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pnixon

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With the new guidelines, are any private practices (Orthopedic specifically) coding 99205/99215 for office visits? I have a provider being told he should always code this. Most of our care is elective and not emergent. I'm struggling justifying making this change. thanks
 
pnixon said:
With the new guidelines, are any private practices (Orthopedic specifically) coding 99205/99215 for office visits? I have a provider being told he should always code this. Most of our care is elective and not emergent. I'm struggling justifying making this change. thanks
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I work for an Orthopedic facility and no, we seldom ever use those codes unless it was a dire situation/emergency that warranted it.
 
pnixon said:
With the new guidelines, are any private practices (Orthopedic specifically) coding 99205/99215 for office visits? I have a provider being told he should always code this. Most of our care is elective and not emergent. I'm struggling justifying making this change. thanks
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Hi there, you're right to question that statement. Each patient visit must still be coded based on the MDM or time for that specific visit. Has your provider said who told them that, and what their source was?
 
There could be times when it's appropriate. However, "always" is not one of them. Elective and non-emergent doesn't mean that it wouldn't be reasonable to see level 5s. Someone telling a provider, "they should always code level 5" is scary and as asked above, you should find out where this is coming from, if it is taken out of context, and the source 100%. If you have a high volume spine or PM&R I could see this. Ortho practices that have limb salvage and bone tumor providers could also have more higher levels. If your providers do trauma call at a Level 1 trauma center those patients could be very complex even if they are following up in the office. It has to be taken in the context of the documentation.

Providers talk to their peers, go to conferences and come back with new ideas sometimes :)

I feel sometimes people are scared to code level 5, but if the documentation supports it why wouldn't you?
Now, having a provider who only codes level 5 definitely requires audit and scrutiny.
 
Jumping on the bandwagon of never say "always." I call this locker room talk, where 1 physician (who probably doesn't understand coding or billing guidelines) makes a statement that is partially true and then is even further misinterpreted by the next physician (who also does not understand coding or billing guidelines). Or goes to a conference and only listens to half the presentation. I remember 1 time my doc came to me and said - I was talking to my friend Artie who said he always bills and gets paid for administering chemo when the patient is in the hospital and I want us to bill for it. I was like - get me Artie on the phone. After a conversation on speakerphone with the 3 of us, turns out Artie was not billing for chemo on inpatients, but was sometimes billing an inpatient visit when appropriate, which was exactly what we were already doing.
Are there situations where an orthopedist could accurately code 99205/99215? Absolutely! But the documentation must support it. 2 of 3 elements of problem data and risk must be high.
Here are some potential level 5 ortho examples:
1) A chronic illness that has documented SEVERE exacerbation or progression and the physician will be performing an elective MAJOR surgery with identified patient/procedure risk factors.
2) Orders 2 outside tests, independent historian, discusses case with cardiologist due to CAHD, discussed typical recommendation of major surgery and why after discussing with cardiologist does not recommend the surgery at this time and will instead treat with PT and prescription meds.
You might often get level 5 risk for patients with a major surgery treatment plan, but you must also reach level 5 for problem or data.
I code for gynecologic oncology and even we don't "always" get level 5 for a cancer patient.
It all depends on the documentation.
 
