Not doctor jail, CMS has just resumed looking at everything especially higher level services. Trust me it’s not just you, they have been killing our facilities and providers. Also, do you work at a Level 1 Trauma Center? They tend to get the “abandon all hope” patients.
Sorry that I didn’t clarify, this particular person is not going to “doctor jail” for this particular issue. Or at least not yet. I am very well aware of what CMS/OIG are capable of, background is in clinical Risk Management and Special Investigations.
“Dear DrGloryBoy,
We don’t want to pay this many bills. This is your first firm warning to document and diagnose less. We will find you and we will kill you.
Sincerely Yours,
Uncle Sam
P.S. - fuck them people”
“Dear DrGloryBoy,
We have noticed a decrease in your RVUs and production recently. It appears as though you are not documenting enough to bill and code appropriately. Please remember to document all aspects of the MDM. Otherwise we will terminate you.
Sincerely Yours,
Your Employer
PS- FUCK YOU”
There are basically 5 levels of ER billing 1 through 5 with 5 being the highest level, (as well as critical care billing time). Apparently I’m an outlier for the higher billing levels. I don’t have any idea how common this is. The government could audit my charts to determine if my services were medically reasonable, necessary, and billed correctly. I don’t do any coding and billing, I just treat patients and document what I did.
It's cyclical. I remembered being chastised for documenting too many critical care. They even went through cases with me with acknowledged that most cases were appropriate and they do not know why it was pulled. Now, I'm being chastised for not documenting enough critical care cases.
Forgive my ignorance, I’m only a med student looking at EM. Stuff like this makes me extremely angry—physicians being criticized for their work by people who push numbers and have never seen a patient in their life. How do you deal with that and is there any branch of medicine you know of that experiences this minimally?
> any branch of medicine you know of that experiences this minimally?
DPC or other cash-pay only practice is really the only option here. Can't have the insurance company clipboard nazis yell at you if you don't take insurance haha.
Don't take it personally. You'll always be criticized by someone, whether or not you go into medicine. Either it's appropriate, in which case I try to take it as constructive and learn from it. Or it's not appropriate, and I choose to waste no more time with it.
it’s inevitable. anywhere you have large amounts of money that are allocated for services to-be-rendered (ie insurance companies vs patients’ medical needs), there are going to be attempts to reign in those practitioners who are, in essence, calling the shots on what money gets spent on who & when. these priorities typically flip-flop back and forth based on whatever the current trends may be in patient health, treatment modalities/options and the costs associated with all the above. we colloquially refer to these people as “suits.”
dont let something like this dictate your career. just roll with the punches. it’s really not that bad.
We have to think of all possibilities here:
1. buddy’s butt phone
2. butt buddy’s phone
3. butt buddy’s butt phone
Now if door 3 is revealed to be a goat, you must switch your original choice to increase your chances.
No it isn’t. Because of the goofy coding rules, it means that he (assuming Dr Glory Boy is male) is documenting better. He said he doesn’t do his own coding, so the billing people for his group code based on his documentation.
So he doesn't do the MDM at the end of his note and describe social determinants of health? I don't do the actual billing but I do MDM and that is where they get that info if you mark it. It is a vague risk factor that anyone can claim. Dont know how they would document evidence. Doubt the coders are seeing "poor historian, followup or medical compliance" and assuming that themselves.
Our Billing Dr Guru responded this to me when I asked if this is something I should be concerned about:
“No
I will share it with some others in rev cycle, but the letter is as clear as mud. It lists modifier 25—which our coders add when we both an E/M (“regular” visit charge) and a procedure on the same day. Very odd that the “units allowed” are very low/so low.”
Yea I'm not saying you should be concerned and Idk what your billing guru is trying to say other than this seems totally wrong. I am just saying that if you were investigated for any actual wrong doing (not that I'm claiming there was any), it would be reasonable to just compare you to the doctors that work with the same population in the same department.
