Business Manager & Consultant Administrative Consultant for Endocrine Offices 703 Mt Rock Rd Carlisle, PA 17015 Tel: 717-798-4820 (Cell)
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Endocrinology Is it: Patient Care? Or A Business? Is it: Patient care driven? Or Business centered? Patient centered? Income driven? Or Payer driven?
Is it: Patient Care? Are patients cared for no matter what their financial status? Do you consider patient care over cost? Will you care for patients free of charge? Do you provide and order services, tests or prescription solely on the need of the patient? Do you take Medical assistance?
Is it: A Business? Do you consider cost, when deciding how to care for a patient? Do you consider cost, when ordering tests or medications? Patients can t schedule appointments if they owe your company money. You only participate with commercial payers since they pay more. Do you charge for NoShows
Payer Driven Payer policy tells you what is considered medically necessary, when deciding how to care for a patient s problems. You consider what payer and cost when ordering tests or medications. You always have to be aware of payers formulary. You have to know what CPT or HCPCS code a payer allows for your service. (S-codes, G-codes)
Endocrinology is all of the above You have to: Balance patient care and medical cost. Balance the payer mix in your office (Medical Assistance vs. Medicare vs. Payer vs. cash patients). commercial Know how to correctly charge for your service. Follow Payer Guidelines. NEED TO BE IDIALISTIC AND BUSINESS SAVY, ONE CANNOT BE WITHOUT THE OTHER TO BE SUCCESSFUL.
U/S (Ultrasound) FNA (fine needle aspiration) ABI (ankle brachial index) Counseling MAXIMIZE PATIENT CARE Consultation request visits POC (point of care) Testing Insulin Pumps and CGM (continuous glucose monitoring)
EVERYTHING ADDS UP! Let s look at some of the services you provide and see if you are charging correctly. PATIENT CASES YOU ALL CAN RELATE TO:
ULTRASOUND EQUIPMENT Costs between $15.000 - $60.000 Reimbursement for U/S : $117.80 2016 Medicare National Fee Schedule Reimbursement for U/S Guidance : $61.58 Single Most Profitable Piece Of Equipment In An Endocrine Practice 2016 Medicare National Fee Schedule Return on Investment with one U/S per day is approx. 2 Years Reference CMS National Fee-Schedule 2016
PATIENT CASE 1 51-year-old male referred to your office by PCP for suspected thyroid nodule and DM. He has a documented history of HTN and dyslipidemia. The patient had noticed his shirt collars are becoming tight. Glucose, HbA1c, and lipid panel by finger stick, with POC Devices performed. Records are reviewed and physical exam reveals a palpable left thyroid nodule, Diabetes, as well as retinopathy, HbA1c 8%, GLU 210, BP-160/90, LDL 150. An U/S is performed and confirms the nodule. You perform a FNA under U/S guidance. The slides are evaluated under microscope for adequacy of samples, packed up, and sent to the pathology lab for evaluation. DM, BP, lipids are addressed appropriately. An ABI is performed to evaluate PAD. TSH and FT4 are ordered, drawn, and analyzed in your office lab.
PATIENT CASE 1 Diagnosis: Thyroid Nodule E04.1 Diabetes Type 2, with Retinopathy E11.39 (controlled and uncontrolled does not exist any longer in ICD10) Benign Essential Hypertension I10 Dyslipidemia E78.4
THE FOLLOWING PROCEDURES ARE CODED: Payments MEDICARE 99204-25 Separately identifiable E/M visit $166.13* X 36415 Blood collection approx. $ 3.00 82947 Glucose Assay (Lab level Analyzer) approx. $ 5.48 80061 Lipid Panel $ 18.72 83036 HbA1c $ 13.56 93922-59 Extremity Study (ABI) $ 90.58* 76536-59 U/S Separately identifiable Procedure $ 117.80* X 10022 Fine needle Aspiration under U/S guidance $ 143.22* X 76942 Ultrasound guidance for Fine Needle Aspiration $ 61.58* X 88172 Immediate cyto-histologic study to determine adequacy of specimen $ 58.00* X 84443 TSH $ 23.47 84439 FT4 $ 12.60 TOTAL: $ 714.14 2016 National Physician Fee-Schedule
SOME RULES TO FOLLOW Should have 2 or more DX codes to use Mod. 25 Several nodules can be billed separately Use Mod LT, RT and/or 51 Multiple Procedures and/or 99 Multiple Modifiers Some procedures may be paid at 50% 2 and more U/S (U/S and U/S guidance, LT, RT) should be charged with Mod 59 Separately Identified Procedure
POINT OF CARE TESTING BNP (TZD-Check for heart failure), GLU, HbA1c, Lipid Panel, Micro albumin, Urinalyses CLIA waived tests. Machine and reagents must be PURCHASED to bill for the test. Results within 5 10 minutes. Payment between $5 and $50 depending on test performed. Some equipment is free with reagent rental
