Home Forums Discussions General Discussion "Maximizing billing"

Hi all,

This has nothing to do with AC per se.

I am a solo family doc, 1 part time PA. Patient population is older, lots of psychosocial/depression/numerous chronic problems/etc. (Sound familiar?) Lots of prior auths/referrals/etc. Lots and lots of forms to fill out etc

Finances have been a struggle, reimbursements flat/expenses up/etc (Nobody else in this situation I'm sure.)

A local practice was bought out by a practice manager who claims that "Maximizing billing" will greatly increase revenue. This practice is looking for another physician, and is offfering considerably more than I am making now. The pitch is "Better billing will bring in lots more money without working harder."

I do not have many details, one example used was in-office spirometry.

My gut sense is that such an approach would push the legal and ethical limits, and create huge red flags inviting audits etc.

Anyone with experience in similar situations?

Anyone find a legitimate way to bring more money in? Locally we have seen physicians try to sell rx meds, sell vitamins, sell weight loss supplements, etc. I have trouble with spirometry etc, I see little useful medical need for this, I have enough trouble keeping symptomatic patients on inhalers, I see no clear benefit prescribing meds for relatively asymptomatic patients.

Thanks. Gene

Gene,

Deja vu! I too am a solo family doc. Your situation sounds very familiar.

What cpt do you use to bill for your typical patient f/u visit?

John

I think spirometry can be useful - I think it helps to instill in patients how bad their disease is, it allows you to measure change with time. It does generate revenue but I think it along with EKGs are useful in the office.

I do think most docs undercode their office visits - when you see a diabetic who comes in for recheck and you do a foot exam, order labs, renew meds and address their HTN and lipids - do you charge a level 3 ? A lot of docs do and they are short changing themselves.

Hi John,

Over the years I have had % 99214 (vs 99213) increase gradually. Ironically, I think it took even a further jump since starting the MU garbage. As long as I list and "address" 3 problems, I think the 99214 is justified, especially for a 3 or 4 mo recheck.

Earlier rechecks, esp to address just 1 item ( BP med adjustment ), are typically 99213. Sore throat/sinus infection/sore knee are typically 99213, UNLESS they also need BP meds adjusted etc.

I'm not billing a lot of annuals, usually bill 99214 based on problems addressed.

Major/int joint injections typically 99213 plus procedure code, unless other problems addressed, then 99214 and injection.

Very few 99215s

Most initial visits 99203s.

Gene

Gene,
Even if they do "maximize" your billing, they will be getting a cut of the profits, hence YOUR profits are not maximized. Become VERY familiar with proper coding and billing. I would strongly recommend www.emuniversity.com for getting a better handle on what exactly constitutes a 99214, and how to document to that code. It's not how we learned it, but it is a necessity in today's climate.
Don't minimize the value of being your own boss and calling the shots (even though there are times...). I can't tell you how many conversations I've had with my disgruntled employed peers. There is a certain value and satisfaction to earned success. Seriously, learn to maximize your own billing and keep the change.
Dave

Gene:

I agree with Dave, check out E/M University's site. I realized that I can very appropriately charge 99214 for almost all f/u visits and many sick visits. For well child visits be sure your using the up to date codes for immunizations 90460 and 90461. I've been trying to find someone I can call with E&M coding questions. Although I hate having to deal with it--it's essential. As Dave said, proper coding is critical for the financial viability of a practice.

John

The statement sounds like you are performing an annual PE/preventive services at the visit, AND addressing (E/M) problems? If so, one simple adjustment to significantly improve revenue is to bill for both, using a -25 modifier on the 99214. You are doing the work required for the codes, you might as well get paid for it.

"Getting Paid": www.aafp.org/fpm/2004/1000/p21.html
Also helpful: "How to Maximize Revenue With Minimal Effort": www.aafp.org/fpm/2009/0500/p18.html

Absolutely!
Dave

I'm sure you have figured this out by now, but our rather loathsome system seems to find doing "things" much more valuable that using intelligence. That said, are you careful that you are billing properly for all the little "things" you do? Are you religiously charging for freezing off that skin tag that took 15 seconds at the end of a half-hour visit? Some things are so mindless that I find it distasteful to charge for them until I remind myself that it is how I make my living...