csperoni said:
Jumping on the bandwagon of never say "always." I call this locker room talk, where 1 physician (who probably doesn't understand coding or billing guidelines) makes a statement that is partially true and then is even further misinterpreted by the next physician (who also does not understand coding or billing guidelines). Or goes to a conference and only listens to half the presentation. I remember 1 time my doc came to me and said - I was talking to my friend Artie who said he always bills and gets paid for administering chemo when the patient is in the hospital and I want us to bill for it. I was like - get me Artie on the phone. After a conversation on speakerphone with the 3 of us, turns out Artie was not billing for chemo on inpatients, but was sometimes billing an inpatient visit when appropriate, which was exactly what we were already doing.
Are there situations where an orthopedist could accurately code 99205/99215? Absolutely! But the documentation must support it. 2 of 3 elements of problem data and risk must be high.
Here are some potential level 5 ortho examples:
1) A chronic illness that has documented SEVERE exacerbation or progression and the physician will be performing an elective MAJOR surgery with identified patient/procedure risk factors.
2) Orders 2 outside tests, independent historian, discusses case with cardiologist due to CAHD, discussed typical recommendation of major surgery and why after discussing with cardiologist does not recommend the surgery at this time and will instead treat with PT and prescription meds.
You might often get level 5 risk for patients with a major surgery treatment plan, but you must also reach level 5 for problem or data.
I code for gynecologic oncology and even we don't "always" get level 5 for a cancer patient.
It all depends on the documentation.
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Your scenario cracked me up. Get me Artie on the phone LoL. It's the "telephone game".
Also fun is when you are adivsing a provider the exact same thing as an external consultant. Yet, they listen to the highly paid and expensive consultant but not their own employee :)
 
Just a couple of extra thoughts:
1. Years ago I would hear about specialists who believed that every E/M visit was a level 5 (or a consult) simply because they were a specialist. But it was always a specialist who was being audited/investigated. However, as others have said, if a visit is a five based on MDM or time, absolutely code it as a five.
2. I propose that we call instances where a provider has picked up dubious info "Talking to Artie." 😆
 
jkyles said:
Just a couple of extra thoughts:
1. Years ago I would hear about specialists who believed that every E/M visit was a level 5 (or a consult) simply because they were a specialist. But it was always a specialist who was being audited/investigated. However, as others have said, if a visit is a five based on MDM or time, absolutely code it as a five.
2. I propose that we call instances where a provider has picked up dubious info "Talking to Artie." 😆
Click to expand...
:ROFLMAO::ROFLMAO::ROFLMAO:
 
I agree with what has been said above. If your physician would like to see data, CMS has E/M level utilization by specialty. You can easily see the distribution by level for Orthopedic Surgery, and show him hard data that demonstrates an ortho who billed all level 5 visits for everything would be an outlier and probably get red-flagged for reviews.

AAPC has a comparison tool for E/M Utilization Benchmarking that uses CMS data. You can enter your practice's utilization and it will generate a bar graph comparing Medicare data for your specialty: https://www.aapc.com/tools/em_utilization.aspx

The original source data from CMS is here: https://www.cms.gov/Research-Statis...eFeeforSvcPartsAB/MedicareUtilizationforPartB

Scroll all the way down to the bottom of that link for the "CY (year) Evaluation and Management (E&M) Codes By Specialty" files.


It's interesting to see how the curve varies for different specialties. I code radiation oncology and new patient consults tend to skew heavily toward Level 4 or Level 5. Most of our new patient visits take a minimum of 60 minutes for reviewing imaging, exam, assessment, discussing all the treatment options, and answering all of the patient's questions. Even without time, most visits would qualify as a 4 or 5 by MDM too. When I was new to the specialty, I felt unsure about coding almost all Level 4 & 5 new patient visits, but the CMS data reassured me that we were typical for the specialty.

(BTW - even with our lengthy consults and MDM, I still don't bill everything at a Level 5.)
 
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I am having this issue with our providers... to the point that we have been notified by a few payers that they will be doing their own audits in 2024 due to the amount of over coding... Since i recently took the coding specialist position that was open for 3 years E/M training on the new guidelines was never really given and is at the top of my agenda. I am almost wondering if they are still using the 95/97 guidelines?.. Does anyone have any provider education resources or tips? I have been all over google looking for something simplified for this training session i have in 2 weeks and am at a loss. our head provider wants me to compare the old guidelines to the new 2023 MDM guidelines and i was horrible with the old ones i failed my test twice in 2022! I wish i could just tell them all to document time and call it a day!
Any help tips or advice would be appreciated!
 
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