Work Smarter, Not Harder: Coding Acute Visits
Updated: Jan 30, 2019
I am convinced that most primary care docs bill less than they could. We do this because we never learned how to code, because we are overwhelmed by the whole system or because we think we are less likely to be audited if we just bill a level 3 every time.
The first two reasons can be fixed, and the last one is incorrect: You are more likely to be audited if your (or your practice's) "CPT profile" shows an unusual distribution of CPT codes. If you predominantly bill one level, someone reviewing your billing might assume your bills do not reflect the work you performed. Accurate billing, with correct documentation, is "safer" than underbilling.
Accurate billing also pays better. A 99213 is worth 0.97 RVUs and a 99214 is worth 1.5 - more than 50% more. At $35.99 per RVU in 2018, that's a difference of $19.09 per acute visit. Eight acute visits per day, four days a week = $610.88 per week you are leaving on the table when you bill a level 3 for what was actually a level 4. If you billed a level 4 for a visit that met criteria for a level 5, you miss out on $52.90.
To be clear: I am not talking about billing for services you did not provide. This is called "upcoding", which is fraudulent and illegal. I am talking about coding and billing correctly for work you are already doing. First, acute care:
If you are like me you have one of those laminated cards in your office, the one that is covered on both sides with multiple text boxes that say "2 of 3 are necessary.." and "8 of 10 OR one of the below and 7 of the above..."
Someone gave you one of these cards during orientation and you haven't looked at it since because you have suffered enough. Also, you are busy.
Here's my advice: put that card somewhere you can find it, and make your own. Simplify the rules down to the point where they make sense to you and then start using them. Here is the card I have taped to my computer:
I primarily bill based on Assessment/Plan (Medical Decision-Making in coder's language). This works for me because my HPI, ROS and physical exam consistently meet or exceed the requirements (and if they didn't, I would make those parts of each visit more consistent). Most of my patients are established, so I only need 2 out of 3 criteria in Medical Decision-Making. Most of the time I use the "diagnosis" and "risk" categories, which usually correlate well with each other. (If I need to use “risk” as one of the three elements of MDM it is usually chart review plus labs or X-rays). Now I only have to know criteria in those two categories to code appropriately. If I'm unsure, I pull out the big laminated card and double-check. The categories you rely on may be different, but the goal is to have as few variables as possible.
You can also code for the add-ons that often come with an acute visit. The patient who walked in to clinic and disrupted the afternoon’s schedule? That’s a 99058, services provided on an emergency basis. Interview a patient or caregiver to assess risk? 96160, health risk assessment. Coordinating care for a patient recently discharged from the hospital is a 99495 (moderate complexity) or 99496 (high complexity). Not all insurance companies will pay for all these codes, but you will still be able to maximize your collections for work you are already doing.
If you aren't confident in your system, run it by someone. Ask for a coding audit (if you are an employed physician with a billing department, ask for an audit with a CPC. If you are self-employed, consider hiring a firm to do an audit for you - better than waiting to be audited by CMS). Check the resources below:
AAP: Coding Tips
Once you feel ready to use your system regularly, you will find that coding gets much, much easier. Maybe you will earn more money (here's hoping), or at least have leverage when it comes to your next contract negotiation.
Next: Coding Routine Visits.
Many thanks to Lydia Siegel MD MPH for sharing her resources about coding and billing.