Spirometry can be a useful tool, but I don't use it much (except for our respirator physicals that require it), although that would be different if there were a number of asthmatics in my practice. The question is whether you will be pressured to use it just to make money, or because the information is medically useful. Similarly, simple audiometry has its place if you have reasonable concern that a patient may be exposed to noise but not covered under a hearing protection program. These things are reasonable. However, I have also watched a video "educating" practices on billing that strongly recommended doing thoracic impedance plesthymography routinely based on a manufacturer's recommendation that it supposedly gave information on cardiac output and billed out nicely. The presenter gave this information without the slightest hint of embarrassment.

I find it a constant struggle within myself to decide if I am doing a procedure because I really need the information or because it makes me money. The decision is all too easily warped by avarice. I truly hate this aspect of medical practice.

I have had many presentations from various manufacturers, etc with things like thoracic impedance (basically billed as poor man's echo for CHF), treadmills, etc. I basically do injections in joints, some PFT's, EKG's - basically if I was sending them out to the hospital/lab for the device then I consider using them in the office. On the other hand I do not sell things - I send them to the pharmacy for vitamins, supplements, even splints, etc as I find it just feels wrong to bill for them - assuming I billed correctly and got paid.

OK, I will weigh in here. As the only remaining solo internist in my community I found it necessary to be creative and think outside the box. I am doing things that 10 years ago I would have found appalling. I tried very hard to make a living with my medical brain but was failing. I now contract services that come in and do ECHOs, other dopplers and ultrasounds. Another service comes in and does bone density scans and nerve conductions. I also recently added spirometry. One of the reasons I reluctantly added these is that many insurance companies now consider it "Quality of Care" measures. Read their recommendations....diabetics need nerve testing, all smokers over 45 should have spirometry...women need their bone densities. Also, even Medicare says all men over 65 who ever smoked should be screened for AAA. Glaucoma testing is also recommended but I have not found a good way to do this yet other than the old Schiotz tonometer. Years ago I used to do screening colonoscopies but gave that up because I did not want the liability issues. Everything I now do adds very little staff time, virtually no added liabilities and are very profitable. These ancillaries are the only reason I am still in business. Why should you give the money to the hospital for things that you are going to have the patient do anyway...you may as well get your cut. Granted, sometimes I wonder if I do more "things" now than I used to but I really do not. Having the tests readily available actually makes me think about getting the studies done that should be done. I have diagnosed a huge number of problems that I think I previously would have missed.

Also, a couple of years ago I began selling generics and some otc meds like omeprazole, zyrtec, calcium with D.....I started this after I ordered some meds for myself and my husband and was flabbergasted at how cheap they were. I got a price list for Mohawk Medical and picked out some of my most-prescribed generics. I keep these in my drug sample closet. I may make 2-6 bucks on a bottle, depending on what the typical price is at WalMart. I only stock those meds that I can compete with them on. I spend maybe 2 hours a month making labels which we stick on the bottles. These have my name and address and a space for the patient's name and directions/warnings for the specific meds. A little more labor-intensive but worth it. I do not file any insurance for these. The patients love it!! Many can get meds from me more cheaply than from their insurance company. Patients in the "Donut Hole" really like it.

Anyway, these maneuvers, like them or not, have kept my head above water. I really loathe the thought of having to join a group or to sell out to the hospital. PM me if you want any more info.

Oh yea, I also do Holters and overnight oximetry

We (2 physicians) run a physicians' office lab, have a CBC machine and a chemistry analyzer, which makes a small profit monthly. We do EKG, spirometry & Holters also.

We have been through all the other expanded services: contract services for office sonograms & Dopplers, DEXA machine, basic X-ray for CXRs & KUBs, treadmill stress, flex sigs. As "quality control" requirements, over-reads, equipment replacement, repairs & component costs have risen and reimbursements haven't, we gave up on these. We used to dispense common meds as well, but the pharmacy industry convinced the state to impose onerous requirements, so our sick patients now have to travel cross town and wait 30 minutes to pay more.

