Wiki NPs billing out almost all 99214s

[staceylw31@aol.com]

I am just looking for some guidance on this one. I work for a pediatric office, and we have a couple of Nurse Practitioners that insist on billing their visits at level 4. I have had to talk to them about it because we keep getting record audits from a couple of insurance companies. I have explained to them that the companies are saying these visits are level 3 because they are simple acute visits with low risk. One of my NP's thinks that if she adds 10,000 DX codes it will get her to a higher level even though when I go through the visit most are redundant codes. My one NP is trying to tell me that coding for pediatric patients is usually a higher level. We have an MDM calculator that they are supposed to use (Created by a PEDIATRIC EHR Company that WE use) and most of the 4s I am getting at 3s. Our office also does a 2 hour walk in service daily which is for acute sick visits where patients can just check in and be seen. I have also told them that these visits are more than likely going to be 99213, but here we are again with mostly 99214's. For example, they try to bill a 99214 for an acute ear infection with nasal congestion even though it's a low risk visit or a 99214 for an acute throat pain visit that is dx's with acute pharyngitis and an in office strep test that was negative. I also tried to explain that you do not get separate points for ordering the test and reviewing a test. I am seriously considering going for my auditing certification because they are driving me crazy. Any advice on how I can make them better understand how serious this is?

 

[xXxPARAGONxXx]

I am just looking for some guidance on this one. I work for a pediatric office, and we have a couple of Nurse Practitioners that insist on billing their visits at level 4. I have had to talk to them about it because we keep getting record audits from a couple of insurance companies. I have explained to them that the companies are saying these visits are level 3 because they are simple acute visits with low risk. One of my NP's thinks that if she adds 10,000 DX codes it will get her to a higher level even though when I go through the visit most are redundant codes. My one NP is trying to tell me that coding for pediatric patients is usually a higher level. We have an MDM calculator that they are supposed to use (Created by a PEDIATRIC EHR Company that WE use) and most of the 4s I am getting at 3s. Our office also does a 2 hour walk in service daily which is for acute sick visits where patients can just check in and be seen. I have also told them that these visits are more than likely going to be 99213, but here we are again with mostly 99214's. For example, they try to bill a 99214 for an acute ear infection with nasal congestion even though it's a low risk visit or a 99214 for an acute throat pain visit that is dx's with acute pharyngitis and an in office strep test that was negative. I also tried to explain that you do not get separate points for ordering the test and reviewing a test. I am seriously considering going for my auditing certification because they are driving me crazy. Any advice on how I can make them better understand how serious this is?

Who has the final say in billing? You or them? I mean, if you were to bill 99213, is someone going to reprimand you?

 

[amyjph]

Who is in charge of your practice? Go to your manager, supervisor or compliance department. Do they have physicians supervising them? Are the coders allowed to change levels according to the documentation or not? Is there an internal audit procedure and program? How big is the group? Getting your auditing certification, while great, is not going to solve this problem unfortunately.
Show the money (and loss of money and/or days in AR). How much is the practice losing in denials, rejections, medical record requests, and audits? Has the practice gotten ADRs, audits, pre-pay reviews, negative appeal results, etc? Sometimes peer reviewers and hearing it from the doctors and providers who do have a better understanding of coding helps.

 

[csperoni]

To me, the bottom line is the AMA E&M guidelines including the definitions.
Those guidelines clearly state if you order a test, you count the order, and the review is included.
You can't state an acute, uncomplicated is more than it is simply because the patient is pediatric. If the NPs are claiming the visit should be a higher level based on time, then they must document the amount of time.
The one "bonus" you often get in a pediatric practice is the independent historian for data (assuming this is being documented).
I would keep referencing those AMA guidelines and specifically ask what the NP is leveling for each of problem, data, and risk. If they refuse to follow the coding advice from AMA, I doubt your auditing certification would make any difference. Certainly feel free to pursue for your own knowledge, but would not matter for this scenario.
I agree with the advice by @amyjph to bring this to a manager or compliance, if applicable after discussing the AMA guidelines with them.
Good luck!

