been that long

sometimes, until I look at the clock & realize I was only in the room 25

minutes. My practice is lower volume but not low volume, and I just can

not spend 45+ minutes too often with one patient. My answer would be more

of a traditional approach: bring them back; they will likely get more out of 2

– 3 shorter visits anyways. In the end though in the few cases

where I’ve spent that much time on a complex pt I have used a 99214 +

extended code, as I still contend that the level 5 codes are not meant for that

type of visit, even though the CPT guideline might technically allow it.

I’ve used the extended codes three or four times & a

99215 about the same, over 2.5 years being open.

-----Original

Message-----

From:

[mailto: ]

On Behalf Of Eads

Sent: Thursday, September 21, 2006

10:27 AM

To:

Subject: RE:

coding

,

I’ve been to coding classes to, and worked with the chart

auditors at my previous large group. Remember that you can code based on

face to face time with established patients. When I’m seeing a

newly diagnosed diabetic and spend an hour with them, I charge a 99214 with a

99354 for the extended time. If I see someone with DM, HTN, metabolic

syndrome, GERD, etc, for 45 minutes, then I code a 99215 based on time and

complexity. As Larry (I think) pointed out, you do get better

reimbursement for the extended time code than using the 99215.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO

80863

From:

[mailto: ]

On Behalf Of Brock DO

Sent: Tuesday, September 19, 2006

11:22 AM

To:

Subject: RE:

Re: money and ODLE

I always get a lot of backlash whenever I bring up the coding

curves, but it makes me suspicious whenever someone says “I rarely code

anything less than a level 4 visit.” If someone has a skin lesion

they want looked at, you see it & decide in 2 seconds it is a wart &

needs nothing other than reassurance how do you code that? That is a

99212 any way you slice it. I think the point most people miss when it

comes to coding is the medical decision making part. They tend to say to

themselves that “I only need 2 out of the 3 for an established code,

& my history & exam met that, so I’m set.” The error

therein is that medical decision has always been intended as the basis for

choosing a code. Yes, technically the chart might pass an audit if you

document a long history & long exam on every visit, but you will be

“flagged” as an upcoder if the medical decision making criteria is

not there. They will forever be watching you more closely. Now,

granted a moderate complexity medical decision making is not too difficult to

obtain (and code a level 4), but a level 5 visit is a whole other ball

game. Every coding lecture I have been to says the same thing: be very

wary of using a level 5 code more than on rare occasion. Most non IMP

docs do the work of a level 4 visit, chart a level 2 visit, and code it a level

3 visit, while we generally do the work of a level 4 AND code a level 4.

Still, many visits should be a level 3 based on medical decision making.

By the way, I have never coded a 99205, ever. I’ve coded 99215

maybe 5 times total. Am I undercoding? Maybe, but I doubt it.

-----Original

Message-----

From:

[mailto: ]

On Behalf Of Ellsworth

Sent: Tuesday, September 19, 2006

11:10 AM

To:

Subject: RE:

Re: money and ODLE

I do not get reimbursed at 137$ a visit, however I RARELY code a

99213- its always an 04 or 14, sometimes an 05, 15. And I’m working with

United Pharm to dispense meds at point of service-a lot of bugs to work out,

And because menopause is my life, I also sell bioidentical hormone creams

at significant less than pharmacies.

As far as efficiency, its no problem getting the patients in and

out, avg visit is 30 minutes. I can clean a room, package up lab samples, print

the next pt’s results and move to the next room ( I run 2 rooms) in 1-2

minutes.

I’m notorious for coming in early or staying late to

see a pt, or squeezing them in during lunch. The problem is the work before and

after. I don’t take lunch and I “catch-up” before and after. So

It is still fun, but the fun definitely wanes as the hour progresses.

That’s why I’m participating with the IMP group. I know

I am on the burnout track and need to make changes.

From:

[mailto: ]

On Behalf Of Brock DO

Sent: Tuesday, September 19, 2006

7:43 AM

To:

Subject: RE:

Re: money and ODLE

I wish I lived nearby because I think I really need a fellow IMP to

sit down & show me on paper how they are averaging $137/visit?

Let’s say I see 50 pt’s in a week. Out of those I might have

10 – 12 99213’s at ~ $50 each, 30 99214’s

at ~ $80 each, & maybe a few preventives at ~ $125 each. There might

also be one preop consult in the mix, a few new pt E/M’s, a few waived

labs, some OMT, etc. As you can see NONE of these visits would pay $137,

let alone create an average of anywhere near $137! What am I missing

here? How can you possibly be collecting $137 per visit? Do you

ever code a 99212 or 99213? Do you have any Medicaid or Medicare?

I’m baffled.

-----Original

Message-----

From:

[mailto: ]

On Behalf Of Gwen Hanson

Sent: Monday, September 18, 2006

11:15 PM

To:

Subject: RE:

Re: money and ODLE

Hi ,

Thanks for being a

former PTA Co-president at Odle! My youngest daughter is there along with Uday's

nephew! Also, I can't believe you're seeing 15-20 patients a day with no

help. How do you do this??? If you give me your efficiency secrets, I'll

try to put them in the WIKI.

I just looked at

my IMP numbers in Bellevue, WA after

being open 21 months. I'm purposely keeping my hours down to spend time with my

husband and 3 teenage daughters. I used Gordon's spread sheet which is an

awesome financial snapshot for those that want to know but don't spend much

time on " financials. "

I'm being

reimbursed an average of $137 per visit, I see a whopping 22 patients per week,

and my overhead is 15%. Notice 7 weeks vacation!

Gwen Hanson

Ellsworth

<jellsworth92> wrote:

Your local county hospital- which one? Overlake

was private last time I was there. I raised my kids in Bellevue

and the plateau (now Sammamish). (You are talking to the former PTA

co-president of Odle Middle School)

Before being an IMP I did some moonlighting

at a large clinic where I saw 30-35 in 7 hours, or 25 during extended

hours at night.

I will be able to answer your

questions on money after my accountant who I just hired sifts through my

financials.

And my average working day is 12-14 hours(patient

time is 9 hours) As an IMP, I avera! ge 15-20 patients a day without a MA or

RN.

However, my practice is a joy and I cannot

really call it work. Sometimes…microseconds… I feel guilty for

being so happy with what I’m doing. I don’t have that twisted

gripping in my stomach or pounding in my chest when climbing out or the car and

entering the workplace that use to haunt me.

The support from Gordon and from this

group ! is incalculable. You are not isolated or alone.

However, what you have outlined

compensation-wise seems excellent.

T. Ellsworth, MD

sdale, Az

From:

[mailto: ]

On Behalf Of umehta00

Sent: Monday, September 18, 2006 3:09 PM

To:

S! ubject: Re: money

Dr Ellsworth, Dr Brock and others,

Sorry for long post and getting back a little late.

I should have clarified that my days are 11 or 12 hr days.

I do Family Medicine and Urgent Care.

I work for my local county hospital 3 days a week (Tuesday, Thursday

and every other weekend) and the salary is 104,000. Yes, I am

usually off every Mon, Wed and Fri.

The clinic is open 1 yr and I see only about 10 pts per day. The max

is 20. (This may change).

All I do is treat the patients.

At the end of the day my eyes are often bleary from too much

computer surfing.

I kept my old job for moon lighting 2 days a month.

I make approximately 23,000 per yr.

80 ($ per hr) x 12 (hrs per shift) x 2(shifts per month) x 12

(months per yr).

These are 12 hr days and very busy occasionally seeing up to 40 pts

per day. (Mostly 27)

At the end of the day I feel satisfied that I did a good job and

kept my skills up.

Total salary approx 127,000/ yr. (104,000 + 23,000)

Working 180 days per year. Not including approx 22 days paid leave

per year.

What does an average Family Medicine Doctor make?

http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_nation

al_HC07000052.html

The summary is below:

Base Pay only:

25 th Percentile – 137,803.

Median - 156,119.

75th Percentile - 183,281.

Total Cash Compensation (Base + Bonus)

25th percentile – 140,838.

Median – 160,044.

75th percentile - 188541

Total Compensation (Base + Bonus + Benefits)

Only Median Reported – 205,701.

The Total Compensation is an additional 23 % of the Total Cash

Compensation and (the Benefits) include:

Social security (4%); 401k/ 403 b (3%); Disability (2%); Healthcare

(3%); Pension (3%); Time off (8 %).

Of course this web site could have incorrect information and things

do change constantly.

I feel these numbers are quite accurate. Benefits do count (20 %

conservatively).

I was let go from my old (now moonlighting) job as they could hire

new doctors cheaper. I grossed about 155 K working hard (although

only approximately 150 shift).

There I had excellent benefits, including the extremely enviable

defined benefit pension plan. (They pay you a fixed amount till the

latter of you or your spouse dies, like social security).

Some points I would like to raise are

1) Average IMP take home is below average non IMP in spite of

working hard.

This may change though as " The expenses for an average non IMP keep

on going up whereas with an IMP they are somewhat controlled " .

2) For the Average non IMP: Financial reward is a great

motivator for working hard.

This is why they keep up with all the extra hours and

lack of family time.

3) It boils down to time and money.

Do you want more time off or more money?

For me I like the fact that I have a lot of time off. I may regret

this decision in the future.

(I know of no one who went to their death bed wishing they had

worked harder).

4) There may be more day to day hassles with an IMP.

5) It is harder to take prolonged/overseas vacation with an IMP.

6) Why do IMP's feel better at the end of the day? It has to do

with a sense of worth and a personal need being fulfilled which is

hard to measure. It is not a way to be financially wealthy but a

great way to contribute to the community and live an honorable life.

7) With an IMP the burn out rate may be low and one can

definitely work longer years therefore financially it all may even

out in the end.

One of the main reasons for me to start an IMP would be to have the

opportunity to work till I am able to (maybe even into my eighties).

I see a lot of older people who have retired and who miss the

intellectual challenge and now have no opportunity to use their

skills. (If you don't use it you loose it).

These are my views only. I am sure this is not the absolute truth as

each case varies. If one is 80 % satisfied/happy with their career

and financial situation then it's great.

Uday Mehta,

Age 46.

Bellevue,

WA

> >

> > I have been thinking about the same things lately, Larry.

> Unfortunately, I

> > only paid myself $45,000 last year (my second year of solo, low

> volume

> > practice) However, my numbers are still not as good as yours. I

> think I

> > average about 8 patients a day. But I also only work about 36

> hours a week.

> > I am definately curious about what others have to say on this

issue

> > Marie Christensen MD

> >

> > _____

> >

> > From: Practiceimprovement <mailto:%

40yahoogroups.com>

> 1

> > [mailto:Practiceimprovement

> <mailto:%40yahoogroups.com> 1 ]

On Behalf

> Of

> Brock DO

> > Sent: Wednesday, September 13, 2006 2:23 PM

> > To: Practiceimprovement <mailto:%

40yahoogroups.com>

> 1

> > Subject: RE: money

> >

> >

> >

> >

> > The problem is that the average of $160,000 includes docs that

do

> the full

> > gamut of FP & usually high volumes. The typical FP still likely

> does AM

> > inpatient work, sees 30+ office patients, sees nursing home

> patients, works

> > 60 hrs per week. It is hard to expect an IMP low volume practice

> to match

> > that because I personally am not working nearly that hard! I do

> not do

> > inpatient, nursing homes, & only work ~ 36 - 40 hrs per week

> (averaging 12 -

> > 15 pts/day), so of course I am not going to make $160,000, but

> that is a

> > lifestyle tradeoff have chosen. At least that is the way I have

> > rationalized not making " average " income in my mind.

> >

> >

> >

> >

> >

> >

> >

> > money

> >

> >

> >

> > Recently I have had money on my mind. After 2 years in my new

> > practice I an finally close to making $150,000 which is still

less

> > than I made at my old job. However I am finding it difficult to

> > figure out how to make anymore than that since I don't think

that

> I

> > can see any more patients in a day. The median income of FP's is

> over

> > $160.000/yr. How many of you are making more than the median FP

> > income and what are you doing to make that much. If the

> micropractice

> > model is not capable of producing enough income to provide at

> least

> > the median income it is probably not going to be a viable model.

> > Larry Lindeman MD

> >

>

>

[Guest guest]

,

I think what you are doing is great and I

have to say I continue to struggle with the whole medical necessity argument. I

feel that every minute doctors spend with their patients enhance the Dr-Patient

relationship and, through the IMP studies, we have shown that indeed IMPs

provide generally twice as good patient centered collaborative care as the

average office. Although we still need to prove this results in better outcomes

and less cost than traditional practice could for our population ( Wasson

already has evidence of this in other populations), I bet it does. So, what

does it matter if the average doc spends 5 minutes with an ear infection and I

spend 30? What does it matter if I am getting caught up discussing how the

patient’s kids are doing in school or if they are going fishing this

weekend? After all, I think we would all agree that the social aspects of one’s

life reflect greatly on their current medical status. By spending more time, I

am enhancing the relationship onto which everything else builds. If that isn’t

important, then I don’t know what is. I guess a similar comparison would

be a traditional psychiatrist who spends 5-10 minutes with a patient for med

recheck vs a Freudian psychiatrist who spends an hour. Should the latter only

get 1/6 the pay because it really could have been done in 10 minutes?

Personally, I think we need to eliminate

the medical necessity argument out of the equation all together. It not only

gives insurance companies the power to down code the visit, but it is

destructive to the one thing that really matters in medicine; our relationship

with our patient.

money

> >

> >

> >

> > Recently I have had money on my mind. After 2 years in my new

> > practice I an finally close to making $150,000 which is still

less

> > than I made at my old job. However I am finding it difficult to

> > figure out how to make anymore than that since I don't think

that

> I

> > can see any more patients in a day. The median income of FP's is

> over

> > $160.000/yr. How many of you are making more than the median FP

> > income and what are you doing to make that much. If the

> micropractice

> > model is not capable of producing enough income to provide at

> least

> > the median income it is probably not going to be a viable model.

> > Larry Lindeman MD

> >

>

>

[Guest guest]

Yes, but the problem is if we eliminate the medical necessity part, what would

stop fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . " and

nothing else. I agree it is important & helpful to spend the extra time, but it

is just not codable & reimbursable right now in and of itself.

>

>

> Date: 2006/09/23 Sat AM 09:30:14 EDT

> To: < >

> Subject: RE: appt length

>

> ,

> I think what you are doing is great and I have to say I continue to

> struggle with the whole medical necessity argument. I feel that every

> minute doctors spend with their patients enhance the Dr-Patient

> relationship and, through the IMP studies, we have shown that indeed

> IMPs provide generally twice as good patient centered collaborative care

> as the average office. Although we still need to prove this results in

> better outcomes and less cost than traditional practice could for our

> population ( Wasson already has evidence of this in other

> populations), I bet it does. So, what does it matter if the average doc

> spends 5 minutes with an ear infection and I spend 30? What does it

> matter if I am getting caught up discussing how the patient's kids are

> doing in school or if they are going fishing this weekend? After all, I

> think we would all agree that the social aspects of one's life reflect

> greatly on their current medical status. By spending more time, I am

> enhancing the relationship onto which everything else builds. If that

> isn't important, then I don't know what is. I guess a similar comparison

> would be a traditional psychiatrist who spends 5-10 minutes with a

> patient for med recheck vs a Freudian psychiatrist who spends an hour.

> Should the latter only get 1/6 the pay because it really could have been

> done in 10 minutes?

> Personally, I think we need to eliminate the medical necessity argument

> out of the equation all together. It not only gives insurance companies

> the power to down code the visit, but it is destructive to the one thing

> that really matters in medicine; our relationship with our patient.

>

>

> money

> > >

> > >

> > >

> > > Recently I have had money on my mind. After 2 years in my new

> > > practice I an finally close to making $150,000 which is still

> less

> > > than I made at my old job. However I am finding it difficult to

> > > figure out how to make anymore than that since I don't think

> that

> > I

> > > can see any more patients in a day. The median income of FP's is

> > over

> > > $160.000/yr. How many of you are making more than the median FP

> > > income and what are you doing to make that much. If the

> > micropractice

> > > model is not capable of producing enough income to provide at

> > least

> > > the median income it is probably not going to be a viable model.

> > > Larry Lindeman MD

> > >

> >

> >

[Guest guest]

I think (and hope) that most doctors are

not willing to stoop this low, and have honest coding practices. With most

docs undercoding, I don’t see that as a real threat of happening. I have

seen, on numerous occasions, the ‘fraud and abuse’ on the insurance

side, however (like not honoring CPT codes like preventative and problem visits

on the same day).

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From:

[mailto: ]

On Behalf Of drbrock@...

Sent: Sunday, September 24, 2006

6:30 PM

To:

Subject: Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity part,

what would stop fraud & abuse of the CPT coding? Then all docs would have

to do is write one sentence: " I spent 45 minutes, over 50% on counseling

re: . . . " and nothing else. I agree it is important & helpful to

spend the extra time, but it is just not codable & reimbursable right now

in and of itself.

>

[Guest guest]

Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home patients.

Lynette Iles

I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices. With most docs undercoding, I don't see that as a real threat of happening. I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day).

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O. Box 7275

Woodland Park, CO 80863

From:

[mailto:

] On Behalf Of drbrock@...Sent: Sunday, September 24, 2006 6:30 PM

To: Subject: Re: RE: appt length

Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: " I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. >

-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

[Guest guest]

Just

spending time with patients is part of your personal style of practicing,

establishing rapport, being kind. However, that is your choice to spend

that time & that does not mean you can code for that simply because you sat

in the room & talked! That is my point. If that were the case,

an auto mechanic could do the same thing: charge you hourly, but only part of

the time was fixing your transmission as needed while the other time was spent

cleaning your interior which was nice & pleasant but not requested or

needed. I really do think a lot of people here may be subtle upcoders but

disguise & not even realize it because they hide it under the cover of “spending

better time with my patients.” In the end, medical necessity will

ALWAYS be the deciding factor for choosing the right code.