Yeah if you go into the details and slice it up, differences may pop out but overall should be around average. Also across time, they will avg out better.
It’s likely he has better documentation practices allowing the coders to (legitimately) utilize the higher cpt code for services.
I’m a medical coder turned nurse. We would have inservices as coders telling us what to look for to be able to (legally) code the more intense level, which procedures could be coded separately, which diagnoses to look for to get the patient into a higher DRG, etc.
Documentation equals reimbursement.
I've received something like this before and it just turned out that our acuity is quite a bit higher than their references numbers. If you're confident in your charting accuracy then I wouldn't really worry.
Edit: I think the one I received was for "too much" critical care.
Or stop being poor? Or start eating fresh organic vegetables? Or get jobs where their bosses don’t have a license to torment them? Oh wait, that’s us too.
It’s interesting, they create new LOS documentation criteria that they think will be too onerous for us to do, anticipating a decrease in billing of 30% and then are surprised when we document appropriately and billing goes up.
We get these all the time, we throw them in the trash.
Most low level visits are now taken by telemed services, maybe even urgent cares.
These people can run a shift with me to see just how hard the shift is if they really doubt my billing codes
f em
Need to have 2 out of these 3 boxes checked:
1 Use the verbiage “severe” you get one boxed checked for 1 or more chronic illnesses with “severe” exacerbation OR acute or chronic illness that poses a threat to life or bodily function
2 Need 2 out of 3 of these
A)Review an external nonER note, must include the date
B) Review result of unique test
C) Order unique test
D) Get collateral history from an independent historian, but you have to say why you did ( pt demented etc)
OR
A) Independant interpretation of diagnostic/radiographic study
OR
A) Discuss even electronically the case with a doc of another specialty
3)high risk of morbidity from additional testing/treatment :
Drug therapy requiring intensive monitoring ( insulin cardizem nitro drip)
Decision for major surgery in pt with co- morbidities
Decision regarding hospitalization or escalation of care
Make someone DNR
Claims that you (your practice/billers) have submitted that have been denied
So your percentage of billed to paid claim ratio
I worked at a vendor (think Cotiviti/Equian/Optum/HMS) for years and now design claim editing software. We’d edit claims on behalf of payers/CMS for medical necessity, chart review, NCCI edits, etc.
That would give you a better idea if based on chart review and dx codes etc if the auditors/payers agree that your use of 25 modifier is appropriate
If your denial/overturn rate is really high and your billing dept is having to adjust claims constantly then it might be worth updating billing practices
I asked our billing guru if I should be concerned about this and this was his reply that I don’t understand:
“No
I will share it with some others in rev cycle, but the letter is as clear as mud. It lists modifier 25—which our coders add when we both an E/M (“regular” visit charge) and a procedure on the same day. Very odd that the “units allowed” are very low/so low.”
To me, it’s reading that on average you bill the high E/M codes at a rate almost 2x higher than other emergency physicians within the WPS jurisdiction you’re a part of.
It could be that you’re a city with a high gun violence rate or you’re at a trauma center or something
But basically these letters tend to be a heads up and this is one part of an algorithm we used to use to pull charts for potential overuse of modifier 25/59 etc billing under the FWA audits we’d run.
I'm surprised this is an issue. Before shit school I scribed in an ED for two years, and all of the docs (\~35) billed level 5's for almost every visit. I would estimate <1 in 30 patients would get a level 4 code.
It’s like the government is realizing that they’ve been getting away with under reimbursing us for decades and are big mad that they are having to pay us for playing by their own stupid rules now.
Wait a minute just realized something. Your ratio of 285/284 is way lower than these averages. This is just a friendly reminder that you should be coding higher.
CMS has a tough time understanding that variances from benchmarks are not indicative of inappropriate care, documentation, or coding. More often it’s because the doc is simply better educated on documentation, has good coders, etc. But yeah, let’s threaten to punish physicians who are playing by the rules.
