FAQs about Billing Part 2

Pre-Sale is now LIVE for my Practical Guide to Attending Documentation!

If you’ve enjoyed these newsletters about professional billing, then you’ll love the deep dive in my video course so you can FINALLY understand billing.

Subscribers get an exclusive pre-sale discount of $49 using this link! Presale will go until the course goes live pending CME approval (2 - 4 weeks).

100+ hours in the making. 2.5 hours of video content so you can

• Gain the confidence to bill correctly

• Reduce medical errors

• Write notes faster

• Reduce your chances of getting sued

This is the biggest discount I’ll offer. Get in early for $197 $148.

This is part two of frequently asked questions about professional billing. If you missed part one, check it out here:

Can I write “Transfer to ICU for Severe COPD exacerbation” and be done with my note? (Meeting a high level for “1 chronic illness with severe exacerbation” and “decision regarding escalation of hospital level care.” - No

• First, don’t forget you need a history and physical.

• Second, while that statement would “check the boxes for MDM,” the rest of your note goes towards proving the medical necessity of that bill. Medical necessity is subjective, yes, but the level of your billing must be medically necessary.

• Example: You bill 100% high-level charges because your documentation “checks all the boxes.” But is your patient population so different from others that requires that level of billing? That’s a red flag and a recipe for an audit. This is why it’s helpful to be aware of regional or national averages for some comparison.

• However, I DO recommend having a section of your note for black/white statements that precisely check off MDM requirements as I discussed in this previous issue.

Will the statement “I reviewed all labs and radiology reports in the last 24 hours?” satisfy billing for MDM - No.

• Notice that the MDM chart includes the word “unique” for ordering and reviewing of tests. It must be a unique test, not generic. Furthermore, auditors look for how THAT test was interpreted for THAT patient THAT day.

• Example:

Can I review all 8 parts of a BMP and get at least 3 points? No.

• 1 Panel = 1 test. So, a BMP = 1 test.

• Also, if an order produces multiple results (like serial troponins) you only get credit for reviewing (and ordering) 1.

Shouldn’t every problem that requires admission to a hospital be considered severe? You might think so, but no.

• Check out the problems column of the low-level row. It includes “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation.”

• By that, it’s clear that’s not a safe assumption. I’d be clear that you consider something a “severe” exacerbation, progression or side effect of treatment.

What does “stable” mean such as “2 or more stable, chronic illnesses?”

• The AMA defines stable as “at their treatment goal.” So, even if you aren’t changing your treatment of their diabetes, if their A1c is not at goal it isn’t stable.

• It’s odd that the AMA makes this distinction as, if you notice on the MDM chart, there is no mention of “non-stable” illnesses. They use other words such as “exacerbation, progression, complicated, etc.” but NOT non-stable.

• As hospitalists we frequently have patients with two or more chronic illnesses which are NOT at goal. So, I often get the question if they can use “2 or more stable, chronic illnesses” as an MDM point. But, the AMA says we can satisfy a certain level if you “meet or EXCEED” that level. So, in my opinion, a “non-stable” illness would exceed, and therefore satisfy, a moderate level.

• I’d be happy to get clarification from any PB experts on this.

Can I get credit for discussing with a nurse? No.

• The AMA uses “external physician, qualified health professional (QHP) or appropriate source” for Category 3 of data analyzed for moderate and high levels.

• They define physicians or QHP as “an individual who…performs a professional service… and independently reports that professional service.” Essentially, someone who can drop E/M bills such as physicians, nurse practitioners, and physician assistants.

• They are different from clinical staff which is a “person who works under the supervision of a physician or QHP…but does not individually report professional services.” So, nurses, social workers, etc. So, the answer is no.

• For “appropriate source,” the AMA includes “case manager” in their list of examples. This confuses many. BUT, these are NOT health care professionals. Other examples include lawyers, parole officers, teachers, etc. So, a “case manager” would be like a foster child’s case manager.

Final MDM Tips:

1. Do not simply copy and paste statements from the MDM chart. For example, don’t just include “Diagnosis or treatment significantly limited by social determinants of health (SDoH).” Instead, include what diagnosis or treatment was limited by what SDoH and how.

2. For “Independent interpretation of a test performed by another physician / QHP” be clear that you interpreted the images to remove all doubt that you looked at the images and not just the report.

   Also, do not include that you “personally interpreted the images…” and then copy/paste the radiology report. That’s a red flag. You’re communicating you didn’t actually interpret the images. Use your own words. Your interpretation does not have to conform to the usual standards of a formal report.

3. To get credit for a problem in the “problems column,” a problem must have MEAT criteria. You must document that you’re Monitoring, Evaluating, Assessing, or Treating it. Including a problems list is not going to cut it as it’s often unclear which problems are actively being MEATed.

4. Although I often mention the “billing timeout” with a separate, precise statement, this is certainly not needed. You can meet billing requirements by the “natural” language of your assessment and plan. My bread and butter for level II (99232) follow ups?

   1. 2 or more stable, chronic illnesses (or non-stable as I mentioned above)

   2. Prescription drug management

   As a hospitalist, almost ALL of my patients have two chronic medical conditions. Almost daily, I’m making medication changes. Even if not, I am specific with my language like “continue amlodipine 10mg daily as BP is stable” to show I made a decision to continue that medication that day. By that, my notes at baseline have enough for a level II (as medically necessary).

   I only typically insert my billing timeout if I know I did more to meet a higher level that requires specific language.

In my next issue, I’ll touch on some FAQ’s about time-based billing.

Don’t miss out on saving $49! Enroll in the exclusive pre-sale for my Practical Guide to Attending Documentation.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two other ways I can help you:

Check out The Resident Guide to Clinical Documentation. The course that helps you:

• Prepare for “real-world” productivity pressures by optimizing your notes for efficiency.

• Prevent medical errors and lawsuits by using notes to stay organized.

• Gain the confidence to write shorter yet more effective notes.

Sponsor this newsletterto promote yourself, your business, your conference, etc to 4,826+ subscribers.

If you were forwarded this newsletter and would like to subscribe: