Home Forums Discussions Coding and Billing It?s different with doctors

When I saw that that a forum for coding and billing was created, I figured that it would involve very specific coding issues. The following broader topic came up and I thought it might be worth posting it here.

A group of doctors were at dinner the other night. At a nearby table, a group of lawyers from different firms discussed their various government contracts, sharing the hourly rates they charged and received for that work. At another table, several caterers talked about how much they were asking for various chicken or steak dishes when they marketed their businesses to companies around town. At other tables, accountants, architects, and business people all discussed the fees they charged and payments they commanded for their services. At our table, one of the doctors said, ?how much do you get from United Healthcare for a 99214?? Someone else said, ?Discussing that is restraint of trade. It?s illegal; we can?t do it.? And the conversation ended.

It seems obvious that in order to negotiate with an insurance company, it would be invaluable to know what other doctors receive for the same services. We have a publicly available Medicare and Medicaid fee schedule, and that serves as some sort of reference point, but do you ever wonder if your leading commercial payer is paying you 25% less (or more) for any given cpt code than they pay the practice down the street? It is very possible that they are. How would you respond if you had this information? How do we operate without it?

So here is my billing question: is there any legal method by which we can share this information? At one end of the spectrum, I would imagine that if I organized a meeting to discuss the minimum we will accept from UHC, that I would be in violation of the law and in big trouble. At the other end, suppose someone (not a physician) put up a website asking docs to anonymously post their zip code and the amount they are paid for a series of cpt?s from various insurance companies. Is that also illegal? What exactly can we legally do? Does anyone have any ideas? Are we really required to negotiate completely in the dark?

Jon,

It would be my honor to solicit, compile, and anonymize rates per payer/region. Just give me more info about how that data could best be communicated.

My single largest take-away from this years ACUC is that we are now in the *Provider Care* business. Thinking about servicemark/trademarking it - although I haven't run into another outfit focused on that - yet.

The more I have learned about the business/regulation side of medicine the last ~ 3 years, the more energized I have become, especially when it comes to dealing with payers/vendors on behalf of Providers and their practices.

In thinking about this conceptually, you may have non-disclosure constraints that limit your ability to publicly disclose payment terms, but I know that is regularly addressed by business consultants with their clients.

Not naming names of course, but I am aware of many prestigious accounting/management consulting firms that provide benchmarking services to their clients. They collect a variety of metrics, and that data goes into internal systems that are 'firewalled' from the account team, but benchmark your company against these internal proprietary systems. The client gets back scoring about how that company is doing against industry norms, regional norms, and competitors.

You folks would have to be the judge of how useful that data would be to your practice, and how/what you want benchmarked. Having implemented datawarehouse/datamining systems with 10 of millions of rows, the challenge would be sufficiently anonymizing data so that a bad actor can't overly isolate specific data. Not that hard, but it would be important to me from a design perspective.

Open to suggestions.

Warning: I'm going to be annoying again.

Reading multiple posts, it seems clear that a basic issue is that many physicians have built unsustainable business models for themselves, and are hoping that technology is going to bail them out. I do not think that is going to happen, nor will wishing make it so.

Here is a sort of brutal example. Let's say that you decide you need to make $200,000 a year to pay a mortgage, repay loans, and have a reasonable life style. Assume you are willing to work the more or less standard 2,000 hrs/year. Let's assume you have a 40% overhead. That means you need to collect $140/hr all day long.

Let's also assume adult primary care medicine, where each mid-level visit is something like hypertension, type II diabetes, a little hyperlipidemia. That's what I envision as a level 3 exam. No padding the numbers here, using the EHR to document meaningless drivel, or the like; just ethically a middle of the road patient with a middle of the road problem set. I can do about three of those an hour, leaving time for phone calls, potty breaks, tending fires, documenting, etc. That means I need to collect $50 per visit, assuming a full schedule.

Now, if insurance company W comes along and offers to pay me $30 for a level three exam, the answer is easy: either learn to say "no" or accept the fact that you are going to 1) start "fudging" what you did; 2) start doing unnecessary stuff; 3) stop spending the amount of time that you really need to do your best work, or 4) accept that your business is going to go tango uniform.

These strike me as being really simple, unassailable facts. Meaningful use is not going to save you. Jon Bertman is not going to save you. Obamacare is not going to save you. As my father told me, you can't get by with the philosophy that "I lose a little on each patient, but then again I have so many patients."

In medically overserved areas, there will always be plenty of physicians who will opt for options 1), 2), and or 3), or work in groups where they can be loss leaders for the procedure oriented specialties. If so, you have IMHO one of four choices: Sell your soul and join them, accept a life of genteel poverty and frustration, change specialties/careers, or move to an area where your services are valued and needed.

If, after 20 years of education and training $18K or $25K or $40K is going to make or break it for you, then let me suggest the handwriting is already on the wall. Remember, if you are going to realistically retire, you can hope to live on 4% of what you put aside. That means you need to have saved $2,500,000 by the time you quit if you want to retire on $100,000/yr. That puts Meaningful Use money squarely in the area of chump change.