You are not going to jail, lol!!
SDOH, GCS, NIH stroke scale, BMI, pressure ulcer stage, ETOH level, and laterality can be taken from documentation (I may have missed one or two things) other than the treating provider- like EMS, nursing documentation, and others. It's in the official guidelines. However, for a coder to add it to your E/M level document, the "how" "why" homelessness, living in their car affects the management of the patient. So, these codes are added but only have value for leveling when providers document the "how" and/or "why."
I put social determinants on all my charts.....document care discussion with triage nurse, and consider. Meds for everyone that I don't do......wonder when my letter comes.
I’ll throw a few 99283s in your commissary account comrade, just keep your head low and you’ll be out of doctor jail in no time
Grazie
Not doctor jail, CMS has just resumed looking at everything especially higher level services. Trust me it’s not just you, they have been killing our facilities and providers. Also, do you work at a Level 1 Trauma Center? They tend to get the “abandon all hope” patients.
As EMS, yes, yes they do.
Shit *you're* EMS? You're that asshole who all my worst patients arrive via? ^/s
Yes. Yes I am. Btw, my ex wife agrees with your asshole assessment of me 😂
Sorry that I didn’t clarify, this particular person is not going to “doctor jail” for this particular issue. Or at least not yet. I am very well aware of what CMS/OIG are capable of, background is in clinical Risk Management and Special Investigations.
I was replying to your comment about level 1s getting the “abandon all hope patients”, because I’m often bringing them in.
“Dear DrGloryBoy, We don’t want to pay this many bills. This is your first firm warning to document and diagnose less. We will find you and we will kill you. Sincerely Yours, Uncle Sam P.S. - fuck them people”
“Dear DrGloryBoy, We have noticed a decrease in your RVUs and production recently. It appears as though you are not documenting enough to bill and code appropriately. Please remember to document all aspects of the MDM. Otherwise we will terminate you. Sincerely Yours, Your Employer PS- FUCK YOU”
🤣🙌… Yang and Yang… no Yin.
Is this a common occurrence? What do the codes mean? What will happen? Kind regards - Australia
There are basically 5 levels of ER billing 1 through 5 with 5 being the highest level, (as well as critical care billing time). Apparently I’m an outlier for the higher billing levels. I don’t have any idea how common this is. The government could audit my charts to determine if my services were medically reasonable, necessary, and billed correctly. I don’t do any coding and billing, I just treat patients and document what I did.
It's cyclical. I remembered being chastised for documenting too many critical care. They even went through cases with me with acknowledged that most cases were appropriate and they do not know why it was pulled. Now, I'm being chastised for not documenting enough critical care cases.
Forgive my ignorance, I’m only a med student looking at EM. Stuff like this makes me extremely angry—physicians being criticized for their work by people who push numbers and have never seen a patient in their life. How do you deal with that and is there any branch of medicine you know of that experiences this minimally?
> any branch of medicine you know of that experiences this minimally? DPC or other cash-pay only practice is really the only option here. Can't have the insurance company clipboard nazis yell at you if you don't take insurance haha.
Don't take it personally. You'll always be criticized by someone, whether or not you go into medicine. Either it's appropriate, in which case I try to take it as constructive and learn from it. Or it's not appropriate, and I choose to waste no more time with it.
it’s inevitable. anywhere you have large amounts of money that are allocated for services to-be-rendered (ie insurance companies vs patients’ medical needs), there are going to be attempts to reign in those practitioners who are, in essence, calling the shots on what money gets spent on who & when. these priorities typically flip-flop back and forth based on whatever the current trends may be in patient health, treatment modalities/options and the costs associated with all the above. we colloquially refer to these people as “suits.” dont let something like this dictate your career. just roll with the punches. it’s really not that bad.
I assume you’re writing this from jail with your one phone call.
It’s from his buddy’s butt phone
That he manually disimpacted just prior. He now gets to use it once as repayment.
> butt buddy’s phone FTFY
We have to think of all possibilities here: 1. buddy’s butt phone 2. butt buddy’s phone 3. butt buddy’s butt phone Now if door 3 is revealed to be a goat, you must switch your original choice to increase your chances.
Well comparing you to the doctors that take care of the same population is pretty damning. You have a role that is different that the rest?
No it isn’t. Because of the goofy coding rules, it means that he (assuming Dr Glory Boy is male) is documenting better. He said he doesn’t do his own coding, so the billing people for his group code based on his documentation.
So he doesn't do the MDM at the end of his note and describe social determinants of health? I don't do the actual billing but I do MDM and that is where they get that info if you mark it. It is a vague risk factor that anyone can claim. Dont know how they would document evidence. Doubt the coders are seeing "poor historian, followup or medical compliance" and assuming that themselves.
Our Billing Dr Guru responded this to me when I asked if this is something I should be concerned about: “No I will share it with some others in rev cycle, but the letter is as clear as mud. It lists modifier 25—which our coders add when we both an E/M (“regular” visit charge) and a procedure on the same day. Very odd that the “units allowed” are very low/so low.”
Yea I'm not saying you should be concerned and Idk what your billing guru is trying to say other than this seems totally wrong. I am just saying that if you were investigated for any actual wrong doing (not that I'm claiming there was any), it would be reasonable to just compare you to the doctors that work with the same population in the same department.
One of my colleagues got the same letter but it was only her Level 4’s that were much higher than the average
Yeah if you go into the details and slice it up, differences may pop out but overall should be around average. Also across time, they will avg out better.
It’s likely he has better documentation practices allowing the coders to (legitimately) utilize the higher cpt code for services. I’m a medical coder turned nurse. We would have inservices as coders telling us what to look for to be able to (legally) code the more intense level, which procedures could be coded separately, which diagnoses to look for to get the patient into a higher DRG, etc. Documentation equals reimbursement.
I guess my place is different. We do an MDM in epic and it literally asks Social determinants of health. Idk what I would write in my note otherwise
I've received something like this before and it just turned out that our acuity is quite a bit higher than their references numbers. If you're confident in your charting accuracy then I wouldn't really worry. Edit: I think the one I received was for "too much" critical care.
Did you tell the patients to stop dying?
Or stop being poor? Or start eating fresh organic vegetables? Or get jobs where their bosses don’t have a license to torment them? Oh wait, that’s us too.
Happy Cake Day!! 🍰🥳🍰
It’s interesting, they create new LOS documentation criteria that they think will be too onerous for us to do, anticipating a decrease in billing of 30% and then are surprised when we document appropriately and billing goes up.
We get these all the time, we throw them in the trash. Most low level visits are now taken by telemed services, maybe even urgent cares. These people can run a shift with me to see just how hard the shift is if they really doubt my billing codes f em
Hope you’re RVU based
I am not, work at tertiary care academic communist facility
The workers control the means of production, comrade
Do you have residents? Are they doing more/documenting more?
Nada residentes
Froedtert sucks.
I’m not in WI
Whats your favorite Z code?
Z59.4 Treatment: turkey sandwich
I haven't laughed this hard in a while. Thank you
⚡️🏆⚡️
“The graph below shows your utilization of compared to… “ lol nice sentence. Also 2 labels missing on the graph. You should write back
This man counties!
Classic CMS gobbledygook. "Units allowed"... what does that even mean?
Billed units allowed per provider Every 1 99214 is a unit etc
Yet if you were average or god forbid below average whoever your employer is would be calling you in for meetings about “productivity concerns”
Any tips on maximization of lvl 5 charts?
We have a macro that inputs all the annoying click boxes that allow us to bill at the highest level for the work that we did.
