Drew Boxler

Today we are featuring the first of our discussions with Bill Dacey, President and CEO of The Dacey Group and one of Physician’s Practice's Pearls contributors.

Twice a month, Bill answers readers’ top coding questions in his wildly popular Q&A columns.

With the advent of MJH Life Science’s video and podcast programs, both of which can be access from Physciain’s Practice’s site, Bill has been gracious enough to sit down with us for supplements to his regular columns.

In this episode, we are taking a look at questions regarding mixing provider types, protocols, and patient behavior.

Our first question concerns Medicare new versus established patients.

A patient is seen in the ER, treated, and released. At a later date—within three years—the same patient is seen by one of the system’s providers who is also credentialed as an ER physician in the clinic for wound care. Although wound care is not considered a specialty under Medicare guidelines, would the patient still be considered established since the provider is credentialed in Emergency Medicine?

This one's a little tangled up just has a few pieces in it. You know, when you get into taxonomy codes and different specialties, in part it depends on the payer. How does every individual payer have every individual provider credentialed or assigned to certain specialties within their system?

You know those taxonomy codes that CMS puts out? I think they originated with BlueCross BlueShield. But not every payer kind of sees every provider the same way. So really, these are two quite separate incidents. Obviously, you've got an ER visit and then you've got a wound care visit some time later. And once all the smoke clears, there really shouldn't be any problem getting both of them paid because even if the physician in question only had an ER taxonomy or designation, if they've got or demonstrated expertise in another area—and you'd probably have to write a letter, this isn't going to be a clean claim, possibly—Medicare or the payer will eventually see the light and say, “Okay, this was a wound care case. And you know, even if we do have the taxonomy codes mixed up, this is a payable event.”

it's within three years, is it established? That's the question that the CPT definition reads—seen within the last three years, same exact specialty, etc. And have you seen the same physician? So yes, it's the same person.

So it's going to be established, but you're probably going to run afoul of the taxonomy things and have to write a letter would be my guess.

 The second question we will look at today involves patient is seen in the hospital or in an office as a new patient under the mid-level. This practice bills the hospital initial visit or office new patient vists under the mid-level only, without supervisor (i.e. not incident-to). The mid-level meets with their supervising provider and comes up with a plan of care for the patient. The patient then has a follow-up visit with the mid-level. 

Since the patient has still never seen the provider, but the provider created the plan of care, can the follow-up visit be billed as ‘incident-to’?

So, really what you need to do, again, this is going to be a potentially payer-specific thing. I would say the mainstream answer is that it could not be billed Incident-to, it would have to be billed under the mid-level’s name because the physician never actually saw the patient.

I recognize that the plan of care is an important component billing Incident-to and that that's one of the requirements for those subsequent incident visits—that you're following up on the physicians plan of care—but I think if you walk through the little tests that the various Medicare payers or contractors have online about, “Does this meet incident two criteria?”, you'll see that it will say something about “Seen by the physician and then their plan of care.”

So, even if it doesn't exactly say it somewhere in a guideline, all of the kind of ancillary evidence is that the expectation is that the patient has been seen by the physician who established a plan of care. This is a little bit off from that and it sounds like more non-physician practitioner work than actual physician work, even though there's a shard of that in there.

RVUs: The basics of physician compensation

 One problem that recurs in this next questioner’s practice is that, when the billing clerk tries to determine tele psychiatry codes, video+voice, most providers aside from United Health give the same reply:

 “We can’t advise you as to how to bill….”

Providers refer this practice to their website, each with their own complications and level of development, but each insurance carrier seems to have different codes/modifiers. This leaves the billing clerk hoping for the best in nearly every situation.

Any suggestions would be greatly appreciated!


You know, this question sounds like it's just kind of about getting paid. I'm not sure what I guess all questions are about getting paid. Coding questions anyway, or billing questions.

 But, you know, the payers have adopted this perspective or it's almost like a mantra these days. That, you know, they can't tell how to code something. And, you know, Medicare has been doing this for years, this person, I guess, mentioned United.