 

[staceylw31@aol.com]

To me, the bottom line is the AMA E&M guidelines including the definitions.
Those guidelines clearly state if you order a test, you count the order, and the review is included.
You can't state an acute, uncomplicated is more than it is simply because the patient is pediatric. If the NPs are claiming the visit should be a higher level based on time, then they must document the amount of time.
The one "bonus" you often get in a pediatric practice is the independent historian for data (assuming this is being documented).
I would keep referencing those AMA guidelines and specifically ask what the NP is leveling for each of problem, data, and risk. If they refuse to follow the coding advice from AMA, I doubt your auditing certification would make any difference. Certainly feel free to pursue for your own knowledge, but would not matter for this scenario.
I agree with the advice by @amyjph to bring this to a manager or compliance, if applicable after discussing the AMA guidelines with them.
Good luck!

That is exactly what I keep telling them. We are having a meeting today so wish me luck LOL!

 

[staceylw31@aol.com]

Who has the final say in billing? You or them? I mean, if you were to bill 99213, is someone going to reprimand you?

They want the docs to have the final say, BUT since I am a CPC I HAVE been changing them to 99213 strictly because I am tired of getting the medical record request for services. We are having a meeting today and I have printed out visits that are clearly 99213 but billed as 99214 and I have spoken to the owner about it. If it continues he is going to have a talk with them.

 

[staceylw31@aol.com]

Who is in charge of your practice? Go to your manager, supervisor or compliance department. Do they have physicians supervising them? Are the coders allowed to change levels according to the documentation or not? Is there an internal audit procedure and program? How big is the group? Getting your auditing certification, while great, is not going to solve this problem unfortunately.
Show the money (and loss of money and/or days in AR). How much is the practice losing in denials, rejections, medical record requests, and audits? Has the practice gotten ADRs, audits, pre-pay reviews, negative appeal results, etc? Sometimes peer reviewers and hearing it from the doctors and providers who do have a better understanding of coding helps.

I did finally go to the owner who is our main pediatrician here. He is going to have a talk with them if they continue to do this.

 

[xXxPARAGONxXx]

They want the docs to have the final say, BUT since I am a CPC I HAVE been changing them to 99213 strictly because I am tired of getting the medical record request for services. We are having a meeting today and I have printed out visits that are clearly 99213 but billed as 99214 and I have spoken to the owner about it. If it continues he is going to have a talk with them.

I wonder if the docs would be okay with you telling them how to do their job.

They have the MD. You have the CPC. They are basically telling you your CPC is meaningless. I'd be offended.

 

[amyjph]

Sometimes it can be an educational issue where guidance is needed to document better. It is difficult when everyone's hackles go up with a right/wrong, black/white scenario. Try to be diplomatic and work together. I have found asking to shadow a provider that codes higher than the peers in the group is helpful. Once when doing this I found the scribe was not capturing everything that was said/done. I also helped them understand time based coding and for their particular sub-specialty it was better and more common to code by time. Ask them about their practice, ask them why the visit is a level 5 (in their eyes). Sometimes they just need education to document better. I do understand though, there are times when you are just not going to get through. If the provider has the final say, I would question why I am even reviewing the documentation if I am not allowed to use my training and CPC to code it according to the documentation.

Again, money talks in this scenario. A formal audit with a bell curve can be helpful. Sometimes even an external audit can help. Does one provider have more days in AR than the others for E/M? If you pulled a month's worth of E/M for one provider, is every single visit a 4 or 5? That's an alert. Does one provider constantly get medical record requests or letters from the payer that they are an outlier compared to peers in the same geographic area? Those are all red flags. I once had a provider than only coded level 5s however, we found out someone else was "pushing the button" in the EMR to submit the charges and they didn't even know. Is the provider new and they had bad habits from somewhere else?

