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  • How Can I Learn More About Billing and Coding?

    I didn't have any substantial understanding of billing and coding rules for E&M services until I found the E/M University online course. Now I understand that I was doing work that justified higher levels of service (based on the rules), but I didn't specifically include that work in my documentation. Lesson learned.

    I'm looking for similar resources to understand charging related to everything else I do as a non-invasive cardiologist, but no luck so far.

    The person in charge of billing and coding at my hospital has answered some of my questions but left many more unanswered, and frankly, I'd prefer to find an authoritative, independent resource. I've asked for my productivity reports, and actually looked at the details for the first time, and I've found coding errors (confirmed by the person in charge).

    Until now, I didn't know that when I do a comprehensive office assessment for a patient < 30 days after pacemaker placement (or even a loop recorder placement) -- done by a different cardiologist -- I was earning zero wRVUs, even though the assessment was not related to the pacemaker. Apparently, that can sometimes be fixed with a -24 modifier, but no one ever pointed that out, and I still don't know the rules around that.

    Our billing supervisor now tells me that Medicaid won't pay for any office visit for 30 days after any procedure; information I could have used six years ago when I started here.

    I need to learn all of the appropriate codes for the ECGs (think I've got those down), the various echo codes, assorted stress test codes, device interrogations, and peripheral ultrasound, as well as their associated wRVUs (for interpretation and/or supervision).

    There are sure to be many more holes in my knowledge that I'm unaware of at this point. I need to be alerted to those holes and fill them in too.

    Any ideas?

  • #2
    Renal physician associates offers an inperson/now online billing course for nephrologist that I attended. I didn't find it that helpful though, I don't attend these meetings anymore because I find that too many people interrupt the presenter to hear their own voice. I would look to your own specialty group for specialty specific rules. Otherwise, what I have found helpful is to always get into the habit of documenting enough data to get the highest level in the hospital, and then deciding what to bill based upon the level of risk. It is fairly easy in the hospital, you just have to -personally review ekg, document a review of prior medical records, document discussion of the case with referring physician, lab review, review the cxr report or personally review the cxr report to get the data part. You basically need four points of data for the highest level, but individual review of ekg, image, records all each count for 2 points with the rest counting for 1 point. It is much harder to find enough data to document the highest level in outpatient visits, but possible sometimes. After that, just make sure that you get into the habit of documenting a hpi with 4 elements, complete ros, fhx, shx, comprehensive exam and then you are basically all set for office visits and inpatient visits. It is amazing to me how I think that >80% of billing is done incorrectly based upon not having enough data or history or both. The more nuances stuff for your specialty will have to come from your own specialty society.

    Comment


    • #3
      Originally posted by nephron View Post
      Renal physician associates offers an inperson/now online billing course for nephrologist that I attended. I didn't find it that helpful though, I don't attend these meetings anymore because I find that too many people interrupt the presenter to hear their own voice. I would look to your own specialty group for specialty specific rules. Otherwise, what I have found helpful is to always get into the habit of documenting enough data to get the highest level in the hospital, and then deciding what to bill based upon the level of risk. It is fairly easy in the hospital, you just have to -personally review ekg, document a review of prior medical records, document discussion of the case with referring physician, lab review, review the cxr report or personally review the cxr report to get the data part. You basically need four points of data for the highest level, but individual review of ekg, image, records all each count for 2 points with the rest counting for 1 point. It is much harder to find enough data to document the highest level in outpatient visits, but possible sometimes. After that, just make sure that you get into the habit of documenting a hpi with 4 elements, complete ros, fhx, shx, comprehensive exam and then you are basically all set for office visits and inpatient visits. It is amazing to me how I think that >80% of billing is done incorrectly based upon not having enough data or history or both. The more nuances stuff for your specialty will have to come from your own specialty society.
      The American College of Cardiology is terrific for education, but no help regarding this subject; I've asked.

      I didn't know any of the E&M guidelines you allude to above until I had the E/M University online course.

      Regarding, "but individual review of ekg, image, records all each count for 2 points with the rest counting for 1 point."

      The physician who provides the E/M University course is a certified coder and he notes in the course that the official source material does not specify whether you will get credit for each study you review independently, or just 2 points for any/all independently reviewed studies (as with labs or x-rays, either category worth 1 point whether you review one or 100). He says that different Medicare carriers will treat this differently. My billing supervisor doesn't know how our carrier views this.

