It’s not fair

“I can’t believe Medicare won’t pay me for complications in the post op period.  It is just not fair.”

Recently, I shipped a package to my son who works at a financial company near the World Trade Center site.  When he received it, he texted me a picture of the package, so I’d know it had arrived. (Oh youth).  To my surprise, the package had a sticker on it that said, “X-rayed by Pitney Bowes.”  X-rayed, of course, because he works at a financial company, with a clear view of the new WTC building.    When I spoke with him, I said, “I didn’t know Pitney-Bowes did anything else besides postage meters.”  He replied, “What’s a postage meter?” (Oh youth). 

Medical practices bemoan changes in reimbursement—always lower—that make it harder for them to stay in business.  Services that were paid separately are bundled into a single payment.  Reimbursement for some diagnostic tests are set to the lower Outpatient Prospective Payment System rate.  This leaves medical practices feeling under siege.  A Podiatrist, who hadn’t started his medical training until long after the global surgical package was in effect, told me “It’s not fair that Medicare won’t pay me to treat post op complications in the office.”   Pitney-Bowes could have complained that people send fewer letters, or they could adapt to the business environment and find a new revenue line. 

It’s easy for us in medical practices to adopt that attitude, but it doesn’t help us to adapt to the new healthcare environment.  As I think about the three most critical strategies for most practices I see them as: 1) Participate in CMS incentive programs (PQRS, e-Prescribing, EMR), 2) keep up to date on coding for your field, and 3) use technology to reduce billing costs and increase billing effectiveness.     

Changes in the business environment in and out of healthcare are challenging, and sometimes seem unfair to us. But like all business, we need to adapt in order to thrive.


Go to the Source

“You tell me one thing, Sue tells me another.  No one knows the answer.”

Coding for physician services used to have more in common with a cottage industry than a profession.  Back in the late 80’s, I was processing paid and denied claims in a Family Practice office.  (Stop me if you’ve heard this one….) Medicare was denying claims for B-12 shots, and I didn’t know why.  I went next door and talked to the biller at the Internal Medicine practice, and she knew at a glance, and told me, “You’re using the wrong diagnosis.  You have to use pernicious anemia in order for B-12 to be paid.”  She didn’t say, “Medicare has a policy about B-12 shots, and if a patient doesn’t have a covered indication, it is a non-covered service.”  Both statements would have been true, but the second explained the reason, and the coverage and payment implications.

How have most physician coders learned about coding?  From the biller or coder in the next office or sitting next to a staff member for a few weeks, whose job they are filling.  I admit that back in the 1980’s the BCBS rep came to our office and showed me how to fill out an insurance claim form.  Can you imagine?  And, there were different claim forms for BCBS, Medicare and Medicaid at the time.  She showed me out to complete them all. 

Coding is the source of revenue in a physician practice and also the source of compliance risk.  Physician practices can’t afford to treat it like a cottage industry anymore, but need to invest time and resources into learning both coding and reimbursement rules. 

Some of the answers to medical practice questions are hidden in plain sight.  With the internet, it’s easy to log on to a Q&A forum and ask a question.  But, before doing that, coders should do some simple research for two reasons: it increases the likelihood of the right answer and the learning is more profound.  Let’s take a simple example.  I got a call recently from a Endocrinology practice wondering how they could charge to implant a Continuous Glucose Monitor.  They had two questions:  Is there a separate procedure code for it, and can we charge an office visit on the same day.  The answer to these questions can be found –hidden in plain sight—in the CPT book.  Looking at the definition of the code of CGM (95250) the definition is: Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording.  The placement is considered part of code 95250 and may not be billed separately.  As to whether an office visit can be charged on the same day, the answer is found in the definition of modifier 25.  A separate and distinct office visit on the same day could be charged.  But, if the purpose of the visit was to implant the device, do not charge a separate office visit.

When a coding question arises in the office, start with the CPT book for your answer. Go the source. 

I Want to Believe

I want to believe!

X-File fans will remember the poster that Agent Mulder had on his bulletin board with a picture of a flying saucer and the words, “I want to believe.”  That’s how I feel reading EMR notes sometimes.  I want to believe, but I doubt.

I know how this happens.  The EMR vendor, the practice implementation team and the doctor have a meeting to develop the “normal” template for a hospital admission or a diabetes follow up visit.  I myself may have participated in these meetings.  Let’s use the admission as an example.  We want to develop a template with a comprehensive exam, so that it will meet the requirements for a level two or three admissions. The coding specialist hastens to add that not all admissions are high level admissions, but if the admission is complex, we don’t want it to down code based on missing one exam element.  The template is done, and the doctor never looks at again.  The doctor never reads, line by line, the admission note that s/he generates using the “normal” exam template.  The results:

  • 86 year old woman admitted with a small bowel obstruction with “gait—non-antalgic.”  Really?  The doctor had the patient get up off the gurney in the ED and walk?
  • Normal external ears for a non-ear problem.  I know: it’s a bullet on the 1997 exam, but have you ever documented it before?  Don’t do it unless it’s relevant.
  • A toddler with normal insight and judgment.  My toddlers didn’t exhibit insight and judgment, but maybe they were backward.
  • Abdominal exam normal, “with normal surgical scars, if any, as described in history.”
  • The same exam for all problems.  I mean, the exact same exam for all problems.

The same difficulty occurs in the ROS, using a “normal” ROS exam.   Use caution with the use of these normal templates.  In the history section, contradictions in the HPI and ROS are particularly troublesome.  For follow up visits, you don’t need a complete ROS except for a 99215.  99213 requires only one system in the ROS and 99214 requires only two systems in the ROS.

What to do?  How to make the best use of EMR, take advantage of their time saving features (I know, almost an oxymoron, but there must be some—I want to believe) and not produce cookie cutter notes?  Here’s my advice:  document what you would have documented when you dictated records.   Don’t do a complete ROS for every follow up patient.  Print out and read line-by-line a sampling of your own notes.   Have different exam templates for different problems.