But you know, they can't give you the formula to get a claim paid. I mean, the whole idea is, is that you use the CPT manual and the ICD 10 system to report what you did.

So, you have to craft a little communication to your payer in every case that should have the combination of what you did. You know, why did you do it your ICD 10 codes, all the little bells and whistles modifiers and whatnot that you need to properly identify to the payer, you know, all of the circumstances surrounding that encounter.

If you have a question about how modifiers work, you just need to figure that out. They're just gonna pay or not pay what you send them. You can't call them up and say, “Hey, if I configure it like this, will you give me a lot of money? If I configure it like this, will you give me more money?” I mean, that's just kind of an invitation to racketeering and fraud. And, you know, they just won't do it.

It's a reasonable kind of a platform that the papers have that say, “Well, we can't really tell you how to code something.” I mean, a, you're the one who did it. So you just need to learn, you know, your how to report things.

If something bounces off, if something is deflected—or denied, or delayed, or diminished, or whatever they do, (and they do all of those things)—then you just have to refile.

You know, if you think you've got something wrong, you have to really pay attention to the denial. That's what it's all about, you know, why did they say now? A lot of people just say, “Oh my gosh, they said no to me and they slink away.” And that's not what you want to do at all.

A denial to a health insurance company, that's just the beginning of a conversation. It's certainly not the end.

So in terms of advice to this person, no, they're never going to tell you how to code. They're just going to say yes or no. Or partly, and you just need to use the tools to, you know, communicate with them in the coding and billing language that they communicate with.

 In our fourth question, a patient is seen by a midlevel in an Endocrinology practice and the patient is a ‘hot mess’. She sees the patient and evaluates them and then sends her MA into the exam room to go over how to use insulin or whatever. This ends up taking the MA 30-40 minutes.

Prolonged services cannot be billed for anything less than 30 minutes, but can the practice bill for prolonged services when extra time is being provided by the MA not the billing provider?

They would bill for 99214 based on documentation and medical decision making and then 99354 for additional time the MA takes with the patient.

That's a big No. Also right out of the gate know, when you're dealing with time-based codes—or many time based codes, certainly from a Medicare perspective—it's the time that the patient spends with the physician or the nurse practitioner or the PA, you know, that whole concept of incident to is more about wrapping the whole visit under the supervision or auspices of, you know, kind of head provider if you will.

But when you start saying “Alright, I'm going to do this and then I'm going to hand it off to so and so. But I'm going to keep billing as if it's me.” If you say it that way, it doesn't sound quite as good. And the AMA doesn't have the ability to report services in his or her own name. They're not really reportable services. And so, you certainly couldn't run the prolong service code on that.

CPT didn't help that. Some years ago, those codes used to say face-to-face with a physician or other qualified health care provider. And then a couple of years ago, they changed it to ‘direct supervision’. So, we weren't entirely sure what that meant, but when you kind of play this question against the larger backdrop of regulations, pretty quickly, you get to the part that I just said about how you You don't build at the physician rate for the work that someone else is doing.

So, the physician would get their nine, nine to one four here, but they wouldn't be able to tack on that 99354 for the time that that ma spent with the patient during other teaching things.

Improving coding processes to achieve value-based care success

 In this next situation, Dr. A and Dr. B both rendered services to the same patient the same day and both subsequently billed for their respective services. One was an actual office visit, later in the day a telehatlh video visit. Can the services be combined and uploaded? The asker says that their biller says they can absorb one of the services into the other and possibly bill for a 99214/99215.

That's more good creative—somebody in the office thinking oh, you can just add them together apples and oranges.

 It's another interesting question. The general rule of thumb and this CPT rule is that you're only going to get one E&M per visit, per day per group per provider type, that kind of thing.

So, if somebody saw someone in the morning, and then somebody saw someone else later in the afternoon in the same group, you know both those claims went out, it would get denied. Same provider, same days, same specialty, you know, the first one that gets there gets paid, the second one doesn't.