      Your HPI can satisfy the highest level of billing with 4 "elements," or 3-4 chronic problems addressed (he says 3 in the basic course but 4 in the next part of the online course). The rules for the ROS and exam are also quite specific. You can't just do what seems appropriate to you. In particular, the 1997 rules are ridiculously specific in their requirements. A comprehensive exam based on '97 rules will not happen by accident; you have to know the rules and plan in advance.

      In any event, I've found a decent source for E&M rules, it's everything else that I need.

      Comment


      • #4
        Originally posted by CM View Post

        The American College of Cardiology is terrific for education, but no help regarding this subject; I've asked.

        I didn't know any of the E&M guidelines you allude to above until I had the E/M University online course.

        Regarding, "but individual review of ekg, image, records all each count for 2 points with the rest counting for 1 point."

        The physician who provides the E/M University course is a certified coder and he notes in the course that the official source material does not specify whether you will get credit for each study you review independently, or just 2 points for any/all independently reviewed studies (as with labs or x-rays, either category worth 1 point whether you review one or 100). He says that different Medicare carriers will treat this differently. My billing supervisor doesn't know how our carrier views this.

        Your HPI can satisfy the highest level of billing with 4 "elements," or 3-4 chronic problems addressed (he says 3 in the basic course but 4 in the next part of the online course). The rules for the ROS and exam are also quite specific. You can't just do what seems appropriate to you. In particular, the 1997 rules are ridiculously specific in their requirements. A comprehensive exam based on '97 rules will not happen by accident; you have to know the rules and plan in advance.

        In any event, I've found a decent source for E&M rules, it's everything else that I need.
        Will reply later with more. It’s not for each. It’s total. There are plenty of free resources online and others I will recommend if wanting to pay. More to come...

        Comment


        • #5
          Originally posted by ENT Doc View Post

          Will reply later with more. It’s not for each. It’s total. There are plenty of free resources online and others I will recommend if wanting to pay. More to come...
          Thanks. Looking forward to it.

          Comment


          • #6
            This link is also of interest: https://www.ama-assn.org/system/file...d-mdm-grid.pdf

            The E&M guidelines are changing on 1/1/21; at least according to the AMA. Medicare and other carriers may or may not go along.

            https://www.ama-assn.org/practice-ma...tation-burdens

            Comment


            • #7
              So lots to cover here. First, you don't have to pay for anything to become good at coding. All of this information is free for the taking on the internet. If you want to become really good for your specific specialty I would compile an excel spreadsheet of E&M codes and CPTs specific to your specialty and their respective RVUs. I have these broken into categories (with good descriptors...see below) then have miscellaneous codes that I might still use like a CT read, or use of image guidance, or a fat graft. I then have all the modifiers listed separately. I then compiled, on the same Excel document, an E&M tool that summarizes everything I put together and that goes over what you need for a new patient, established, consult, hospital consult, hospital f/u, etc. Doing this exercise proved invaluable. The CPT codes on the CMS file (see below) are listed numerically, and as you probably know the CPTs for your specialty could bounce around. This is why paring down this file to what is specifically relevant to YOUR practice is helpful - keeps things neat and concise. Then update this yearly with RVU changes. CMS puts this out yearly:

              https://www.cms.gov/Medicare/Medicar...ve-Value-Files

              You can also do code look-ups via the CMS website:

              https://www.cms.gov/apps/physician-fee-schedule/

              CMS also puts out E&M guidance on the Medicare Learning Network - look it up, you'll find all sorts of interesting files. Here's one on E&M Coding:

              https://www.cms.gov/Outreach-and-Edu...-ICN006764.pdf

              This one does a nice job too, randomly found on the internet:

              https://www.mssny.org/Documents/2016...-14-09-add.pdf

              The CMS files will show the global periods for any given service, whether you can bill multiple procedures, whether there is a reduction in payment, etc.. If you really want to know more about E&M I would stop by any coding/billing office at your hospital and ask them for the recent AMA CPT guide - they should have it. The first section of that is about E&M and is invaluable IMO. Covers a lot of the stuff in the above links but also gives important rules (such as when a new patient is a new patient, how to code given a place of service and when they were seen by you most recently, etc.). It also goes over modifiers in detail. Again, free stuff.

              As for the 2021 coding, you are correct. The house of medicine is trying to get CMS to delay this because of the Coronavirus outbreak, so we'll see. This change is a consolidation of levels 2-5, effectively giving slightly more than a level 3 for any given level 2-5 visit. So documentation can be more limited (bye bye MA jobs). As to whether commercial insurers follow suit, who the heck knows.