The younger you are, the more hope you have of survival if you dump wishful thinking. As I said, I know I am annoying. I just prefer not to see my buddies go down.

David is right on.

But, I would like to have a safer, legal way to be able to look at my contracts and say that I'm in the average range for Aetna by accepting 130% of Medicare E/M charges and 150% for procedural codes...or whatever it is. Obviously, that's supposedly collusion if we all get together and try to have our rates all the same (which is completely silly). But it's probably not going to happen.

We just have to negotiate the rate that will keep us with each insurance and if it isn't good enough, quit accepting them.

David,
Thank you for saying that out-loud. I've spent the last year with my jaw hanging open reading what we physicians are willing to do to ourselves, our practices and our patients for a government handout (of taxpayer money, remember). Do other Americans really need to subsidize the poor physicians so they can enter the electronic age? A good idea stands on it's own merits and drives it's own demand. Nobody had to offer gov't money to get me to buy my iPad. God bless Jon Bertman for trying, but I'm afraid the promise of wealth beyond imagination (44K) is going to turn our thoroughbred EMR into a 3 humped camel. (It was 1973 government regulation that killed the muscle car era). Nobody's even touched the ethical considerations of agreeing to let the government mine our practice data and what that means for our poor patients down the road. Anyway, right on David--except that I would never 99213 a three problem visit. 99214 all the way.
David

I would echo David's comment regarding an average followup visit being a 99214. It's been hard for me to change my ways considering a 99213 an average visit, but if you actually study the coding guidelines, 99214 is your average followup visit if the patient has any complexity at all. This is a huge difference on an annual basis.

If you want to learn more about coding I would suggest

http://www.codinggrowthstrategies.com/

This guy probably "pushes it" but I learned some good tips.

Disclosure: I have no financial ties to this website.

Here is my issue with the 99214 as you suggest:

99212... patient comes in with head cold.. simple, self limited, you wonder why they came in, but feel you need to charge SOMETHING.

99213... As described, your typical, ho-hum, things looking good, come back in 3-4 months.

99214... Oops, things not looking so good. Need to start insulin, add another blood pressure medication, may need nephrology consult.

99215.... Things are going to worms. BP way out of control, creatinine 1.8,, hypoglycemic episodes during the night, have to change meds all around, mentioning some chest pain, issues at home with spouse/job, need to plead with cardiology to see NOW, etc.

So, if as you suggest 99214 is the everyday visit that does not get my pulse above 60, what do you do with MY 99215? I'd agree with you if there was a code for 99217 0r 99218, but there isn't. That's why I argue for coding (and charging adequately) routine stuff as 99213; to leave room to get paid properly for the really tough encounters.

What I've learned from using an EMR is that I am the one that is doing more and more. Yes, I could do away with my transcriptionist, but guess who replaces her-me. (Besides, both my nurses were cross-trained in medical transcription, so nobody really left). Who does the med refills now-me. (Yeah, I know, but I'm still on 5.0.29, waiting for 6 and not wanting to authorize a "workaround"). Who does the coding-yeah, you betcha it's me. It always was before, but now I have to be good at it and know the ins and outs of modifiers, new immunization codes, etc. I was initially really pushing for the integrated PM, but right now I'm having the girls do double entry into Medisoft (blech), and finding that it does act as a buffer for some of my really bad coding boo boos. (On our last batch of 128 submissions we had only one re-bill and that was just a 4 digit code that needed a 5th digit. (Sometimes I really do picture myself sitting at the computer with cymbals between my knees, a bass drum on my back and a kazoo in my mouth).

Sorry for the rant. All that is to say that coding is very important. Too important to delegate and too important to base on a gut feeling of what the code should be. History is a bad teacher when it comes to doctors getting paid. (Does any of medicine feel like it did 20 years ago?). A long time ago I learned to document an appt from the history to the physical, to the assessment and to the plan, and I still do it that way. When I had to start paying attention to my coding, I followed the same pattern, counting up the elements in my history and physical, the number of my diagnoses and my plan. Simple math to arrive at a billing code, and that's how I was devaluing my work by 30%. When it comes to accurate billing it is extremely important to look first at the level of medical decision making (MDM) that was involved at that visit. That is where the true value, both monetary and professional, of that patient interaction lies. The MDM determines the level of coding, it is then imperative for the physician to make sure the elements of history and physical exam support the MDM , again for the monetary value but also for the professional value (thoroughness) as well.

I have found the EMUniversity.com website extremely helpful in polishing my coding skills. I have absolutely no financial, professional, or romantic association with the site, but am just passing on some really good information which has helped me. I keep a shortcut link to their MDM calculator on my desktop and still use it about once a day. About half the time I find that my MDM supports a lower level of service than my gut feeling. I find it makes me a better coder, not necessarily a richer one.

Again, sorry for the long post. I'm passionate that docs get paid for the value of their work.

Here's a link to that MDM calculator if you're interested:
http://www.emuniversity.com/MDMCalculator.html

David
FP

David, you and I are saying exactly the same thing. The crucial element is the medical decision making. If I check all the little boxes to justify a level 4 exam for a few issues which are pretty straight forward, which is admittedly easy, then what is left for me on those times where every bit of my training and experience is put to the test?