Re: RE:

appt length

Yes,

but the problem is if we eliminate the medical necessity part, what would stop

fraud & abuse of the CPT coding? Then all docs would have to do is write

one sentence: " I spent 45 minutes, over 50% on counseling re: . . . "

and nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care

'Modern medicine the old-fashioned way' This e-mail and attachments may contain

information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

[Guest guest]

,Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it.At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen. What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression. My point is, that I believe that spending time with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them. Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values. I grant that there are some patients who don't care to share their personal lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car?I would also like to be paid like a family physician, rather than like a piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota. SetoSouth Pasadena, CAJust spending time with patients is part of your personal style of practicing, establishing rapport, being kind.  However, that is your choice to spend that time & that does not mean you can code for that simply because you sat in the room & talked!  That is my point.  If that were the case, an auto mechanic could do the same thing: charge you hourly, but only part of the time was fixing your transmission as needed while the other time was spent cleaning your interior which was nice & pleasant but not requested or needed.  I really do think a lot of people here may be subtle upcoders but disguise & not even realize it because they hide it under the cover of “spending better time with my patients.”  In the end, medical necessity will ALWAYS be the deciding factor for choosing the right code.   -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, September 25, 2006 1:05 PMTo: Subject: Re: RE: appt length Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home patients.Lynette Iles On 9/25/06, Eads <michelle.eadsworldnet (DOT) att.net> wrote:I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices.  With most docs undercoding, I don't see that as a real threat of happening.  I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day).  A. Eads, M.D.Pinnacle Family Medicine, PLLC phone faxP.O. Box 7275Woodland Park, CO 80863From: [mailto: ] On Behalf OfdrbrockrrohioSent: Sunday, September 24, 2006 6:30 PMTo: Subject: Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. >-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee.  If you have received this email in error, please notify the sender immediately and delete it from your computer.

[Guest guest]

Yes, I

agree completely except that, unfortunately, CPT coding currently does not

allow that. Now, if you are cash only you can do whatever you like.

I agree that time spent is important but that is not what they mean when they

talk about time-based coding. Sure, I to think the coding rules need

changed to reflect this time value more accurately, but right now we’ve

got what we’ve got. I did ask this coding question of a physician

coder/consultant. I recently attended his lecture in South Carolina. Here is what he

said (I will cut & paste):

,

I don’t know what will say,

but coding things of low medical decision making a 99214 only due to time spent

face-to-face is concerning to me and I feel is a bit too much “pushing

the envelope”. There should be a level of severity behind the time based

codes (just sitting in the room does not count) and when you look at it, some

studies have shown the average visit to be less than 10-15 minutes. So,

getting a level 99214 in 12 minutes beats a 25 minute counseling session any

day.

I am a die-hard bill based on medical

decision making type of guy because that makes most sense clinically. So,

the time based code usage in a sore throat for a 99214 would be a stretch

(unless we had other predisposing circumstances).

I will be at the AAFP presenting on

Saturday AM. I will be covering time based coding as part of my Dialogue

session. Call me if you have other questions.

Thank you,

Nick Ulmer, MD CPC FAAFP

Partner/Cofounder

The Family Healthcare Center, PA

Principal Consultant

Protime, LLC

(o)

©

www.TheFHC.com

Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity

part, what would stop fraud & abuse of the CPT coding? Then all docs would

have to do is write one sentence: " I spent 45 minutes, over 50% on

counseling re: . . . " and nothing else. I agree it is important &

helpful to spend the extra time, but it is just not codable & reimbursable

right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is

only for the named addressee. If you have received this email in

error, please notify the sender immediately and delete it from your computer.

[Guest guest]

I agree

completely with . As far as I’m concerned the time I spend with my patients

is “medically necessary.” Yes, I could and have been “efficient”

with patients in the past (saw 63 on one horrible day at my old practice), but

the problem is that I am not the one with the appointment. It doesn’t

matter how long it takes me to diagnose and come up with at treatment plan for

the presenting acute problem (that is done in seconds for most of us), but what

matters is how long it takes me to then translate that to the patient in a

simple but comprehensive way that takes into consideration all the other

patient issues. In order to do that, a rapport has to be established, and the

most important aspect of any relationship is time. You can always be more

efficient, but that is why medicine is in such horrible shape now. In a rodeo, roping

a calf in the shortest amount of time wins, but in medicine, that kind of

system makes us all losers.

Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity

part, what would stop fraud & abuse of the CPT coding? Then all docs would

have to do is write one sentence: " I spent 45 minutes, over 50% on

counseling re: . . . " and nothing else. I agree it is important &

helpful to spend the extra time, but it is just not codable & reimbursable

right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is

only for the named addressee. If you have received this email in

error, please notify the sender immediately and delete it from your computer.

[Guest guest]

Again,

I absolutely agree except that we are creating our own rules here as to “medical

necessity.” I wish the CPT codes allowed that, but they do

not. Maybe the system can be recreated for the better somehow. If I

could afford (ie, be paid appropriately) to spend all that time “needed”

with every patient I would for sure, but I would be out of business.

Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity

part, what would stop fraud & abuse of the CPT coding? Then all docs would

have to do is write one sentence: " I spent 45 minutes, over 50% on

counseling re: . . . " and nothing else. I agree it is important &

helpful to spend the extra time, but it is just not codable & reimbursable

right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is only

for the named addressee. If you have received this email in error,

please notify the sender immediately and delete it from your computer.

[Guest guest]

Can't help but jump in on this,though this is such an old "discussion" (battle) by now. A 99214 coded on time spent with a patient is rarely matched with a 465.9 - URI. The point is that as you spend time, gain rapport, you also usually are working on root causes of illnesses, and the ICD-9's will follow that discussion. There are days I long for a URI only case. And when that's really it, then it's a 99213. But the majority of my encounters include pain, emotional issues, a blood pressure that is elevated today (can I get them to recheck it 3 times outside of the office and bring it back), weight, borderline lipids. All of those issues have ICD-9s and make a 99214 quite legitimate. I don't bill a head cold as a 99214 even is I chat with someone for most of a half hour just because I enjoy seeing them. I doubt anyone on this list does.Again, I absolutely agree except that we are creating our own rules here as to “medical necessity.”  I wish the CPT codes allowed that, but they do not.  Maybe the system can be recreated for the better somehow.  If I could afford (ie, be paid appropriately) to spend all that time “needed” with every patient I would for sure, but I would be out of business.  -----Original Message-----From: [mailto: ] On Behalf Of Brady, MDSent: Tuesday, September 26, 2006 7:34 AMTo: Subject: RE: appt length I agree completely with . As far as I’m concerned the time I spend with my patients is “medically necessary.” Yes, I could and have been “efficient” with patients in the past (saw 63 on one horrible day at my old practice), but the problem is that I am not the one with the appointment. It doesn’t matter how long it takes me to diagnose and come up with at treatment plan for the presenting acute problem (that is done in seconds for most of us), but what matters is how long it takes me to then translate that to the patient in a simple but comprehensive way that takes into consideration all the other patient issues. In order to do that, a rapport has to be established, and the most important aspect of any relationship is time. You can always be more efficient, but that is why medicine is in such horrible shape now. In a rodeo, roping a calf in the shortest amount of time wins, but in medicine, that kind of system makes us all losers. -----Original Message-----From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 4:15 AMTo: Subject: Re: appt length ,Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it. At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen. What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression.  My point is, that I believe that spending time with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them.  Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values.  I grant that there are some patients who don't care to share their personal lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car? I would also like to be paid like a family physician, rather than like a piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota.  SetoSouth Pasadena, CA  Just spending time with patients is part of your personal style of practicing, establishing rapport, being kind.  However, that is your choice to spend that time & that does not mean you can code for that simply because you sat in the room & talked!  That is my point.  If that were the case, an auto mechanic could do the same thing: charge you hourly, but only part of the time was fixing your transmission as needed while the other time was spent cleaning your interior which was nice & pleasant but not requested or needed.  I really do think a lot of people here may be subtle upcoders but disguise & not even realize it because they hide it under the cover of “spending better time with my patients.”  In the end, medical necessity will ALWAYS be the deciding factor for choosing the right code.   -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, September 25, 2006 1:05 PMTo: Subject: Re: RE: appt length Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home patients.Lynette Iles On 9/25/06, Eads <michelle.eadsworldnet (DOT) att.net> wrote:I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices.  With most docs undercoding, I don't see that as a real threat of happening.  I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day).  A. Eads, M.D.Pinnacle Family Medicine, PLLC phone faxP.O. Box 7275Woodland Park, CO 80863From: [mailto: ] On Behalf OfdrbrockrrohioSent: Sunday, September 24, 2006 6:30 PMTo: Subject: Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. >-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee.  If you have received this email in error, please notify the sender immediately and delete it from your computer.   

[Guest guest]

Exactly.

I agree 100%, but that is definitely not what some others seem to be

doing. Some have said straight up that they feel they can legitimately

code a 99214 or 99215 just based on sitting & talking because it is “good

medicine” & “medically necessary” regardless of the

complexity of the visit, and that just goes against good old common sense to

me. What I recall hearing was that is was OK to code based purely on time regardless of complexity, and that is upcoding,

plain & simple.

You summarized it well though, and

hopefully most here do agree with your synopsis.

Re: RE:

appt length

Yes, but the

problem is if we eliminate the medical necessity part, what would stop fraud

& abuse of the CPT coding? Then all docs would have to do is write one

sentence: " I spent 45 minutes, over 50% on counseling re: . . . " and

nothing else. I agree it is important & helpful to spend the extra time,

but it is just not codable & reimbursable right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is

only for the named addressee. If you have received this email in

error, please notify the sender immediately and delete it from your computer.