What you pretty much need to do is add them together, like this person said, and file one claim. A couple of things come up in here. Number one, physicians are, over the past few years, even more cognizant of their own RVU production and what did I do today and what does it look like to the, you know, administrator or the group leadership? You know, they need to put their points up on the board, what did they do? So, Dr. B may not really be so interested in just saying “You know, take whatever I did and just you report it under your name and you take the money, you know, and the RVUs, that's good.”

You know, if it all comes out in the wash, and everybody kind of agrees that, you know, this happens to me is obviously happens to you, you know, maybe that's not a problem.

But kind of the other issue in here is it These were two different visit types was one of them a, an office visit, and the other one was a was it a phone call? Or was it a video?

 Okay, so that would have, in the current public health emergency, qualify for use with those offices, it codes and now you're kind of tracking to do that to have the same codes again, which you don't want to do.

So, this brings up even more, you know, how do you add it together questions: do you take the totality of the history exam and decision making and sort of glue them together?

And you could do that. But the documentation is not really going to look like that. Unless somebody has some kind of foreknowledge here. The second person would have to be kind of aware that you had this first visit, and kind of build their note around that. They may be referred to the earlier, you know, physical exam or whatnot, and maybe refer to some of the decision making elements that happened before and they would have to kind of package it with all of the pieces in it.

Because what a payer isn't really going to be interested in doing is taking this apple and this orange from over there. 213 and a 213 and adding them together and magically coming up with a 214—that's not really gonna work.

Probably the best way to do it would be for the second person to talk about time—total time in both encounters—but again, the first person doesn't know that there's going to be a second visit, so they may or may not say anything about timing might not how long know how long that is.

It's just an awkward set of circumstances. And each one of those would have to be kind of handled the way that you could handle it. Sometimes when you try to kind of retrofit documentation into some code structure that you want to put out there, it's not a good fit. It's just going to look right, because, you know, people weren't thinking that way when they wrote those notes.

So yes, you can probably, maybe get a higher level of service out of that. But there's probably going to have to be an addendum somewhere along the line and one of the docs is going to have to give a little ground That’s not a perfectly clean answer, but those are the considerations.

 Our final question for this episode concerns HHC code capture in the note. When an annual wellness visit is performed, this physician often adds the HCC at the end to increase RAF score. Their auditor said they can’t do this if they don’t actively manage these things. Is there a way to do this legally? 

So the office manager said don't just list HCC scores in the assessment plan when you're doing an annual wellness visit that provider or someone wants to know but I want to and so how can I How can I do this?

So the coder or whoever it was is right that you know a list of codes a list of diagnosis codes at the end of a note in the assessment and plan isn't really what the HCC and RAF scores are all about.

Physicians do confuse those things on a pretty regular basis. You know, they're responding to requests from administration and coders and payers and everybody else to report all these codes report all these codes, make sure we know how complex the patient is every year, you need to tell us all of the patient's problems. And so that probably sounds to them, like if give me a list of codes, but what those what's really behind that and what's behind that whole payment system is they want you to evaluate each of those problems in the course of the year or to tell them how many problems needed to be evaluated addressed in the course of the year so that they can properly kind of assemble that total fabric, if you will, of the patient. You know, how complex are they how many, how bad how often all that.

But just naming things and just a list of diagnosis codes, that's not that's just a list of diagnosis codes. I mean, you could kind of copy the problem list and stick it down there too

A.) You can't typically address all of the patient's problems if they've got any complexity at all in one visit. Certainly, if the visit is an annual wellness visit, and then maybe some Problem Management, you can't do all of them, you know, that visits going to get pretty long.

So let's stay there. question is, is there a way to do this legally? No, there's no, it's not correct to just give them a list of diagnosis codes.