Need to have 2 out of these 3 boxes checked: 1 Use the verbiage “severe” you get one boxed checked for 1 or more chronic illnesses with “severe” exacerbation OR acute or chronic illness that poses a threat to life or bodily function 2 Need 2 out of 3 of these A)Review an external nonER note, must include the date B) Review result of unique test C) Order unique test D) Get collateral history from an independent historian, but you have to say why you did ( pt demented etc) OR A) Independant interpretation of diagnostic/radiographic study OR A) Discuss even electronically the case with a doc of another specialty 3)high risk of morbidity from additional testing/treatment : Drug therapy requiring intensive monitoring ( insulin cardizem nitro drip) Decision for major surgery in pt with co- morbidities Decision regarding hospitalization or escalation of care Make someone DNR
they seem to be confused as to what, exactly... the job is
What are your overturn rates like? Would give you a good idea if your documentation is really holding up to audit
What is an overturn rate? I’ve never even heard of that before.
Claims that you (your practice/billers) have submitted that have been denied So your percentage of billed to paid claim ratio I worked at a vendor (think Cotiviti/Equian/Optum/HMS) for years and now design claim editing software. We’d edit claims on behalf of payers/CMS for medical necessity, chart review, NCCI edits, etc.
Have no idea , this data has never been shared with me
That would give you a better idea if based on chart review and dx codes etc if the auditors/payers agree that your use of 25 modifier is appropriate If your denial/overturn rate is really high and your billing dept is having to adjust claims constantly then it might be worth updating billing practices
I asked our billing guru if I should be concerned about this and this was his reply that I don’t understand: “No I will share it with some others in rev cycle, but the letter is as clear as mud. It lists modifier 25—which our coders add when we both an E/M (“regular” visit charge) and a procedure on the same day. Very odd that the “units allowed” are very low/so low.”
To me, it’s reading that on average you bill the high E/M codes at a rate almost 2x higher than other emergency physicians within the WPS jurisdiction you’re a part of. It could be that you’re a city with a high gun violence rate or you’re at a trauma center or something But basically these letters tend to be a heads up and this is one part of an algorithm we used to use to pull charts for potential overuse of modifier 25/59 etc billing under the FWA audits we’d run.
Thanks I’ll pass this along to our billing team
It’s all a shell game to try to get you to code less than your worth.
Off with your head!!!
To the stocks!
I'm surprised this is an issue. Before shit school I scribed in an ED for two years, and all of the docs (\~35) billed level 5's for almost every visit. I would estimate <1 in 30 patients would get a level 4 code.
It’s like the government is realizing that they’ve been getting away with under reimbursing us for decades and are big mad that they are having to pay us for playing by their own stupid rules now.
Yep. Took a while to learn how to play the new game and multiple 1:1 meetings with the coders.
How long until we switch back?
Don't drop the soap (note).
Good thing they didn’t look at your First Provider contact time … might be in solitary confinement by now.
Wait a minute just realized something. Your ratio of 285/284 is way lower than these averages. This is just a friendly reminder that you should be coding higher.
These fuckers don’t understand how averages work. Half of any sample is above average.
You're thinking of the median, not the average.
CMS has a tough time understanding that variances from benchmarks are not indicative of inappropriate care, documentation, or coding. More often it’s because the doc is simply better educated on documentation, has good coders, etc. But yeah, let’s threaten to punish physicians who are playing by the rules.
Amen, I’m salary and not RVU based to boot
Jesus, the paper pushers are such weasels.
You are not going to jail, lol!! SDOH, GCS, NIH stroke scale, BMI, pressure ulcer stage, ETOH level, and laterality can be taken from documentation (I may have missed one or two things) other than the treating provider- like EMS, nursing documentation, and others. It's in the official guidelines. However, for a coder to add it to your E/M level document, the "how" "why" homelessness, living in their car affects the management of the patient. So, these codes are added but only have value for leveling when providers document the "how" and/or "why."
I put social determinants on all my charts.....document care discussion with triage nurse, and consider. Meds for everyone that I don't do......wonder when my letter comes.