[Guest guest]

: I agree with you that every visit should be coded based on medical necessity. Each physicaian determines that for himself/herself. I do not think anyone would code a URI a 99214 without addressing additional issues at the same visit. Brock DO wrote: Again, I absolutely agree except that we are creating our own rules here as to “medical necessity.” I wish the CPT codes allowed that, but they do not. Maybe the system can be recreated for the better somehow. If I could afford (ie, be paid appropriately) to spend all that time “needed” with every patient I would for sure, but I would be out of business. -----Original

Message-----From: [mailto: ] On Behalf Of Brady, MDSent: Tuesday, September 26, 2006 7:34 AMTo: Subject: RE: appt length I agree completely with . As far as I’m concerned the time I spend with my patients is

“medically necessary.” Yes, I could and have been “efficient” with patients in the past (saw 63 on one horrible day at my old practice), but the problem is that I am not the one with the appointment. It doesn’t matter how long it takes me to diagnose and come up with at treatment plan for the presenting acute problem (that is done in seconds for most of us), but what matters is how long it takes me to then translate that to the patient in a simple but comprehensive way that takes into consideration all the other patient issues. In order to do that, a rapport has to be established, and the most important aspect of any relationship is time. You can always be more efficient, but that is why medicine is in such horrible shape now. In a rodeo, roping a calf in the shortest amount of time wins, but in medicine, that kind of system makes us all losers. -----Original Message-----From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 4:15 AMTo: Subject: Re: appt length , Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it. At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to

patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen. What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why

your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression. My point is, that I believe that spending time with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell

you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them. Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values. I grant that there are some patients who don't care to share their personal

lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car? I would also like to be paid like a family physician, rather than like a piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota. Seto South Pasadena, CA Just spending time with patients is part of your personal style of practicing, establishing rapport, being kind. However, that is your choice to spend that time & that does not mean you can code for that simply because you sat in the room & talked! That is my point. If that were the case, an auto mechanic could do the same thing: charge you hourly, but only part of the time was fixing your transmission as needed while the other time was spent cleaning your interior which was nice & pleasant but not requested or needed. I really do think a lot of people here may be subtle upcoders but disguise & not even realize it because they hide it under the cover of “spending better time with my patients.” In the end, medical necessity will ALWAYS

be the deciding factor for choosing the right code. -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, September 25, 2006 1:05 PMTo: Subject: Re: RE: appt length Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home

patients. Lynette Iles On 9/25/06, Eads <michelle.eadsworldnet (DOT) att.net> wrote: I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices. With most docs undercoding, I don't see that as a real threat of happening. I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day). A. Eads, M.D. Pinnacle Family Medicine, PLLC phone fax P.O. Box 7275 Woodland Park, CO 80863 From: [mailto: ] On Behalf OfdrbrockrrohioSent: Sunday, September 24, 2006 6:30 PMTo: Subject: Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. > -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

Talk is cheap. Use Yahoo! Messenger to make PC-to-Phone calls. Great rates starting at 1¢/min.

[Guest guest]

: Actual time based average visits for internists across the country are about 20 minutes per visit. Brock DO wrote: Yes, I agree completely except that, unfortunately, CPT coding currently does not allow that. Now, if you are cash only you

can do whatever you like. I agree that time spent is important but that is not what they mean when they talk about time-based coding. Sure, I to think the coding rules need changed to reflect this time value more accurately, but right now we’ve got what we’ve got. I did ask this coding question of a physician coder/consultant. I recently attended his lecture in South Carolina. Here is what he said (I will cut & paste): , I don’t know what will say, but coding things of low medical decision making a 99214 only due to time spent face-to-face is concerning to me and I feel is a bit too much “pushing the envelope”. There should be a level of severity behind the time based codes (just sitting in the room does not count) and when you look at it, some studies have shown the average visit to be less than 10-15 minutes. So, getting a level 99214 in 12 minutes beats a 25 minute counseling session any day. I am a die-hard bill based on medical decision making type of guy because that makes most sense clinically. So, the time based code usage in a sore throat for a 99214 would be a stretch (unless we had other predisposing circumstances). I will be at the AAFP presenting on Saturday AM. I will be covering time based coding as part of my Dialogue session. Call me if you have other questions. Thank you, Nick Ulmer, MD CPC FAAFP Partner/Cofounder The Family Healthcare Center, PA Principal Consultant Protime, LLC (o) © www.TheFHC.com -----Original Message-----From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 3:15 AMTo:

Subject: Re: appt length , Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it. At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen.

What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression. My point is, that I believe that spending time

with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them. Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values. I grant that there are some patients who don't care to share their personal lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car? I would also like to be paid like a family physician, rather than like a

piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota. Seto South Pasadena, CA Just spending time with patients is part of your personal style of practicing, establishing rapport, being kind. However, that is your choice to spend that time & that does not mean you can code for that simply because you sat in the room & talked! That is my point. If that were the case, an auto mechanic could do the same thing: charge you hourly, but only part of the time was fixing your transmission as needed while the other time was spent cleaning your interior which was nice & pleasant but not requested or needed. I

really do think a lot of people here may be subtle upcoders but disguise & not even realize it because they hide it under the cover of “spending better time with my patients.” In the end, medical necessity will ALWAYS be the deciding factor for choosing the right code. -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, September 25, 2006 1:05 PMTo:

Subject: Re: RE: appt length Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most

effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home patients. Lynette Iles On 9/25/06, Eads <michelle.eadsworldnet (DOT) att.net> wrote: I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices. With most docs undercoding, I don't see that as a real threat of happening. I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day). A. Eads, M.D. Pinnacle Family Medicine, PLLC phone fax P.O. Box 7275

Woodland Park, CO 80863 From: [mailto: ] On Behalf OfdrbrockrrohioSent: Sunday, September 24, 2006 6:30 PMTo: Subject: Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. > -- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee. If you have received this email in error, please notify the sender immediately and delete it from your computer.

Get your own web address for just $1.99/1st yr. We'll help. Yahoo! Small Business.

[Guest guest]

OK,

so I’ll get off my soapbox in a second. No, I don’t typically code

a 99214 for a cold (although I certainly can get the documentation to be there

for it), and I realize that the powers that be have determined that medical

necessity is the key. My argument is not that I code that way, but that I

should not have to worry about it in the first place. Let’s say someone

comes in and we talk about their URI and I ask briefly how their back pain is

and if they are exercising and have stopped smoking. Generally, this should be

a 99214, but instead of documenting everything, I decide to “code for

time.” Oops, no longer is it about medical necessity, it’s about

documentation. So now we are stuck in this limbo where if we document too much,

we are committing fraud because it is not medically necessary, but if we don’t

document everything, we are told it never happened. This is the reason we have

to go to coding class after coding class only to leave scratching our heads. It’s

a crooked system where the one’s with the money can decide what they want

and shift reality to focus on that. I believe that my time with my patient is

valuable, and I shouldn’t have to justify it based on the perception of

medical necessity. Worried about me overcoding? Look at my schedule to see if I

saw 5 patients/hr and coded 99214 for all of them. I

think you’ll find that much easier than searching charts looking to

justify necessity.

Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity

part, what would stop fraud & abuse of the CPT coding? Then all docs would

have to do is write one sentence: " I spent 45 minutes, over 50% on

counseling re: . . . " and nothing else. I agree it is important &

helpful to spend the extra time, but it is just not codable & reimbursable

right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is

only for the named addressee. If you have received this email in

error, please notify the sender immediately and delete it from your computer.

[Guest guest]

That sounds

about right to me, especially if they have the usual multiple medical

problems. Of course, those are easily a 99214 at almost every

visit. There would be no need to code those based only on time because

the MDM/complexity easily justifies the higher codes. The ambiguous

visits are those hypothetical, seemingly straight forward, one problem visits (ie,

sore throat). If the doctor sits & talks for 30 minutes to really get

to know the patient, but all that was really uncovered & treated was the

sore throat, can they code for the time spent? I say no way, CPT does not

work that way, but apparently some think they can interpret the coding rules a

bit more loosely and code higher. But as you mentioned, how common are

those single problem-focused visits? They are pretty rare, especially if

you are an internist. On the flip side though, if the average internist

visit is 20 minutes but you decide you

are going to spend an hour with your average patient because it seems like good

medicine and you believe it to be

medically necessary, can you code for the hour whereas the average internist

only codes that same patient as a 20 minute visit? I say no that you can

not because that was just your personal style of slower more methodical

practice, but I guess that is where some would beg to differ.

Re: RE:

appt length

Yes, but the problem is if we eliminate

the medical necessity part, what would stop fraud & abuse of the CPT

coding? Then all docs would have to do is write one sentence: " I spent 45

minutes, over 50% on counseling re: . . . " and nothing else. I agree it

is important & helpful to spend the extra time, but it is just not codable

& reimbursable right now in and of itself.

>

-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments

may contain information which is confidential and is only for the named addressee. If

you have received this email in error, please notify the sender immediately and

delete it from your computer.

Get your

own web

address for just $1.99/1st yr. We'll help. Yahoo!

Small Business.

[Guest guest]

I hope

not too, that was just what I was hearing initially.  Maybe it was my

misinterpretation, which is obviously to do easy online.  I

Re: RE:

appt length

Yes, but the problem is if we eliminate

the medical necessity part, what would stop fraud & abuse of the CPT

coding? Then all docs would have to do is write one sentence: " I spent 45

minutes, over 50% on counseling re: . . . " and nothing else. I agree it

is important & helpful to spend the extra time, but it is just not codable

& reimbursable right now in and of itself.

>

-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments

may contain information which is confidential and is only for the named

addressee. If you have received this email in error, please notify

the sender immediately and delete it from your computer.

 

Talk is

cheap. Use Yahoo! Messenger to make PC-to-Phone calls. Great

rates starting at 1¢/min.