If you want to lay claim to the HCC assessment portion of a problem, you know, that I looked at this this year. The trick there really is to assign it a status. It's the same way that the E&M codes the decision making works with the new medical decision making guidelines at the AMA just came out where there's a little bit of discussion about what constitutes problems constitutes whether a problem has counts today. It really hinges on some kind of evidence that the physician evaluated or assessed it and how do we know that it? it's characterized as you know, stable, well controlled, improving, you know, continue with, you know, nephrology, whatever it is. That last one might not count, because if you're not managing it, but for HCC purposes, you know, that code is now in there and we know what's going on, it's being managed by nephrology.

So, I would say, to try to straddle the fence a little bit. If you are really interested in reporting HCC codes, and it's because you have assessed some of these problems or have something to say about them, then you can just add a little section in your assessment plan underneath the annual wellness visit. portion that says, you know, conditions, you know, address today or conditions assessed today and list them and give them some sort of assessment or evaluation or characterization, if you will.

I see physicians write problems not addressed today, and they just give a big long list of things. If a third-party payer, if risk payer wants to take that list and credit you with that, why then, you know, bless them, but that's not really what the, program says it's looking for the status or problems. So, I would say that that's kind of a now you can't really just give a list and get credit for it. The trick there is to either you're saying something about those problems or you're not.

I would encourage you know, physicians to get on board with this characterization or, you know, describing problems as stable, improved, worsening, etc. It's always been the core of the decision-making piece and that's now going to be not just in the front seat, it's going to be the only thing that payers are really looking at come January 21st. With the change in the E&M guidelines, they're just going to be looking at decision making. It's actually a federal rule that, you know, for an established problem, you have to say it's part of the documentation guidelines, whether that problem is stable improve or worsening, etc. And, you know, even to preserve levels of service, you know, that's kind of in there, too, is it mildly exacerbated,wildly exacerbated, you know, that might be the difference between a four and a five

Som that language is tremendously important. And there's a, I would say, a pretty systemic over reliance on computer generated lists of codes, when what they're really looking for is, you know, how bad is this? You know what, what is going on? On this problem, that's what they really want to know.

Thanks again, Bill. That sums up our questions for this first podcast edition of Bill Dacey’s Coding Q&A.

Thank you all for listening to this seventh episode of Perspectives, brought to you by Physician’s Practice.

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Podcasts

Bill Dacey, president and CEO of The Dacey Group, pens the popular Coding Columns on Physician's Practice. In our first podcast version of this column, we answer contributed questions on provider types, protocols, and patient behavior.

Coding Q&A: Mixing provider types, protocols, and patient behavior

R1 measures roughly 39 metrics in the financial clearance process. What’s more important is setting up in-process and outcome metrics. Learn more from our discussion with Dan Dooley, VP of physician services at R1.

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Financial performance metrics and goals for physicians

Current revenue cycle management (RCM) processes in some practices may be well established, but there is always room for improvement and optimizations.

At MGMA's virtual Medical Practice Excellence Conference, Lawrence Jones, MD, partner and physician of One Pediatrics; and Daniel Pope, senior vice president and general manage at R1 RCM, presented "Thriving Financially through Better Claims and Collections".

One Pediatrics, Dr. Jones' practice, started out as an independent practice founded in 2014. Now a total of seven integrated practices all operate independently across nine locations, comprised of over 40 providers. In 2019, the practice group recorded 179,000 visits, roughly 35% of which came from the Lousiville market.

During the time from establishment through the present day, Jones says that his practice was increasingly challenged by hospital groups that purchased smaller independent practices. He and his group wanted to remain fairly independent; however, he was learning that, as autonomous practices, they were not leveraging best practices for streamlined operations.

"As small practices, we were really competing against each other," Jones says.

Particular issues in their individual practices included inconsistent or outdated payer contracts, as well as missed opportunities for negotiation that resulted in lower reimbursement revenue. For example, Jones says that his contracts at the time of consolidation were were nearly 20% lower than that of the competing hospital system.