We always thought we could do a better job with these services, and our patients agreed. And as Leslie says, why just let an inferior provider collect the charges instead of us? We have to review the results with the patients and apologize for their bad service as well! Did we over utilize -- I doubt it, it is time consuming to add these services to an office practice, and my time has value to me.

But our political leaders have decided that personal service and patient satisfaction is trumped by superficially cheap prices (though typically paying more due to rampant fraud and waste). They want to kill us off and the patients be damned.

John,

I have had the reimbursements battles as well. I simply tell the contracted services that, if I have to take a cut, they do too or I will cancel the service. I have never had one not comply.
I have had a particular insurance company (Anthem) fail to reimburse me what it costs me to do a bone density scan ($70) but they will reimburse the hospital $160 to do one....makes no sense. But, my Anthem patients have to go to the hospital.
I guess the success or failure of ancillaries depends on the market in which you practice (disgusting that you have to think of it as a "market").
But for me,the very little extra time and headaches are far better than group or hospital-managed practice.

Leslie, et al...

I think a pivotal point in my offering a service in the office, contracted or not, is whether I am as qualified as the competing providers to interpret the results of a test that equipment generates (overreading or not). I have hospital privileges in stress EKG's, and Holter monitors, so it does not bother me to buy the equipment for my office to provide the same test more cheaply and keep the profit, as the result would be interpreted by me the same way both places. But, I am not trained as a radiologist, so office echos and DEXA's are out for me. I am trained and privileged in GI endoscopy, and used to do them in the office, but it is much more efficient for me to use the hospital endoscopy suite, and they have better safety equipment and personnel than I can afford, so I do them there. I just want to look myself in the mirror and know that the service I am providing in office is as good or better than is available elsewhere, not just more lucrative.

A radiologist isn't needed for a DEXA. The software calculates the bone density and graphs the patient result. The decision-maker as always is the physician, who as Leslie points out gets paid a fraction of the hospital's charge, for more work. It is almost criminal to allow our tax dollars or the patient's premium to be wasted in this way.

David,

The bone densities are self-explanatory. The ECHOs are over-read by a local cardiologist hired by the contracted company. The other ultrasounds are read by a radiologist hired by the company. The nerve conductions are read by a neurologist hired by the contracted company. You would need to check your state regulations to make sure you can do this.

I have been in solo internal medicine practice for the last four years. I do offer 2DECHO's, abdominal US, DEXA scans, exercise stress test, Holter, spirometry, EKG, metabolic testing, joint injections, electrocautery, small skin lesions excisions and (recently added)cryotherapy to my patients. They really like that they don't have to go anywhere to have all this procedures done. From my perspective I can only say that if it was not for this ancillary procedures I would not be able to survive as solo internist.

Gene,

My advice:

Learn how to code the 99214 visits and use TiME when doing int 99215 visits.

If you are like me, and have patients with multiple, chronic problems, most of those visits are 99214.
If you document properly, a bronchitis episode can be a 99214.
Somebody with 4-6 problems can be a 215.

I have gone through this as well with my own practice. I think we tend to undercharge because we want to be fair and not feel guilty about charging people for our skills. REMEMBER: the current coding system was not created by you.
It has a structure, and if you learn the structure and meet the documentation requirements, you should not have to worry about an audit. REMEMBER, someone else made the rules, you just follow them.

Suggest you look at Peter Jensen's website, EMU University. His approach is priceless. The basic is look at the decision making and then add the appropriate documentation.

You could have a consultant look at how you are coding and billing and make suggestions.

I am still debating getting a spirometer, but I don't see it as a money maker.

If you would like to discuss further, email me at rgobao@comcast.net

Rick Gobao, MD
Down the road from you in Pittsburgh

We just signed a contract to allow sonograms to be performed in our office. We only pay for the services provided and we do the scheduling and billing. So far so good.

Also it is ok to bill for services rendered. If you have the documentation for a 14, bill it.

Finally, make sure someone is following up on denied claims and make sure your cash controls are sound.