[Guest guest]

Plus even when we do follow the complicated coding rules, the health plans can unilaterally say they won't pay anyways. The example of a well visit plus 99213 modifier 25 is the most obvious example. Reimbursement is not about medical necessity, it is about playing by the rules of a convoluted and unfair system where we physicians are at a disadvantage. Medical necessity should be determined by the physician, not an administrator.For the record, I never code based SOLELY on the amount of time I spend with a patient. However, according to this article from Family Practice Management (http://www.aafp.org/fpm/20030600/27time.html), If a physician spends more than 50 percent of a face-to-face visit counseling or coordinating a patient's care, the physician can code the visit on the basis of time, even if the history, exam or medical decision-making elements are lacking.That means a visit of between 25-39 minutes in length, which includes most return visits for my chronic care patients. I chart the time I start and the time I end each visit, and if more than half the time is spent talking about behavioral changes, ways to increase exercise, explaining their disease process, etc. then it should qualify as a 99214. Interestingly, when I used to work at Kaiser, I timed myself without regard to being on time, and found that I averaged 20 minutes per visit. Unfortunately, I was only allotted 15 minutes per visit so I was consistently behind by 45-60 minutes at the end of a half day.  SetoSouth Pasadena, CAOK, so I’ll get off my soapbox in a second. No, I don’t typically code a 99214 for a cold (although I certainly can get the documentation to be there for it), and I realize that the powers that be have determined that medical necessity is the key. My argument is not that I code that way, but that I should not have to worry about it in the first place. Let’s say someone comes in and we talk about their URI and I ask briefly how their back pain is and if they are exercising and have stopped smoking. Generally, this should be a 99214, but instead of documenting everything, I decide to “code for time.” Oops, no longer is it about medical necessity, it’s about documentation. So now we are stuck in this limbo where if we document too much, we are committing fraud because it is not medically necessary, but if we don’t document everything, we are told it never happened. This is the reason we have to go to coding class after coding class only to leave scratching our heads. It’s a crooked system where the one’s with the money can decide what they want and shift reality to focus on that. I believe that my time with my patient is valuable, and I shouldn’t have to justify it based on the perception of medical necessity. Worried about me overcoding? Look at my schedule to see if I saw 5 patients/hr and coded 99214 for all of them. I think you’ll find that much easier than searching charts looking to justify necessity. -----Original Message-----From: [mailto: ] On Behalf Of Brock DOSent: Tuesday, September 26, 2006 2:03 PMTo: Subject: RE: appt length Exactly.  I agree 100%, but that is definitely not what some others seem to be doing.  Some have said straight up that they feel they can legitimately code a 99214 or 99215 just based on sitting & talking because it is “good medicine” & “medically necessary” regardless of the complexity of the visit, and that just goes against good old common sense to me.  What I recall hearing was that is was OK to code based purely on time regardless of complexity, and that is upcoding, plain & simple.  You summarized it well though, and hopefully most here do agree with your synopsis.  -----Original Message-----From: [mailto: ] On Behalf Of GuinnSent: Tuesday, September 26, 2006 10:44 AMTo: Subject: Re: appt length Can't help but jump in on this,though this is such an old "discussion" (battle) by now. A 99214 coded on time spent with a patient is rarely matched with a 465.9 - URI. The point is that as you spend time, gain rapport, you also usually are working on root causes of illnesses, and the ICD-9's will follow that discussion. There are days I long for a URI only case. And when that's really it, then it's a 99213. But the majority of my encounters include pain, emotional issues, a blood pressure that is elevated today (can I get them to recheck it 3 times outside of the office and bring it back), weight, borderline lipids. All of those issues have ICD-9s and make a 99214 quite legitimate. I don't bill a head cold as a 99214 even is I chat with someone for most of a half hour just because I enjoy seeing them. I doubt anyone on this list does.     Again, I absolutely agree except that we are creating our own rules here as to “medical necessity.”  I wish the CPT codes allowed that, but they do not.  Maybe the system can be recreated for the better somehow.  If I could afford (ie, be paid appropriately) to spend all that time “needed” with every patient I would for sure, but I would be out of business.  -----Original Message-----From: [mailto: ] On Behalf Of Brady, MDSent: Tuesday, September 26, 2006 7:34 AMTo: Subject: RE: appt length I agree completely with . As far as I’m concerned the time I spend with my patients is “medically necessary.” Yes, I could and have been “efficient” with patients in the past (saw 63 on one horrible day at my old practice), but the problem is that I am not the one with the appointment. It doesn’t matter how long it takes me to diagnose and come up with at treatment plan for the presenting acute problem (that is done in seconds for most of us), but what matters is how long it takes me to then translate that to the patient in a simple but comprehensive way that takes into consideration all the other patient issues. In order to do that, a rapport has to be established, and the most important aspect of any relationship is time. You can always be more efficient, but that is why medicine is in such horrible shape now. In a rodeo, roping a calf in the shortest amount of time wins, but in medicine, that kind of system makes us all losers. -----Original Message-----From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 4:15 AMTo: Subject: Re: appt length ,Several years ago I got involved with teaching medical students at UCLA in a new curriculum they called "Doctoring". It involved learning interviewing techniques, active listening, recognizing body language (the patient's and your own) and using a standardized patient (an actor who played a role modeled on real patients). "Touchy feely stuff", I called it. At first, I thought it was nice that the 1st year medical students got a chance to learn how to talk to patients and take a medical history without worrying about making a mistake or asking inappropriate questions. But they would wonder, as did I, as they were taking social histories and family histories when they were going to start dealing with "REAL" medical issues and problems. Eventually as I read over the course material, I began to see the utility in what we were teaching the students, especially since I had never been taught these kinds of things before but had to learn them on my own through trial and error. I started to incorporate these same techniques in my busy practice at Kaiser and found that I got to know more about my patients by just letting them talk and forcing/training myself to listen. What I learned is that the more time you spend with a person, the more you get to know them, and they you. What follows is a rapport, a relationship, whatever you want to call it. And when this connection is made, then and only then is when you find out the reason why your so-called non-compliant diabetic is the way he is is because he is totally stressed from his low-paying job and alcoholic wife and ADD son while also trying to care for his mother with Alzheimer's who is living with them. That is when you find out the woman who came in for a cold has also had low back pain for 6 months because she is being sexually harrassed at work and it is causing insomnia and depression.  My point is, that I believe that spending time with patients and making small talk with them and learning what makes them tick is not just "being kind". It is *medically necessary* for me to do my job as a family physician. It is one of my most valuable tools in helping to diagnose (because they won't tell you everything unless they trust you), and to treat (good rapport can help improve compliance rates, exert a positive placebo effect) whatever ails them.  Normally, I'm not this "touchy-feely", but I really believe that being a good doctor involves treating the whole person. I can't adequately treat their bodies without knowing their personalities/preferences/values.  I grant that there are some patients who don't care to share their personal lives with their doctors, they just want to get their physical exam and blood tests and medication refills and get the hell out of there. But people, unlike cars, have souls and spirits which can affect the health of the bodies they share and which require a different kind of attention. Would you rather be treated like a car, or like a person? And how do you treat your patients, like a person or like a car? I would also like to be paid like a family physician, rather than like a piece-rate worker, but until then, I will abide by the coding rules as established by the powers that be and code correctly and not by a quota.  SetoSouth Pasadena, CA   Just spending time with patients is part of your personal style of practicing, establishing rapport, being kind.  However, that is your choice to spend that time & that does not mean you can code for that simply because you sat in the room & talked!  That is my point.  If that were the case, an auto mechanic could do the same thing: charge you hourly, but only part of the time was fixing your transmission as needed while the other time was spent cleaning your interior which was nice & pleasant but not requested or needed.  I really do think a lot of people here may be subtle upcoders but disguise & not even realize it because they hide it under the cover of “spending better time with my patients.”  In the end, medical necessity will ALWAYS be the deciding factor for choosing the right code.   -----Original Message-----From: [mailto: ] On Behalf Of Lynette IlesSent: Monday, September 25, 2006 1:05 PMTo: Subject: Re: RE: appt length Since when is it fraud and abuse to charge for spending time with patients. I agree with Dr. Bradley, every minute I spend with a patient is time spent healing. I tell my patients that I'm the cheapest and most effective part of the healthcare system. The insurance company is getting a lot of bang for their buck! I do code 90205's... new ob patients to my practice, new nursing home patients.Lynette Iles On 9/25/06, Eads <michelle.eadsworldnet (DOT) att.net> wrote:I think (and hope) that most doctors are not willing to stoop this low, and have honest coding practices.  With most docs undercoding, I don't see that as a real threat of happening.  I have seen, on numerous occasions, the 'fraud and abuse' on the insurance side, however (like not honoring CPT codes like preventative and problem visits on the same day).  A. Eads, M.D.Pinnacle Family Medicine, PLLC phone faxP.O. Box 7275Woodland Park, CO 80863From: [mailto: ] On Behalf OfdrbrockrrohioSent: Sunday, September 24, 2006 6:30 PMTo: Subject: Re: RE: appt length Yes, but the problem is if we eliminate the medical necessity part, what would stop fraud & abuse of the CPT coding? Then all docs would have to do is write one sentence: "I spent 45 minutes, over 50% on counseling re: . . . " and nothing else. I agree it is important & helpful to spend the extra time, but it is just not codable & reimbursable right now in and of itself. >-- Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This e-mail and attachments may contain information which is confidential and is only for the named addressee.  If you have received this email in error, please notify the sender immediately and delete it from your computer.      

[Guest guest]

Thanks , you

are the fastest article finder I have ever seen J

Re: RE:

appt length

Yes, but the problem is if we eliminate the medical necessity

part, what would stop fraud & abuse of the CPT coding? Then all docs would

have to do is write one sentence: " I spent 45 minutes, over 50% on

counseling re: . . . " and nothing else. I agree it is important &

helpful to spend the extra time, but it is just not codable & reimbursable

right now in and of itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington

IA 52353 Flexible Family Care 'Modern medicine the old-fashioned way' This

e-mail and attachments may contain information which is confidential and is

only for the named addressee. If you have received this email in

error, please notify the sender immediately and delete it from your computer.

[Guest guest]

, I have been saying the same thing for years! The 15 minute primary care visit is obsolete (but the bean-counting accountants and MBAs don't see the whole picture). A malpractice study of FPs over a decade ago showed that, of FPs in practice at least 10 years, those who had been sued 2 or more times averaged 15 minutes a visit, while those who had never been sued averaged 20 minutes a visit. That alone should compensate for the so-called "productivity loss" of only 3 patients per hour, not to mention the savings elsewhere in the system by doing primary care right (the Gordon way, taking the amount of time we really need with each patient rather than clock-watching with a bouncer to eject the patient when the alarm clock goes off and it's time to start on the next hamster-wheel patient).

On coding for a longer visit, be sure to list all of the diagnoses you discussed, and also document in the Objective and Plan that you covered them. A good EMR template (I use Praxis) should make that documentation quick and almost automatic. Don't just list "URI" alone and then try to claim a 99214 or 99215 based on time only; if you were a claim screener, you would be suspicious of that too.

Wes Bradford

Redondo Beach/Rancho Palos Verdes, CA

From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 1:46 PMTo: Subject: Re: appt length

Plus even when we do follow the complicated coding rules, the health plans can unilaterally say they won't pay anyways. The example of a well visit plus 99213 modifier 25 is the most obvious example. Reimbursement is not about medical necessity, it is about playing by the rules of a convoluted and unfair system where we physicians are at a disadvantage. Medical necessity should be determined by the physician, not an administrator.

For the record, I never code based SOLELY on the amount of time I spend with a patient. However, according to this article from Family Practice Management

(http://www.aafp.org/fpm/20030600/27time.html),

If a physician spends more than 50 percent of a face-to-face visit counseling or coordinating a patient's care, the physician can code the visit on the basis of time, even if the history, exam or medical decision-making elements are lacking.

That means a visit of between 25-39 minutes in length, which includes most return visits for my chronic care patients. I chart the time I start and the time I end each visit, and if more than half the time is spent talking about behavioral changes, ways to increase exercise, explaining their disease process, etc. then it should qualify as a 99214. Interestingly, when I used to work at Kaiser, I timed myself without regard to being on time, and found that I averaged 20 minutes per visit. Unfortunately, I was only allotted 15 minutes per visit so I was consistently behind by 45-60 minutes at the end of a half day.

Seto

South Pasadena, CA

OK, so I’ll get off my soapbox in a second. No, I don’t typically code a 99214 for a cold (although I certainly can get the documentation to be there for it), and I realize that the powers that be have determined that medical necessity is the key. My argument is not that I code that way, but that I should not have to worry about it in the first place. Let’s say someone comes in and we talk about their URI and I ask briefly how their back pain is and if they are exercising and have stopped smoking. Generally, this should be a 99214, but instead of documenting everything, I decide to “code for time.” Oops, no longer is it about medical necessity, it’s about documentation. So now we are stuck in this limbo where if we document too much, we are committing fraud because it is not medically necessary, but if we don’t document everything, we are told it never happened. This is the reason we have to go to coding class after coding class only to leave scratching our heads. It’s a crooked system where the one’s with the money can decide what they want and shift reality to focus on that. I believe that my time with my patient is valuable, and I shouldn’t have to justify it based on the perception of medical necessity. Worried about me overcoding? Look at my schedule to see if I saw 5 patients/hr and coded 99214 for all of them. I think you’ll find that much easier than searching charts looking to justify necessity.

[Guest guest]

, I have been saying the same thing for years! The 15 minute primary care visit is obsolete (but the bean-counting accountants and MBAs don't see the whole picture). A malpractice study of FPs over a decade ago showed that, of FPs in practice at least 10 years, those who had been sued 2 or more times averaged 15 minutes a visit, while those who had never been sued averaged 20 minutes a visit. That alone should compensate for the so-called "productivity loss" of only 3 patients per hour, not to mention the savings elsewhere in the system by doing primary care right (the Gordon way, taking the amount of time we really need with each patient rather than clock-watching with a bouncer to eject the patient when the alarm clock goes off and it's time to start on the next hamster-wheel patient).

On coding for a longer visit, be sure to list all of the diagnoses you discussed, and also document in the Objective and Plan that you covered them. A good EMR template (I use Praxis) should make that documentation quick and almost automatic. Don't just list "URI" alone and then try to claim a 99214 or 99215 based on time only; if you were a claim screener, you would be suspicious of that too.

Wes Bradford

Redondo Beach/Rancho Palos Verdes, CA

From: [mailto: ] On Behalf Of Seto Sent: Tuesday, September 26, 2006 1:46 PMTo: Subject: Re: appt length

Plus even when we do follow the complicated coding rules, the health plans can unilaterally say they won't pay anyways. The example of a well visit plus 99213 modifier 25 is the most obvious example. Reimbursement is not about medical necessity, it is about playing by the rules of a convoluted and unfair system where we physicians are at a disadvantage. Medical necessity should be determined by the physician, not an administrator.

For the record, I never code based SOLELY on the amount of time I spend with a patient. However, according to this article from Family Practice Management

(http://www.aafp.org/fpm/20030600/27time.html),

If a physician spends more than 50 percent of a face-to-face visit counseling or coordinating a patient's care, the physician can code the visit on the basis of time, even if the history, exam or medical decision-making elements are lacking.

That means a visit of between 25-39 minutes in length, which includes most return visits for my chronic care patients. I chart the time I start and the time I end each visit, and if more than half the time is spent talking about behavioral changes, ways to increase exercise, explaining their disease process, etc. then it should qualify as a 99214. Interestingly, when I used to work at Kaiser, I timed myself without regard to being on time, and found that I averaged 20 minutes per visit. Unfortunately, I was only allotted 15 minutes per visit so I was consistently behind by 45-60 minutes at the end of a half day.

Seto

South Pasadena, CA

OK, so I’ll get off my soapbox in a second. No, I don’t typically code a 99214 for a cold (although I certainly can get the documentation to be there for it), and I realize that the powers that be have determined that medical necessity is the key. My argument is not that I code that way, but that I should not have to worry about it in the first place. Let’s say someone comes in and we talk about their URI and I ask briefly how their back pain is and if they are exercising and have stopped smoking. Generally, this should be a 99214, but instead of documenting everything, I decide to “code for time.” Oops, no longer is it about medical necessity, it’s about documentation. So now we are stuck in this limbo where if we document too much, we are committing fraud because it is not medically necessary, but if we don’t document everything, we are told it never happened. This is the reason we have to go to coding class after coding class only to leave scratching our heads. It’s a crooked system where the one’s with the money can decide what they want and shift reality to focus on that. I believe that my time with my patient is valuable, and I shouldn’t have to justify it based on the perception of medical necessity. Worried about me overcoding? Look at my schedule to see if I saw 5 patients/hr and coded 99214 for all of them. I think you’ll find that much easier than searching charts looking to justify necessity.

[Guest guest]

Regarding appointment length, I don't think that you can compare the

average office length visit in an IMP to the average visit with an

internist or a family practitioner in a regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more

time with a physician and often have more problems. Even a URI for

some of my patients can be a bit more complicated than average although

I am always so happy to see just a URI so that I can quickly finish and

code a 99213 visit.

I saw a patient today for her yearly exam, but we really dealt with

her hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She also

has a history of anxiety that is currently stable, that I reviewed with

her. Now this took me 70 minutes of visit time. In a regular practice

she would have had to come back at least 3 times to deal with all of

those issues and since she lives at least 30 minutes away that would be

an extra 2 hours of travel time for her. Now someone could say that

none of those are really " complex " , but honestly we didn't just shoot

the breeze during the visit. How else does one code other than with

time. 99214 and extended time. Oh yeah and she has osteopenia and I

scheduled a bone density and reviewed her treatment and renewed

medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me

may take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you need

to do, as well as a quick physical exam and have them out the door in

20 minutes, but they may not have understood anything, if I didn't take

time to listen, get feedback, get more family and social history, write

down instructions, set up followup appointments and pertinent referrals

etc. That is all important stuff and should be part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they spent

talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I

think that being social in a visit is also therapeutic. I was

listening to a radio program called Speaking of Faith in which a

physician by the name of Naomi Remen discusses the difference

between curing and healing. A good portion involves taking time to

listen. She gives an example of a man with cancer who continued take

his chemo treatments even though they weren't doing any good, just so

he could talk with his doctor weekly. His doctor would only see him

if he was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can get

a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/

index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

> Plus even when we do follow the complicated coding rules, the health

> plans can unilaterally say they won't pay anyways. The example of a

> well visit plus 99213 modifier 25 is the most obvious example.

> Reimbursement is not about medical necessity, it is about playing by

> the rules of a convoluted and unfair system where we physicians are at

> a disadvantage. Medical necessity should be determined by the

> physician, not an administrator.

