Billing and Coding

1. Residents can bill 99214 or 99215! if attending sees the patient. 

   • under PATH (physician at a teaching hospital): if attending is present for encounter with patient, LEVEL 4 or 5 can be billed if visit meets medical decision making complexity (use coding calculator in EPIC when submitting bills "wand")

   • attendings must use correct attestation to indicate patient was seen by them ("Saw patient" attestation)

   • In the future: providers/attendings may get RVU performance cards and be incentivized for higher RVUs

2. You/MA must document a chief complaint for every visit

   • Claim will be denied for: "referral" "follow up"

   • Acceptable to use: "Follow up per HPI" 

   • try to link the CC to the primary diagnosis you bill for 

3. Care about the RAF score (Risk Adjustment Factor)!

   • RAF scores communicate to insurance companies the complexity of your patients which leads to patients qualifying for insurance company benefits like home monitoring programs AND approval/denial of services you request: VNS, home PT/OT, care managers, DME supplies, rx medication coverage, imaging/studies needed for diagnosis

   • Accountable Care Organizations (ACO) set benchmarks for how much a patient should "cost" to the organization based on RAF scores. 

     • • cost = utilization of ED/urgent care, hospitalizations, medications, imaging, etc

       • if your organization's patient population looks more well than it is (lower RAF scores) then they will lower this expected cost benchmark 

       • if your patients have higher RAF scores, their care is going to cost more and if your ACOs cost benchmark reflects that, your practice will be more likely to earn shared savings (more $$$ = better financial health of clinic AND patients get services they need)

       • RAF scores get recalculated every year on Jan 1

       • read more here: AFP article: It's Time to Go RAFing 

   • Get highest RAF scores by: 

     • • use diagnosis codes that are as specific as possible (see images below; Scenario 1: DO NOT DO; Scenario 2: DO!)

       • using diagnosis codes that link diagnoses with complications (e.g. diabetic CKD; see examples in image below) 

       • avoid using symptoms (chest pain) ---> use diagnoses instead (stable angina) (particularly important when ordering imaging studies) 

4. Use Social Determinants of Health ICD 10 codes (most if not all of our patients are impacted by SDOH!)

   • WHY: because SDOH "z" codes communicate the complex needs of our patients to insurance companies which leads to better patient care: 

     • more benefits and qualification for programs the insurance plan may have (e.g. meals program that insurance company reaches out to patient to offer) 

     • higher levels of billing for your patient (bump up from level 3 --> 4, 5) = more $$$, better financial health of clinic

   • Z60.9: "problems related to social environment- unspecified) --> internal tracking and optimizing communications/information sharing amongst interprofessional team (SW/IDT/providers)

5.  Think matching socks: ICD 10 codes + CPT codes must be matched appropriately otherwise claims can get DENIED.

   • DO NOT use Z00.00 preventative codes when billing for problem visits (99213, 4, 5s) 

   • preventative ICD 10 codes (Z00.00) should match preventative CPT codes (age appropriate, like wcc, and wellness visits) 

   • even if you addressed HCM needs at the visit, do not add diagnosis to your visit diagnoses

6. Medical Advice Messaging Billing (ATTENDINGS ONLY): you can bill for providing medical advice via MyChart

   • cannot do for: adolescents (privacy considerations), surgical patients, perinatal patients, patient can't have office visit where problem was addressed 7 days prior of 7 days after the message. 

   • must have components: established patient, message has to be initiated by the patient, at least 5 mins of MDM time

   • CPT code: 99421: 5-10 mins; 99422: 11-20 mins; 99423: 21+ mins

7. When you see a patient Post hospitalization (transitional care management code): can only bill for this --> do not combine modifiers  or other CPT codes 

   • patient was seen within 14 days of discharge: use CPT code 99495

   • patient was seen within 7 days of discharge: use CPT code 99496

   • https://www.cms.gov/files/document/mln908628-transitional-care-management-services.pdf 

8. Billing for pap smears during non-preventative visits 

   • use modifier 25 linked to ICD 10 for screening for cervical cancer with pap procedure CPT Q0091 

9. Billing for wcc with abnormal findings 

   • use preventative code for age appropriate wcc

   • use modifier 25 and link to the CPT code for the diagnosis code for problem you addressed 

10. Preventative visits for adults 

• ICD10 code: Z00.00 (once per calendar year, don't have to wait 365 days to use)

• can use modifier 25 if also addressed problems 

11. ADD ON Codes 

• G2211: Use as add on for any visit that is inhertently more complex because you managed a problem that requires ongoing longitudinal care related to a single, serious condition, or a complex condition. Medicare Specific but other insurances will reimburse you for it. Gets you 0.33 additional RVUs per visit (~$18). Aimed at primary care providers, and other specialists delivering prolonged care to patients with a single, serious condition or a complex condition with a consistency and continuity over a long period of time. Can't use if using any other modifiers!