ABI ADA recommends checking anyone at risk for PAD (over 50, diabetic, hypertension, dyslipidemia or with other indications of PAD) Insurance companies request ABI done on patients at risk for PAD (received letters from payers) Reimbursement = ~ $90.58* Return on investment with as little as 15 patients Over 500 DX codes cover the test (example type 1,DM peripheral Angiopathy, w/o Gangrene= E10.51) ABI code 93922 Performed by MAs, interpreted and documented by Provider * 2016 Medicare Fee Schedule
COUNSELING Remember counseling can be billed by time (if more than 50% of the time was spend counseling the patient and/or family member) Time alone determents the level of visit 99215 is the correct level if 21+ minutes out of 40 spent counseling. 99406: 3-10 minutes and 99407: >10 minutes should be used for smoking cessation ADA recommends Smoking Cessation Counseling MU requirement 2017 CPT published by AMA
EDUCATION FOR DIABETES Utilize ADA or AADE DSMT/E, as well as MNT on your patients. Own Accredited Program? Most Patients have the right to annual Education by a CDE and RD Programs closing because not enough referrals 2017 CPT published by AMA
CGM BILLING 95250: Patient CGM Initiation session Pt wears CGM device for minimum of 72 hours: includes training, hookup, calibration, removal, and download 95251: Physician Interpretation and Report Physician reviews and interprets CGM data and generates report Patient owned CGM download and interpretation
FAQs REGARDING 95251 What documentation is needed to bill 95251? Provider should contact their payers for specific coverage criteria. It is our understanding that physicians should document analysis and interpretation. CGM reports should be printed and in some form included in patient s medical record. (scanned or electronic) Can a CDE or RN bill 95251? No. 95251 is a professional code only billable by an MD, NP, CNS, or PA (as appropriate).
PATIENT CASE 2 Patient with Diabetes 51-year-old male in your office for Type 1 DM. He has a documented history of HTN and dyslipidemia. The patient complains of tingling in his feet and circulatory problems. He has been a smoker all his life. Glucose, HbA1c, and lipid panel by finger stick, with POC Devices performed. Records are reviewed and a complete physical exam is performed and reveals possible Retinopathy, HbA1c 10%, GLU 280, BP- 160/90, LDL 150. BP and lipids are addressed appropriately. An ABI is performed to evaluate PAD, DSMT is ordered and provided in the office following the clinical visit, he is also referred to the Neurologist.
PATIENT CASE 2 The following is coded as diagnosis: Diabetes Type 1, with Retinopathy, E10.39 Other specified symptoms and signs involving the circulatory and respiratory system R09.89 Benign Essential Hypertension I10 Dyslipidemia E78.4
THE FOLLOWING PROCEDURES ARE CODED for: Office Visit #1 including DSMT Visit #1 on the same day: 99204-25* E/M visit $ 166.13* X 82947 Glucose Assay (Lab level Analyzer) $ 5.62 80061 Lipid Panel $ 19.19 83036 HbA1c $ 13.90 93922-59* Extremity Study (ABI) $ 90.58* 99406 Smoking Cessation Counseling <10 Minutes$ 14.32* X G0108** Diabetes Self Management Training 60 min $ 106.70* TOTAL: $ 416.44 *-59 Modifier is used to identify separate procedures ** Must be ADA or AADE accredited *2016 National Physician Fee-Schedule
Insulin Pumps Have a Certified Pump Trainer on staff. Contract with the pump companies for reimbursement of pump training Time. Utilize DSMT and MNT to get the patient ready for the pump (carb counting) Management and follow-up visits are E/M visits
Example 3 Pump Patient Patient with type 1 diabetes and retinopathy, on an Insulin pump came to the office with high glucose because the pump mal functioned. Code for: Diabetes Pump Mal-function With or Without Poisoning by Insulin Long term Insulin Use
ICD 10 E10.319 - DM Type1 w/unspecified Diabetic Retinopathy w/o macular edema T85.6114 - (needs 7 characters) Breakdown (mechanical) of Insulin Pump T38.3x96 - (needs 7 characters) Poisoning by Insulin or oral hypoglycemic Drugs, accidental Z79.4 - Long term (current) use of Insulin
NEW CPT CODES Prolonged Clinical Staff Services 99415 (0.24 RVU) 99216 (0.13 RVU) -Use in addition to E&M code -does not have to be continues time -should not be used for the first 45 min -45 min starts after E&M visit -time includes E&M provider time -must all be Face to Face time
EXAMPLE 4 Diabetic patient comes to the office, a standing order of random glucose is performed by the staff. The test result shows a glucose of 551mg/dl. The provider orders an injection of x-amount of insulin to bring the glucose down to a lower level. The provider counsels the patient for 15 minutes and examines the patient for 10 minutes. After the visit the glucose levels are still not much lower. The patient receives several additional glucose tests and additional insulin injection until the glucose level reaches office policy acceptable levels. Staff spends additional documented, noncontinues, Face-To-Face time of 60 minutes with the patient.