>

> For the record, I never code based SOLELY on the amount of time I

> spend with a patient. However, according to this article from Family

> Practice Management 

> (http://www.aafp.org/fpm/20030600/27time.html), 

>

> If a physician spends more than 50 percent of a face-to-face visit

> counseling or coordinating a patient's care, the physician can code

> the visit on the basis of time, even if the history, exam or medical

> decision-making elements are lacking.

>

> That means a visit of between 25-39 minutes in length, which includes

> most return visits for my chronic care patients. I chart the time I

> start and the time I end each visit, and if more than half the time is

> spent talking about behavioral changes, ways to increase exercise,

> explaining their disease process, etc. then it should qualify as a

> 99214. Interestingly, when I used to work at Kaiser, I timed myself

> without regard to being on time, and found that I averaged 20 minutes

> per visit. Unfortunately, I was only allotted 15 minutes per visit so

> I was consistently behind by 45-60 minutes at the end of a half day. 

>

> Seto

> South Pasadena, CA

>

>

>

>

> OK, so I’ll get off my soapbox in a second. No, I don’t typically code

> a 99214 for a cold (although I certainly can get the documentation to

> be there for it), and I realize that the powers that be have

> determined that medical necessity is the key. My argument is not that

> I code that way, but that I should not have to worry about it in the

> first place. Let’s say someone comes in and we talk about their URI

> and I ask briefly how their back pain is and if they are exercising

> and have stopped smoking. Generally, this should be a 99214, but

> instead of documenting everything, I decide to “code for time.” Oops,

> no longer is it about medical necessity, it’s about documentation. So

> now we are stuck in this limbo where if we document too much, we are

> committing fraud because it is not medically necessary, but if we

> don’t document everything, we are told it never happened. This is the

> reason we have to go to coding class after coding class only to leave

> scratching our heads. It’s a crooked system where the one’s with the

> money can decide what they want and shift reality to focus on that. I

> believe that my time with my patient is valuable, and I shouldn’t have

> to justify it based on the perception of medical necessity. Worried

> about me overcoding? Look at my schedule to see if I saw5

> patients/hrand coded 99214 for all of them. I think you’ll find that

> much easier than searching charts looking to justify necessity.

>

>

>

>  

>

> Re: RE: appt length

>

>  

>

> Yes, but the problem is if we eliminate the medical necessity part,

> what would stop fraud & abuse of the CPT coding? Then all docs would

> have to do is write one sentence: " I spent 45 minutes, over 50% on

> counseling re: . . . " and nothing else. I agree it is important &

> helpful to spend the extra time, but it is just not codable &

> reimbursable right now in and of itself.

>

>

> >

>

>

>

>

> --

> Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

> Family Care 'Modern medicine the old-fashioned way' This e-mail and

> attachments may contain information which is confidential and is only

> for the named addressee.  If you have received this email in error,

> please notify the sender immediately and delete it from your computer.

>

>  

>

>  

>

>  

>

>  

>

>  

>

>  

>

>

>

>

>

[Guest guest]

Regarding appointment length, I don't think that you can compare the

average office length visit in an IMP to the average visit with an

internist or a family practitioner in a regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more

time with a physician and often have more problems. Even a URI for

some of my patients can be a bit more complicated than average although

I am always so happy to see just a URI so that I can quickly finish and

code a 99213 visit.

I saw a patient today for her yearly exam, but we really dealt with

her hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She also

has a history of anxiety that is currently stable, that I reviewed with

her. Now this took me 70 minutes of visit time. In a regular practice

she would have had to come back at least 3 times to deal with all of

those issues and since she lives at least 30 minutes away that would be

an extra 2 hours of travel time for her. Now someone could say that

none of those are really " complex " , but honestly we didn't just shoot

the breeze during the visit. How else does one code other than with

time. 99214 and extended time. Oh yeah and she has osteopenia and I

scheduled a bone density and reviewed her treatment and renewed

medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me

may take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you need

to do, as well as a quick physical exam and have them out the door in

20 minutes, but they may not have understood anything, if I didn't take

time to listen, get feedback, get more family and social history, write

down instructions, set up followup appointments and pertinent referrals

etc. That is all important stuff and should be part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they spent

talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I

think that being social in a visit is also therapeutic. I was

listening to a radio program called Speaking of Faith in which a

physician by the name of Naomi Remen discusses the difference

between curing and healing. A good portion involves taking time to

listen. She gives an example of a man with cancer who continued take

his chemo treatments even though they weren't doing any good, just so

he could talk with his doctor weekly. His doctor would only see him

if he was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can get

a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/

index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

> Plus even when we do follow the complicated coding rules, the health

> plans can unilaterally say they won't pay anyways. The example of a

> well visit plus 99213 modifier 25 is the most obvious example.

> Reimbursement is not about medical necessity, it is about playing by

> the rules of a convoluted and unfair system where we physicians are at

> a disadvantage. Medical necessity should be determined by the

> physician, not an administrator.

>

> For the record, I never code based SOLELY on the amount of time I

> spend with a patient. However, according to this article from Family

> Practice Management 

> (http://www.aafp.org/fpm/20030600/27time.html), 

>

> If a physician spends more than 50 percent of a face-to-face visit

> counseling or coordinating a patient's care, the physician can code

> the visit on the basis of time, even if the history, exam or medical

> decision-making elements are lacking.

>

> That means a visit of between 25-39 minutes in length, which includes

> most return visits for my chronic care patients. I chart the time I

> start and the time I end each visit, and if more than half the time is

> spent talking about behavioral changes, ways to increase exercise,

> explaining their disease process, etc. then it should qualify as a

> 99214. Interestingly, when I used to work at Kaiser, I timed myself

> without regard to being on time, and found that I averaged 20 minutes

> per visit. Unfortunately, I was only allotted 15 minutes per visit so

> I was consistently behind by 45-60 minutes at the end of a half day. 

>

> Seto

> South Pasadena, CA

>

>

>

>

> OK, so I’ll get off my soapbox in a second. No, I don’t typically code

> a 99214 for a cold (although I certainly can get the documentation to

> be there for it), and I realize that the powers that be have

> determined that medical necessity is the key. My argument is not that

> I code that way, but that I should not have to worry about it in the

> first place. Let’s say someone comes in and we talk about their URI

> and I ask briefly how their back pain is and if they are exercising

> and have stopped smoking. Generally, this should be a 99214, but

> instead of documenting everything, I decide to “code for time.” Oops,

> no longer is it about medical necessity, it’s about documentation. So

> now we are stuck in this limbo where if we document too much, we are

> committing fraud because it is not medically necessary, but if we

> don’t document everything, we are told it never happened. This is the

> reason we have to go to coding class after coding class only to leave

> scratching our heads. It’s a crooked system where the one’s with the

> money can decide what they want and shift reality to focus on that. I

> believe that my time with my patient is valuable, and I shouldn’t have

> to justify it based on the perception of medical necessity. Worried

> about me overcoding? Look at my schedule to see if I saw5

> patients/hrand coded 99214 for all of them. I think you’ll find that

> much easier than searching charts looking to justify necessity.

>

>

>

>  

>

> Re: RE: appt length

>

>  

>

> Yes, but the problem is if we eliminate the medical necessity part,

> what would stop fraud & abuse of the CPT coding? Then all docs would

> have to do is write one sentence: " I spent 45 minutes, over 50% on

> counseling re: . . . " and nothing else. I agree it is important &

> helpful to spend the extra time, but it is just not codable &

> reimbursable right now in and of itself.

>

>

> >

>

>

>

>

> --

> Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

> Family Care 'Modern medicine the old-fashioned way' This e-mail and

> attachments may contain information which is confidential and is only

> for the named addressee.  If you have received this email in error,

> please notify the sender immediately and delete it from your computer.

>

>  

>

>  

>

>  

>

>  

>

>  

>

>  

>

>

>

>

>

[Guest guest]

Regarding appointment length, I don't think that you can compare the

average office length visit in an IMP to the average visit with an

internist or a family practitioner in a regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more

time with a physician and often have more problems. Even a URI for

some of my patients can be a bit more complicated than average although

I am always so happy to see just a URI so that I can quickly finish and

code a 99213 visit.

I saw a patient today for her yearly exam, but we really dealt with

her hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She also

has a history of anxiety that is currently stable, that I reviewed with

her. Now this took me 70 minutes of visit time. In a regular practice

she would have had to come back at least 3 times to deal with all of

those issues and since she lives at least 30 minutes away that would be

an extra 2 hours of travel time for her. Now someone could say that

none of those are really " complex " , but honestly we didn't just shoot

the breeze during the visit. How else does one code other than with

time. 99214 and extended time. Oh yeah and she has osteopenia and I

scheduled a bone density and reviewed her treatment and renewed

medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me

may take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you need

to do, as well as a quick physical exam and have them out the door in

20 minutes, but they may not have understood anything, if I didn't take

time to listen, get feedback, get more family and social history, write

down instructions, set up followup appointments and pertinent referrals

etc. That is all important stuff and should be part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they spent

talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I

think that being social in a visit is also therapeutic. I was

listening to a radio program called Speaking of Faith in which a

physician by the name of Naomi Remen discusses the difference

between curing and healing. A good portion involves taking time to

listen. She gives an example of a man with cancer who continued take

his chemo treatments even though they weren't doing any good, just so

he could talk with his doctor weekly. His doctor would only see him

if he was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can get

a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/

index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

> Plus even when we do follow the complicated coding rules, the health

> plans can unilaterally say they won't pay anyways. The example of a

> well visit plus 99213 modifier 25 is the most obvious example.