99214 for an acute ear infection with nasal congestion even though it's a low risk

I could see how this *might* be an established 4... depending on what was done and documented. *might*.
But yes, the test order/review thing is an issue.

 

[staceylw31@aol.com]

I wonder if the docs would be okay with you telling them how to do their job.

They have the MD. You have the CPC. They are basically telling you your CPC is meaningless. I'd be offended.

I kind of AM offended, but I was justified in our meeting. The point got across and now they are watching their billing, plus I do have the main MD on my side for this. I have been doing this for 20 years and have not had an issue until now, but I have no clue what I am talking about...

 

[amyjph]

I kind of AM offended, but I was justified in our meeting. The point got across and now they are watching their billing, plus I do have the main MD on my side for this. I have been doing this for 20 years and have not had an issue until now, but I have no clue what I am talking about...

So fun, right? It can be frustrating.
When ICD-10 happened, where I was, an outside consultant was hired and paid large sums... to literally explain and educate the exact same thing our internal staff was saying. Guess who the providers listened to?
Normally, I have found it is more education and diplomacy than anything else thank goodness.

 

[staceylw31@aol.com]

Sometimes it can be an educational issue where guidance is needed to document better. It is difficult when everyone's hackles go up with a right/wrong, black/white scenario. Try to be diplomatic and work together. I have found asking to shadow a provider that codes higher than the peers in the group is helpful. Once when doing this I found the scribe was not capturing everything that was said/done. I also helped them understand time based coding and for their particular sub-specialty it was better and more common to code by time. Ask them about their practice, ask them why the visit is a level 5 (in their eyes). Sometimes they just need education to document better. I do understand though, there are times when you are just not going to get through. If the provider has the final say, I would question why I am even reviewing the documentation if I am not allowed to use my training and CPC to code it according to the documentation.

Again, money talks in this scenario. A formal audit with a bell curve can be helpful. Sometimes even an external audit can help. Does one provider have more days in AR than the others for E/M? If you pulled a month's worth of E/M for one provider, is every single visit a 4 or 5? That's an alert. Does one provider constantly get medical record requests or letters from the payer that they are an outlier compared to peers in the same geographic area? Those are all red flags. I once had a provider than only coded level 5s however, we found out someone else was "pushing the button" in the EMR to submit the charges and they didn't even know. Is the provider new and they had bad habits from somewhere else?

I could see how this *might* be an established 4... depending on what was done and documented. *might*.
But yes, the test order/review thing is an issue.

Yes, it is really one provider that is getting the record requests and I have had to speak to her multiple times. I have explained to her that she does double dx coding (I think she thinks it will get her a higher level, but she will always try to bill wheezing with asthma for an example and the ins co constantly kicks it back.) I have gone over time-based billing because I think that would be the way to bill for a lot of her visits because she is very thorough and does spend the time. I have told her though that her documenting needs improvement because I am sure with the proper documentation there would not be so many denials for her.

 

[staceylw31@aol.com]

So fun, right? It can be frustrating.
When ICD-10 happened, where I was, an outside consultant was hired and paid large sums... to literally explain and educate the exact same thing our internal staff was saying. Guess who the providers listened to?
Normally, I have found it is more education and diplomacy than anything else thank goodness.

When they said they were going to have a meeting with outside people....I said ok bring it on and she told them the same thing. There really was no reason for them to come here and they had to drive for about 2 hours to get here. If ONLY there was someone here that knew what they were talking about....

 

[amyjph]

Yes, it is really one provider that is getting the record requests and I have had to speak to her multiple times. I have explained to her that she does double dx coding (I think she thinks it will get her a higher level, but she will always try to bill wheezing with asthma for an example and the ins co constantly kicks it back.) I have gone over time-based billing because I think that would be the way to bill for a lot of her visits because she is very thorough and does spend the time. I have told her though that her documenting needs improvement because I am sure with the proper documentation there would not be so many denials for her.

Difficult because the coding guidelines do not always make sense in a clinical context.