CHARGES Provider charge: 99214 (25 minutes <50% Counseling) Additional charge for staff time over 45 minutes past provider time: 99415 (first 30 minutes) Charge for the injectable (unites of insulin J-Code) Charge for each glucose tests performed on office equipment 82947-91 (use Mod.91 repeat clinical diagnostic laboratory services) Charge for Finger stick 36416
NEW CPT CODES Non Face to Face Telephone Services 99441-5-10 minutes Medical Discussion 99442 11-20 minutes Medical Discussion 99443 21 30 minutes Medical Discussion
NEW CPT CODES Telephone service codes 99441 99443 Non Face-to-Face E&M service Must be initiated by established patient or guardian of an established patient can not end in a decision to see the patient within the following 24 hours Cannot be a follow-up to a patient visit within the past 7 days. Since the fee schedule includes RVUs for 99441 99443, some private and other public payers may pay for the codes Medicare considers telephone call codes 99441 99443to be non covered services
NEW CPT CODES On-line Medical Evaluation 99444 Online electronic medical examination Non Face-to-Face evaluation and management Performed by a physician In response to a patient s online inquiry Think of patient portals, where patients have 24 hour access, to send inquires to the provider. These messages can end up to be problem solving, online, E&M visits. Documentation is the key for these kind of services.
Myth about Consult Codes Consultation CPT codes are not accepted anymore Most government payer will not allow consult codes to be charged (99241-99245) Most commercial payers will still allow Consultations and allow consult codes 99241-99245 to be used.
Myth about Consult Codes Consultation requests cannot be made within the same office or the same specialty Requests can be made by lower licensed professionals (CRNP, PA, CNM) if they are not qualified to have the knowledge about certain diseases. Requests can also be made by same licensed professionals in the same office if the requesting provider is not familiar with a disease and the consulting provider has significant more knowledge about the disease.
UNDER USED CODES Prolonged Service Codes Used if unexpected a Face-to-Face visit ends up to be much more time consuming then expected. Scheduled time 25 minutes (99214 office visit) Actual time 60 minutes (99214+99354) Scheduled time 40 minutes (99215 office visit) Actual time 75 minutes (99215+99354)
UNDER USED CODES - Prolonged Service codes - 99354 and 99355 - Less than 30 minutes no extra code - 30-74 minutes 99354-75 -104 minutes 99354 x1 + 99355 x1-105 minutes 99354 x1 + 99355 x2 or more for each additional 30 minutes - 99356 and 99357 for inpatient - 99358 + 99359 used to report non face to face time for before and/or after direct patient care first hour and each additional 30 minutes, does not have to be continues. Documentation
The most important ways to maximize your business and maximizing patient care: Code and document correctly Always Document medical necessity Why did you perform or order a service Code all services performed and documented Add additional services according to standard of care (ABI, POC Lab Tests, Eye Exam)
ABOVE ALL ELSE: VERIFY INSURANCE COVERAGE FOR EVERY PATIENT FOR EVERY VISIT RE-WORK REJECTIONS RE-SUBMIT CORRECTED CLEAN CLAIMS UNTIL THEY ARE PAID
Business Manager Administrative Consultant for Endocrine Offices 703 Mt Rock Rd Carlisle, PA 17015 Tel: 717-798-4820 (Cell)