> Reimbursement is not about medical necessity, it is about playing by

> the rules of a convoluted and unfair system where we physicians are at

> a disadvantage. Medical necessity should be determined by the

> physician, not an administrator.

>

> For the record, I never code based SOLELY on the amount of time I

> spend with a patient. However, according to this article from Family

> Practice Management 

> (http://www.aafp.org/fpm/20030600/27time.html), 

>

> If a physician spends more than 50 percent of a face-to-face visit

> counseling or coordinating a patient's care, the physician can code

> the visit on the basis of time, even if the history, exam or medical

> decision-making elements are lacking.

>

> That means a visit of between 25-39 minutes in length, which includes

> most return visits for my chronic care patients. I chart the time I

> start and the time I end each visit, and if more than half the time is

> spent talking about behavioral changes, ways to increase exercise,

> explaining their disease process, etc. then it should qualify as a

> 99214. Interestingly, when I used to work at Kaiser, I timed myself

> without regard to being on time, and found that I averaged 20 minutes

> per visit. Unfortunately, I was only allotted 15 minutes per visit so

> I was consistently behind by 45-60 minutes at the end of a half day. 

>

> Seto

> South Pasadena, CA

>

>

>

>

> OK, so I’ll get off my soapbox in a second. No, I don’t typically code

> a 99214 for a cold (although I certainly can get the documentation to

> be there for it), and I realize that the powers that be have

> determined that medical necessity is the key. My argument is not that

> I code that way, but that I should not have to worry about it in the

> first place. Let’s say someone comes in and we talk about their URI

> and I ask briefly how their back pain is and if they are exercising

> and have stopped smoking. Generally, this should be a 99214, but

> instead of documenting everything, I decide to “code for time.” Oops,

> no longer is it about medical necessity, it’s about documentation. So

> now we are stuck in this limbo where if we document too much, we are

> committing fraud because it is not medically necessary, but if we

> don’t document everything, we are told it never happened. This is the

> reason we have to go to coding class after coding class only to leave

> scratching our heads. It’s a crooked system where the one’s with the

> money can decide what they want and shift reality to focus on that. I

> believe that my time with my patient is valuable, and I shouldn’t have

> to justify it based on the perception of medical necessity. Worried

> about me overcoding? Look at my schedule to see if I saw5

> patients/hrand coded 99214 for all of them. I think you’ll find that

> much easier than searching charts looking to justify necessity.

>

>

>

>  

>

> Re: RE: appt length

>

>  

>

> Yes, but the problem is if we eliminate the medical necessity part,

> what would stop fraud & abuse of the CPT coding? Then all docs would

> have to do is write one sentence: " I spent 45 minutes, over 50% on

> counseling re: . . . " and nothing else. I agree it is important &

> helpful to spend the extra time, but it is just not codable &

> reimbursable right now in and of itself.

>

>

> >

>

>

>

>

> --

> Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

> Family Care 'Modern medicine the old-fashioned way' This e-mail and

> attachments may contain information which is confidential and is only

> for the named addressee.  If you have received this email in error,

> please notify the sender immediately and delete it from your computer.

>

>  

>

>  

>

>  

>

>  

>

>  

>

>  

>

>

>

>

>

[Guest guest]

Kathy,

Thanks for giving us that link....I had heard that Naomi Remen

was going to do that interview, but I missed it. Gotta love

technology, now I can listen to it. I love her books.

Sharon

At 08:24 PM 9/26/2006, you wrote:

Regarding appointment length, I

don't think that you can compare the average office length visit in an

IMP to the average visit with an internist or a family practitioner in a

regular practice.

At least in my practice

1.the patients self select for a practice where they can spend more time

with a physician and often have more problems. Even a URI for some

of my patients can be a bit more complicated than average although I am

always so happy to see just a URI so that I can quickly finish and code a

99213 visit.

I saw a patient today for her yearly exam, but we really dealt with her

hyperlipidemia-followup and review of labs, but lipids also not in

control, hypothyroidism-stable, urge incontinence-followup with

additional advice, new breast lump-requiring mammogram, myalgias and

arthralgias-ongoing but I continue to advise on different treatment

options, hormone replacement requiring medication adjustment. She

also has a history of anxiety that is currently stable, that I reviewed

with her. Now this took me 70 minutes of visit time. In a

regular practice she would have had to come back at least 3 times to deal

with all of those issues and since she lives at least 30 minutes away

that would be an extra 2 hours of travel time for her. Now

someone could say that none of those are really " complex " , but

honestly we didn't just shoot the breeze during the visit. How else

does one code other than with time. 99214 and extended time.

Oh yeah and she has osteopenia and I scheduled a bone density and

reviewed her treatment and renewed medications for everything.

2.How does one figure out complexity and time accurately anyway.

Sometimes explaining something that seems very straight forward to me may

take a long time getting across to the patient. Diabetes is pretty

straightforward until it happens to someone and they have to wrap their

mind around suddenly having an illness and needing to make huge life

changes. I could sure give results, do a quick this is what you

need to do, as well as a quick physical exam and have them out the

door in 20 minutes, but they may not have understood anything, if I

didn't take time to listen, get feedback, get more family and social

history, write down instructions, set up followup appointments and

pertinent referrals etc. That is all important stuff and should be

part of coding for time.

What about someone who is having anxiety about a social or family

situation. How does one decide on that complexity other than with

time?

3. I feel that often my whole visit is counseling and coordination of

care as I listen, give feedback and bits of advice throughout the whole

visit. I don't save the counseling all for the end or the visit and

then measure and divide and subtract. How does a counselor measure

their time counseling? Do they calculate just the time that they

spent talking or do they include listening, and give and take with the

patient.

4. I don't include time in which I am just being social, although I think

that being social in a visit is also therapeutic. I was listening

to a radio program called Speaking of Faith in which a physician by the

name of Naomi Remen discusses the difference between curing and

healing. A good portion involves taking time to listen. She

gives an example of a man with cancer who continued take his chemo

treatments even though they weren't doing any good, just so he could talk

with his doctor weekly. His doctor would only see him if he

was " receiving some sort of treatment " , but it was the actual

visit with the doctor that was keeping the patient going. One can

get a podcast of that program if interested.

http://speakingoffaith.publicradio.org/programs/listeninggenerously/index.shtml

Kathy Broman

Mason City, IA

kmlb2@...

On Tuesday, September 26, 2006, at 03:46 PM, Seto wrote:

Plus even when we do follow the

complicated coding rules, the health plans can unilaterally say they

won't pay anyways. The example of a well visit plus 99213 modifier 25 is

the most obvious example. Reimbursement is not about medical necessity,

it is about playing by the rules of a convoluted and unfair system where

we physicians are at a disadvantage. Medical necessity should be

determined by the physician, not an administrator.

For the record, I never code based SOLELY on the amount of time I spend

with a patient. However, according to this article from Family Practice

Management

(

http://www.aafp.org/fpm/20030600/27time.html

),

If a physician spends more than 50

percent of a face-to-face visit counseling or coordinating a patient's

care, the physician can code the visit on the basis of time, even if the

history, exam or medical decision-making elements are lacking.

That means a visit of between 25-39 minutes in length, which includes

most return visits for my chronic care patients. I chart the time I start

and the time I end each visit, and if more than half the time is spent

talking about behavioral changes, ways to increase exercise, explaining

their disease process, etc. then it should qualify as a 99214.

Interestingly, when I used to work at Kaiser, I timed myself without

regard to being on time, and found that I averaged 20 minutes per visit.

Unfortunately, I was only allotted 15 minutes per visit so I was

consistently behind by 45-60 minutes at the end of a half day.

Seto

South Pasadena, CA

OK, so I’ll get off my soapbox in a second.

No, I don’t typically code a 99214 for a cold (although I certainly can

get the documentation to be there for it), and I realize that the powers

that be have determined that medical necessity is the key. My argument is

not that I code that way, but that I should not have to worry about it in

the first place. Let’s say someone comes in and we talk about their URI

and I ask briefly how their back pain is and if they are exercising and

have stopped smoking. Generally, this should be a 99214, but instead of

documenting everything, I decide to “code for time.” Oops, no longer is

it about medical necessity, it’s about documentation. So now we are stuck

in this limbo where if we document too much, we are committing fraud

because it is not medically necessary, but if we don’t document

everything, we are told it never happened. This is the reason we have to

go to coding class after coding class only to leave scratching our heads.

It’s a crooked system where the one’s with the money can decide what they

want and shift reality to focus on that. I believe that my time with my

patient is valuable, and I shouldn’t have to justify it based on the

perception of medical necessity. Worried about me overcoding? Look at my

schedule to see if I saw5 patients/hrand coded 99214 for all of them. I

think you’ll find that much easier than searching charts looking to

justify necessity.

Re: RE:

appt length

Yes, but the problem is if we

eliminate the medical necessity part, what would stop fraud & abuse

of the CPT coding? Then all docs would have to do is write one sentence:

" I spent 45 minutes, over 50% on counseling re: . . . " and

nothing else. I agree it is important & helpful to spend the extra

time, but it is just not codable & reimbursable right now in and of

itself.

>

--

Lynette I Iles MD 210 South Iowa Ste 3 Washington IA 52353 Flexible

Family Care 'Modern medicine the old-fashioned way' This e-mail and

attachments may contain information which is confidential and is only for

the named addressee. If you have received this email in error,

please notify the sender immediately and delete it from your

computer.

<br>

<br>

<br>

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