Now, one answer is to say "Yes, well, those times are not frequent, and if we buff the chart for all those ordinary visits and the bottom line at the end of the year is good, then we can afford to just eat it on the complex visits and accept that we are being cruelly underpaid for being brilliant." But, I find that really intellectually offensive. I am really PROUD when I yank some poor quivering soul back from the edge because I was really competent that day. I want to be recognized for that, and our society uses money to do that. If that nets me only an additional 15% or so over and beyond the encounters when I don't have to turn on my brain, I feel cheated.

I want to be paid appropriately for the day to day stuff. AND I want to be lavished with gold and jewels when I pull of something really cool. If I upcode everything, I cheat myself of that.

The day to day stuff is the 214. You should get paid for the work done assessing three chronic, even though stable, problems. You've talked to the pt about them, reviewed the labs they had done, assessed their meds/treatments, probably discussed goals. This is utilizing your expertise and you should get paid for it. "Something really cool" should identifying the 215 and getting them controlled efficiently, not performing miracles.

Check out the FPM toolbox
www.aafp.org/online/en/home/publications/journals/fpm/fpmtoolbox.html

Under the Coding:CPT section, you'll find some PDF that go over examples of the variety of codes...
here's what one says about when to think about 914:
"Think level IV if you do any of the following at a patient visit:
? Order an X-ray and review it;
? Order an ECG and review it;
? See a new problem with uncertain prognosis (e.g., lump in breast);
? See a complicated injury (e.g., fall with loss of consciousness);
? See three chronic, stable illnesses;
? Spend more than 25 minutes with a patient."

and later there is an example of a visit:

"(Three chronic, stable illnesses)
CC: Follow-up on medical problems
HPI: 63-year-old male with hypertension. Blood pressure
has been controlled. Denies headache. His emphysema is
stable, but he does get mildly short of breath with activity.
His hypothyroidism is now stable. Recent thyroid stimulating
hormone testing was normal.
PH: Not smoking.
ROS: Noted above.
EXAM: Vitals: BP 138/78
Chest: Clear to auscultation
CV: Regular rhythm and rate
A/P:
Hypertension, stable, continue meds.
Emphysema, stable, continue meds.
Hypothyroidism, stable, continue meds."

Source: "Coding Level-IV Visits Without Fear" Thomas A. Waller, MD; Fam Pract Manag. 2006 Feb;13(2):34-38.
www.aafp.org/fpm/2006/0200/p34.html

I also, like AmazingDave, use the E/MUniversity to polish my documentation/coding.

A good rule of thumb:
Gut: 99214
Sphincter: 99215

David
FP

Dave,that's wonderful!!

Th.anks!

Thanks to all for your responses. The information above is really helpful.

Indy, thanks for stepping-up with your offer.

What I had in mind with my initial question was something a little different, though. David G, I agree that a certain level of compensation for a given code is unacceptable (you mention $30 for a level 3 follow-up). One way to deal with this is to refuse to participate with that company, or even to go non-par with everyone and run a cash-only practice. Cash-only is like the Holy Grail of medical practice now. I admire those who have achieved it, and encourage anyone who is going down the road to eliminating contracts with insurance companies that refuse to pay fairly.

Nonetheless, most practitioners must continue to contract with at least some insurance companies. I think we are trying to do that with one hand tied behind our backs. Most docs simply renew or sign contracts without even knowing what the fee schedule provides. One of the barriers to negotiating effectively is that we are essentially in the dark with regard to what other providers are paid. You can try to decide if $50 is acceptable for a level 3 exam, but wouldn?t it be tremendously helpful to negotiate knowing that the same insurance company is paying others $60 or $70? This is a situation that is unique to medicine; ALL others can discuss and share this information.

My proposal is that we try to find a way to collect and share this information. The conventional wisdom is that there are many legal obstacles to this. Is this true? Are there ways around the legal limitations?

To echo KenP I have been to two Coding Growth Strategies courses and found them very helpful. I have no financial or any other connection to them at all. It is pretty aggressive and I do not incorporate everything they say, but it does provide a good framework for thinking about how to code appropriately.

Most of us were taught:

Level 1 - really easy
Level 2 - easy
Level 3 - medium
Level 4 - hard
Level 5 - pt dying

This is not what the coding guidelines say at all and if you code that way you are cheating yourself.

I have hijacked Jon's thread enough, and will leave it, except to say that we have different viewpoints going here. A great quote I came across says it like this:

Good management is doing things right
Good leadership is doing the right things.

What I am getting from reading this thread is that there should be at least 1 additional level of E&M code. At least. Maybe more. That (those) would be your Really tough visits.

Level 6 - Gawd! Who gave that patient an appointment?

don't forget that if you prescribe meds (you may as well erx so that you get paid by medicare more) even if they don't need a med, you can bill a level higher usually from a99212 to a 99213 because it adds a level of complexity...hahaha....what a system!!!

I agree. Most of my visits are patients with 3 or more chronic diseases coded at 99214 and I'll use the time guidelines when that allows a higher code. I also use emuniversity.com and all the coding guides in the AAFP Practice Management ToolBox.