              As for stuff that I'd consider paying for, Encoder Pro is pretty good. It will show you which codes you can and can't bill together and gives far better descriptions of any given CPT than the AMA book. Might be worth paying for - 2-3 months should be all you need. The CMS CPTs that are released in those above files give descriptors that are pure garbage. They don't tell you what the CPT really is. That's where a good book like the AMA book, or one of the Optum Health books that they put out for given specialties does you a lot of favors when making that Excel spreadsheet. But after you do it you'll be happy you did. Because then you just need to keep your ear to the grindstone about new codes, ones that are the chopping block, and ones that are up for being revalued. Societies will typically put this guidance/notification out yearly to members. And again, they are updated on the CMS files. If you want a FULL explanation of each yearly update and background see the Physician Fee Schedule Final Rule that CMS puts out yearly. It's hundreds of pages of anti-fun reading.

              Hope this helps.

              Comment


              • #8
                So to clarify, the 2021 changes will only apply to Medicare/Medicaid?? And extensive HP will still be needed for your commercial insurance pts?

                Comment


                • #9
                  Originally posted by Sundance View Post
                  So to clarify, the 2021 changes will only apply to Medicare/Medicaid?? And extensive HP will still be needed for your commercial insurance pts?
                  My (limited) understanding is that the AMA is producing the new rules, and it is up to Medicare and other carriers to accept them or not.

                  Comment


                  • #10
                    Originally posted by ENT Doc View Post
                    So lots to cover here. First, you don't have to pay for anything to become good at coding. All of this information is free for the taking on the internet. If you want to become really good for your specific specialty I would compile an excel spreadsheet of E&M codes and CPTs specific to your specialty and their respective RVUs. I have these broken into categories (with good descriptors...see below) then have miscellaneous codes that I might still use like a CT read, or use of image guidance, or a fat graft. I then have all the modifiers listed separately. I then compiled, on the same Excel document, an E&M tool that summarizes everything I put together and that goes over what you need for a new patient, established, consult, hospital consult, hospital f/u, etc. Doing this exercise proved invaluable. The CPT codes on the CMS file (see below) are listed numerically, and as you probably know the CPTs for your specialty could bounce around. This is why paring down this file to what is specifically relevant to YOUR practice is helpful - keeps things neat and concise. Then update this yearly with RVU changes. CMS puts this out yearly:

                    https://www.cms.gov/Medicare/Medicar...ve-Value-Files

                    You can also do code look-ups via the CMS website:

                    https://www.cms.gov/apps/physician-fee-schedule/

                    CMS also puts out E&M guidance on the Medicare Learning Network - look it up, you'll find all sorts of interesting files. Here's one on E&M Coding:

                    https://www.cms.gov/Outreach-and-Edu...-ICN006764.pdf

                    This one does a nice job too, randomly found on the internet:

                    https://www.mssny.org/Documents/2016...-14-09-add.pdf

                    The CMS files will show the global periods for any given service, whether you can bill multiple procedures, whether there is a reduction in payment, etc.. If you really want to know more about E&M I would stop by any coding/billing office at your hospital and ask them for the recent AMA CPT guide - they should have it. The first section of that is about E&M and is invaluable IMO. Covers a lot of the stuff in the above links but also gives important rules (such as when a new patient is a new patient, how to code given a place of service and when they were seen by you most recently, etc.). It also goes over modifiers in detail. Again, free stuff.

                    As for the 2021 coding, you are correct. The house of medicine is trying to get CMS to delay this because of the Coronavirus outbreak, so we'll see. This change is a consolidation of levels 2-5, effectively giving slightly more than a level 3 for any given level 2-5 visit. So documentation can be more limited (bye bye MA jobs). As to whether commercial insurers follow suit, who the heck knows.

                    As for stuff that I'd consider paying for, Encoder Pro is pretty good. It will show you which codes you can and can't bill together and gives far better descriptions of any given CPT than the AMA book. Might be worth paying for - 2-3 months should be all you need. The CMS CPTs that are released in those above files give descriptors that are pure garbage. They don't tell you what the CPT really is. That's where a good book like the AMA book, or one of the Optum Health books that they put out for given specialties does you a lot of favors when making that Excel spreadsheet. But after you do it you'll be happy you did. Because then you just need to keep your ear to the grindstone about new codes, ones that are the chopping block, and ones that are up for being revalued. Societies will typically put this guidance/notification out yearly to members. And again, they are updated on the CMS files. If you want a FULL explanation of each yearly update and background see the Physician Fee Schedule Final Rule that CMS puts out yearly. It's hundreds of pages of anti-fun reading.

                    Hope this helps.
                    Amazing. :-) I'll start on this in the morning. Thank you.

                    Comment

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