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  • #61
    Originally posted by Savedfpdoc View Post

    The justification is easy…the suspicious mole would require a separate discussion with the patient and meets the criteria for using modifier 25 “a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.”

    Keep in mind just bc I can bill it doesn’t mean I always do. I would do as someone else here said..just put in a referral to derm without billing a separate visit.
    I still don't understand. In the scenario as described, would YOU bill or not. I'm not asking if it is theoretically possible. I am asking if you would bill it and if you would, what would your specific justification be (and what would you actually do in the visit).

    So far, by my count, we have zero people who would actually bill for this.

    It sounds like what you are saying, "That looks suspicious, I'm referring you to a dermatologist" is something that is acceptable to bill for, but you don't personally do it. Am I understanding you correctly?

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    • #62
      i have had 2 pcps in my real adult life

      1 did a head to toe exam for my yearly, clothes off, hospital gown, poked and prodded everything. cannot even imagine how low yield this must be on a healthy dude in 30s.

      1 hasn't even laid a hand on me.

      i don't think i really care either way.

      the physical exam is over-rated in sick patients, let alone healthy ones. don't @ me bro. i think when i realized that surgeons stopped even seeing consults until a CT was done some of the shine came off the whole process for me. i had literally worked at hospitals where a surgeon would not come to the bedside until a CT was done and final read by an attending. they will still tell you their exam skills are superior to everyone else's. if a surgeon were to come back and say "well i can't tell you how many times i was consulted for gas or AGE" i would respond, "yeah, you're right, the physical exam isn't very good."

      Comment


      • #63
        Originally posted by AR View Post

        I still don't understand. In the scenario as described, would YOU bill or not. I'm not asking if it is theoretically possible. I am asking if you would bill it and if you would, what would your specific justification be (and what would you actually do in the visit).

        So far, by my count, we have zero people who would actually bill for this.

        It sounds like what you are saying, "That looks suspicious, I'm referring you to a dermatologist" is something that is acceptable to bill for, but you don't personally do it. Am I understanding you correctly?
        -yes, you got it. What's not to understand? The pain of a patient complaint and work generated outweighs the benefit of a low RVU visit. Learned helplessness is a real issue in primary care when people complain about these -25 bills on smaller things.

        Comment


        • #64
          Originally posted by StarTrekDoc View Post

          -yes, you got it. What's not to understand? The pain of a patient complaint and work generated outweighs the benefit of a low RVU visit. Learned helplessness is a real issue in primary care when people complain about these -25 bills on smaller things.
          If the consensus that it is perfectly kosher to bill in that scenario, but no one actually does it, that is a little weird.

          For those who work in big groups, is there no pressure from the billers and coders to bill for "I'm referring you to a dermatologist for this mole I saw on your annual visit"?

          Comment


          • #65
            Originally posted by MPMD View Post
            i have had 2 pcps in my real adult life

            1 did a head to toe exam for my yearly, clothes off, hospital gown, poked and prodded everything. cannot even imagine how low yield this must be on a healthy dude in 30s.

            1 hasn't even laid a hand on me.

            i don't think i really care either way.

            the physical exam is over-rated in sick patients, let alone healthy ones. don't @ me bro. i think when i realized that surgeons stopped even seeing consults until a CT was done some of the shine came off the whole process for me. i had literally worked at hospitals where a surgeon would not come to the bedside until a CT was done and final read by an attending. they will still tell you their exam skills are superior to everyone else's. if a surgeon were to come back and say "well i can't tell you how many times i was consulted for gas or AGE" i would respond, "yeah, you're right, the physical exam isn't very good."
            I agree that physical exams are largely overrated. I can do about 95% of what I need to do with my eyes. The old ocular pat down will give you what you need to know.

            Comment


            • #66
              Originally posted by AR View Post

              I still don't understand. In the scenario as described, would YOU bill or not. I'm not asking if it is theoretically possible. I am asking if you would bill it and if you would, what would your specific justification be (and what would you actually do in the visit).

              So far, by my count, we have zero people who would actually bill for this.

              It sounds like what you are saying, "That looks suspicious, I'm referring you to a dermatologist" is something that is acceptable to bill for, but you don't personally do it. Am I understanding you correctly?
              Correct

              Comment


              • #67
                Originally posted by AR View Post

                If the consensus that it is perfectly kosher to bill in that scenario, but no one actually does it, that is a little weird.

                For those who work in big groups, is there no pressure from the billers and coders to bill for "I'm referring you to a dermatologist for this mole I saw on your annual visit"?
                As a pcp, billing the separate visit will most of the time generate a long winded complaint by the patient at the next visit. Something I don’t have time for. So if it’s something minor like a referral for a suspicious skin lesion then I’m not gonna bill that. However if I do a steroid injection for arthritic knee pain then I’ll for sure bill that.