Then, the COVID-19 pandemic introduced a new onslaught of complications, including reduced patient volume, costs that weren't budgeted (e.g. PPE), and an inability or unwillingness to collect from patients between March and May of 2020.

To remain independent, but also remain competitive against the larger hospital system, One Pediatrics and other local independent practices merged and became the system that exists today.

Consolidation may not sound appealing to every independent physician, but Jones says that it was well worth it.

"It was painful when it started," he says, regarding the funding processes, which were funded by the physicians themselves. "For anybody who wants to do this, I'd highly recommend it, but you've got to be all in because it's going to hurt at the beginning. In the long run, it's wildly successful, I would never go back to doing what I was doing before."

These are the lessons they have learned for all independent practices to be able to thrive financially.

"As an individual practice, it's a little bit challenging, a little daunting to try to go to some of these large payers and try to negotiate on your own behalf," says Pope. "There's definitely strength in numbers when it comes to this area of negotiation."

It is equally important for independent practices, whether solo or in groups, to use data analytics to identify opportunities in their negotiations.

"A payer's contract group is trained. They are going to try to get you to settle for less than what they what they want to pay," Pope says.

If you have data behind you—regional, market, national, individual payers and collective groups, commercial groups, managed care groups, etc—Pope says you will come to the negotiations more sophisticated and with a greater strategic approach.

Knowing things like patient volume, contributions from HCPC, and CPT code patterns are very important. Also, practices should review capitation rates and annual bonus incentives by payer

Practices without a value-based care program should also establish one, as demand for these services will only continue to increase.

"You need to be able to understand where it is you can deliver value to your specific patient population, whether it be a pediatric project such as One Pediatrics, or whether you're a geriatric practice," says Pope.

Understanding your patient population, and subsequently your payer population, can help to renegotiate your practice's quality metrics and capitation programs. Pope says, for One Pediatrics, knowing their specific patient populations led to a renegotiation that led to an achievement of $110,000 for the growing practice.

Pope says they were also helped by the knowledge of CPT code distribution, which allowed them to tighten up negotiations around high-volume CPT codes at their practice.

While the presentation considered the experience of a consolidation among independent practices, these are still areas that solo or even other group practices should consider optimizing.

The most important thing, Pope says, was taking monotonous processes out of providers' and staff's hands, thus allowing each to operate to their greatest ability in their respective disciplines.

Outsource things like payroll processing, recruitment and new employee onboarding when necessary and where applicable

host monthly safety calls; monthly PCMH calls

move OSHA/HIPAA training to online modules

review and revise care coordination policies

Together, these HR, IT, Safety and PCMH optimizations allowed One Pediatrics to achieve quality goals that they can take to insurance companies, Jones says.

One Pediatrics also optimized the following areas of their practice, areas that other practices should consider optimizing as well.

Bi-annual individualized coding audits not only ensure providers are coding accurately, but also that they are coding with the best optimization possible

Use slot utilization analysis and data-visualization tools to track historic trends

implement reminder and balance messaging, including overdue messaging

Systematic patient satisfaction reporting can also help identify where you can make adjustments for your patients

Draft and publish monthly wellness articles

Engage in active online reputation management

Use data-driven analytics and easily accessible reports for managers

Hold monthly review of denials by provider, payer, reason

Creating a structure to fuel your best decision-making process

To begin creating your best decision-making structure, practices should start with month managers' meetings.

The conversation should start by covering three pillars: quality, revenue integrity, and employee engagement. From there, review income statements, G&L reports, discuss expense management best practices, and suggest ways to reduce costs and labor.

Practices should also hold a monthly leadership call, especially if you are part of a group. This conversation will be a high-level review of what each practice is doing and cover topics like hiring decisions. In all, these conversations should help to keep independent practices aware of each others' challenges and initiatives.

By optimizing in these areas, One Pediatrics reportedly experienced:

Days in AR below national standard: 17% better (25 days) (national avg = 28-32 days)

Author | Drew Boxler

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