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  • #31
    If there is an assessment and evaluation, then yes, drop a -25 charge. If simple referral....nope.

    Like a house inspection. If you merely point out abnormals and recommend a follow up with person, then that's part of the inspection. If you ask them to evaluate further and address the issue, there's an additional charge.

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    • #32
      Originally posted by StarTrekDoc View Post
      If there is an assessment and evaluation, then yes, drop a -25 charge.
      What does this mean, exactly? You've got the E&M code that you bill for, and the -25 modifier is for a procedure performed at the same time.

      What is the additional code that you are talking about which makes the -25 necessary?

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      • #33
        Primary care here. I am increasingly parsimonious with labs (otherwise my inbasket is ridiculous and you chase a lot of BS). Like lordosis I follow uspstf (so a lot of healthy people get q5 glucose and lipid and that’s it). I tell patients that just because insurance may cover something doesn’t mean you need it. I will refer patients who are demanding unnecessary tests to “any lab test now” down the street (yes, you walk in, pay cash, and get what you want). Oftentimes from our meetings, I know that some insurers will NOT PAY US for something they deem medically unnecessary yet also NOT LET US BILL THE PATIENT (how does that work? Hence any lab test now). Lots of times once people know that unnecessary TSH is $300 and vitamin D is ditto…. Not so interested.

        i have never ordered cbc cmp lipid ua tsh as my standard annual exam labs- even at beginning of career when that was more common. I have one dude who was a big executive and used to 3 hour executive physicals with a bunch of unnecessary crap. Over time, we have come to an agreement where I order a little more than usual but all is justifiable.

        On PSA and MMG I have a relatively quick spiel. I keep thinking that I need a brief video to play after the MA leaves the room.

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        • #34
          Honestly you can order a fasting insulin and glucose level. Calculate the HOMA IR:

          https://thebloodcode.com/homa-ir-calculator/

          tell people to cut out eating sh!t, exercise, and be done with it. You can't care more about a patient's health than they can.

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          • #35
            Originally posted by AR View Post

            What does this mean, exactly? You've got the E&M code that you bill for, and the -25 modifier is for a procedure performed at the same time.

            What is the additional code that you are talking about which makes the -25 necessary?
            Presume you're a specialist so never use annual visit as primary CPT code.
            -25 doesn't have to be specifically only for procedure.


            CPT Code: Annual visit: 99394-7
            Modifier -25
            2nd CPT Code: E+M: 99213-5

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            • #36
              Originally posted by StarTrekDoc View Post

              Presume you're a specialist so never use annual visit as primary CPT code.
              -25 doesn't have to be specifically only for procedure.


              CPT Code: Annual visit: 99394-7
              Modifier -25
              2nd CPT Code: E+M: 99213-5
              You're right, I'm not familiar with that code. Out of curiosity, how is the reimbursement of that code compared to a level 4 established patient visit?

              I still don't understand how you justify billing the second E&M code in this case. You do an exam and you see a suspicious skin lesion. Here are some things you could do

              1. You could do a biopsy of it (in which case that should be billed for separately, and the biopsy code includes time spent evaluating the lesion)
              2. You could refer the patient to another specialist for a biopsy (you said this wouldn't be enough to justify the additional E&M code)

              So what justification do you use? I'm not saying there isn't one, I'm just curious about what you would use in this specific case.

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              • #37
                I try to use the PE for education purposes mainly. I think it is a little different if you are a physician going in as a patient.

                I don't nickel in dime patients, and everything is included except the bw

                We check a vision screen and hearing screen, it is amazing how many seniors out there are driving with vision less than 20/100 and don't even realize it. We also do a quick hearing screen. Usually , ekg on those over 50. Once a week or so , pick up someone with undiagnosed afib, hopefully saved them a future stroke. I do a quick skin check on the parts people cant see well.

                this is also a great time to talk patients into mammos ,colonoscopies and dm bw that they usually forget to do. Also a good time to review meds and follow up on any loose ends.

                I do a lot of screening bs,hga1cs and lipids , try to limit the other labs

                My data says I get close to a 90% yearly return rate for PEs , so I feel like I am providing a useful service.

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                • #38
                  Originally posted by Random1 View Post
                  Usually , ekg on those over 50. Once a week or so , pick up someone with undiagnosed afib, hopefully saved them a future stroke.
                  Are these people really asymptomatic and do you really get one a week? There’s a lot of unnecessary EKGs done in the ED (we also get the privilege of doing them on anyone that is going to surgery at some point and we get a lot of broken hips) and I don’t think I’ve ever picked up afib in someone who didn’t have a history of being in afib all the time or someone who didn’t have symptoms that would lead to an EKG in the first place.