                I work for a large hospital system, yes we do get pressure from admin to bill everything possible

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                • #68
                  Originally posted by Lordosis View Post
                  Now only if I could bill a separate E&M code for counseling for obesity during a physical I would double my productivity!
                  Well you could always add the code for obesity counseling minimum 15 minutes to the physical codes…

                  Comment


                  • #69
                    Originally posted by Anne View Post
                    So do you PCPs out there like the patients who just come for their annual physical and don’t have any complaints/meds/etc or do you feel it is a waste of time? I go for my recommended screening and keep an annual visit with my PCP because I feel like it’s good to have a PCP in case something comes up…but maybe I’m wasting her time. On the other hand, whenever I see patients with random badness I always like to know what their original symptoms were because I feel like I will have a tendency to downplay anything until it becomes too late.
                    I love the 26 yr old male with no meds, who works out everyday. That’s an easy 99394. Keep em coming!

                    Comment


                    • #70
                      Originally posted by Savedfpdoc View Post

                      However if I do a steroid injection for arthritic knee pain then I’ll for sure bill that.
                      Yeah, that's completely different. I don't think there is any disagreement on that scenario.

                      Comment


                      • #71
                        Originally posted by gap55u View Post
                        Re separate billing: 9939X -25 modifier.
                        9921X (for their uncontrolled DM / new back pain/ whatever)
                        As I mentioned before, our coding/compliance people -- who are ludicrously conservative - have said that an E&M is not paid for at a wellness series 9939X. Is there a chance they are lying? Or do payors vary that much state to state? Additionally, for those who do the 9921X modifier, do you have some who pay and some who don't?

                        Right now, it's only my medicare wellness patients who get 9921x-25 + AWV G code. Even then our compliance person gets her panties in a wad without very clear documentation. And luckily I know how to play that game and teach others to play that game too.

                        (Off-topic: if you are primary care and bill 99215's, I would be interested in vignettes or even anonymized snippets of a note. Same coder is pretty ridiculous about 99215's. Management sent out "initiation of methotrexate" as the kind of visit that warrants a 99215 - oh so primary care focused - and if there isn't clear threat to life or limb pushes back on 99215's. Whereas I think an uncontrolled hypertensive uncontrolled diabetic multiple labs and review of chart and multiple med changes probably does in fact qualify. Right now I get a lot of 99214.99999's).
                        Regarding billing modifier 25-my local coder pushed back initially saying “no ones ever done this blah blah”. So I sat down with her and the office manager and taught them how to bill. Most commercial insurance plans don’t have a problem with it. Also ok w traditional Medicare +\- supplement plan. Medicare advantage plans have given us a lot of headaches so not worth it to me to have that fight. Medicaid also has been a fight so I avoid doing it with those plans.

                        regarding 99215- I bill if sending to Er for hypoxia, chest pain, stroke etc. I also bill if I have multiple uncontrolled chronic conditions (atleast 3) that puts pt At significant risks. Also bill if a condition comes up and patient declines to pursue treatment or sending to hospice (ie 90 yr old w psa 70 who’s poa declines referral to urology). You also use the time (40+min ) to bill for 15 but my visits are never that long unless I’m I include time on phone w local nursing homes when I’m trying to admit a pt.

                        Comment


                        • #72
                          Originally posted by CordMcNally View Post

                          I agree that physical exams are largely overrated. I can do about 95% of what I need to do with my eyes. The old ocular pat down will give you what you need to know.
                          if that isn't a sunny reference then we are in a fight

                          "wait..... ...... ...... ..... ...... ..... ..... .... he's clear"

                          Comment


                          • #73
                            Originally posted by CFEonline View Post
                            A real physical exam once a year seems very reasonable. Look for skin cancer, murmurs, bruit, etc. At the very least document what you actually did accurately so acute care physicians have a better idea what patients baseline exam actually is. I don't think a screening ECG in healthy patients at some point is unreasonable at all though repeating them annually as a matter of routine seems excessive. You could catch a long QT, brugada, HCM, etc before patient has a bad outcome from them. Additionally, it gives a baseline to compare to when the show up at the hospital with chest pain.
                            Is this based on actual recommendations of some medical society?

                            Comment


                            • #74
                              Originally posted by gap55u View Post
                              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.
                              See the ND down the street and get your antimony and molybdenum blood levels

                              Comment


                              • #75
                                I turned down Locum once as they wanted to do ekg on every kid for sports physical! The office manager told me that’s what parents want
                                I said sounds like you need a different doc

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