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                  • #39
                    Originally posted by StarTrekDoc View Post

                    CPT Code: Annual visit: 99394-7
                    Modifier -25
                    2nd CPT Code: E+M: 99213-5
                    Do your payors actually pay for that? Ours universally reject the E&M code. It's a racket on their part.

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                    • #40
                      Originally posted by AR View Post

                      You're right, I'm not familiar with that code. Out of curiosity, how is the reimbursement of that code compared to a level 4 established patient visit?

                      I still don't understand how you justify billing the second E&M code in this case. You do an exam and you see a suspicious skin lesion. Here are some things you could do

                      1. You could do a biopsy of it (in which case that should be billed for separately, and the biopsy code includes time spent evaluating the lesion)
                      2. You could refer the patient to another specialist for a biopsy (you said this wouldn't be enough to justify the additional E&M code)

                      So what justification do you use? I'm not saying there isn't one, I'm just curious about what you would use in this specific case.
                      The skin lesion is a bad example. It happens and if it is obviously something benign I reassure the patient and do not bill anything. If it is worrisome and I refer the patient I also do not bill for something like that.

                      The most typical is either patients who come in with one or several complaints; Back pain, fatigue, dizziness, etc. Or patients who have chronic medical problems that are not well controlled necessitating a change in therapy like uncontrolled DM or HTN or if you discover something like that which needs to be addressed.

                      I have seen physicians try to bill for reviewing controlled chronic conditions during a CPE but I do not do that. Only if there is a meaningful change or discussion.

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                      • #41
                        PCP here. I tend to be in the "less is more" camp and follow USPSTF guidelines. I try to encourage my young, healthy patients that they don't need blood work every year, but many still want it. I have lost some patients because I don't order 20 tests on their physicals. I have had other patients complain when they ask for those tests and then get charged for it. I now have to spend time telling patients they will potentially get a bill for any extra tests.

                        No "screening" EKGs, as it's not indicated from everything I've read.

                        I will do a physical exam, as I think that's more reassuring for the patient and sometimes leads me to find something (most often thyroid nodules).

                        I often have to explain why a breast exam and pelvic exam is not required annually, but most women are ok with that.

                        I will order PSAs after discussing with men, but I don't do a prostate exam (will save this for urology if we get to that point...most men appreciate not getting multiple rectal exams, and evidence is lacking as a "screening).

                        I will bill a separate office visit charge when patients come in with a list of complaints and we do something about it. I think a lot of people view it as their yearly "free" visit where they can discuss all of their concerns. I will also charge for a chronic condition that requires a change (i.e. DM uncontrolled and adding a medication) vs not charging for controlled issues (HTN controlled, just needs a refill).

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                        • #42
                          Shouldn't there be some physical examination of mouth, ears, lungs, prostste
                          and an ekg every yr
                          no more chest X-rays???

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                          • #43
                            Are these people really asymptomatic and do you really get one a week?

                            It is surprising how many asymptomatic patients have afib, or "I don't know whats wrong , I just dont feel right." . If I can save someone from a devastating stroke, for a test that takes next to no time in effort , it is worth it ( I dont bill for it separately anyway)

                            I can't tell you how many new patients who come in an say, I went to my doctor for a physical and the doctor did not even listen to my heart.

                            Comment


                            • #44
                              Originally posted by Random1 View Post
                              Are these people really asymptomatic and do you really get one a week?

                              It is surprising how many asymptomatic patients have afib, or "I don't know whats wrong , I just dont feel right." . If I can save someone from a devastating stroke, for a test that takes next to no time in effort , it is worth it ( I dont bill for it separately anyway)

                              I can't tell you how many new patients who come in an say, I went to my doctor for a physical and the doctor did not even listen to my heart.
                              Wow - cursory exam will pick up IRIR even for medical students. Doesn't need EKG routine for that.

                              And you get this 1/week new diagnosis -- Who do you see >90yo only new patients?

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                              • #45
                                Originally posted by Random1 View Post
                                It is surprising how many asymptomatic patients have afib, or "I don't know whats wrong , I just dont feel right." . If I can save someone from a devastating stroke, for a test that takes next to no time in effort , it is worth it ( I dont bill for it separately anyway)

                                I can't tell you how many new patients who come in an say, I went to my doctor for a physical and the doctor did not even listen to my heart.
                                As I said, the ED is the king of unnecessary EKGs and the EKG is pretty low yield for the old *insert non-specific complaint here*. I also say this from a cynical point from the unnecessary ED referrals because of whatever craziness the computer read says.

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