Am I underbilling ?

[A-med Onc]

Hello!
I’m at a rural employed oncology position - 4 days a week about 18 patients a day. I generate about 7200 RVU roughly 2.15 wRVU a visit. Practice is 80% + oncology. I recently spoke to some colleagues who work in Northern California , seeing approximately the same number of patients , 4 days a week , generates close to 8800 RVU.
Would appreciate your thoughts..

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[HemeOncHopeful19]

I mean if they're truly seeing the same number of patients and generating 20% more RVUs then they're either billing higher codes or using newer RVU values? Do you use that new G2211 modifier when able?

For whatever it's worth your 2.15 RVU per patient generally follows what @gutonc has always guesstimated

 

[gutonc]

I'm using the G2211 a lot these days (~80% of encounters) and on the 2022 CMS values I'm averaging 2.35 wRVU/pt for the year so far.

I track my own productivity so I can double check my employer's work. This way I can pay attention not just to the wRVU #s but the breakdown of codes. For follow ups through April this year, I'm at ~35%/30%/35% for 99213-5. I think this is a better way to compare apples to apples since not all employers/practices use the sam wRVU values.

 

[A-med Onc]

I didn’t know about G2211 looks like they could explain the delta. I’ll be speaking to our coders about this. Can’t believe we have not been educated about this.

 

[dozitgetchahi]

I mean if they're truly seeing the same number of patients and generating 20% more RVUs then they're either billing higher codes or using newer RVU values? Do you use that new G2211 modifier when able?

For whatever it's worth your 2.15 RVU per patient generally follows what @gutonc has always guesstimated

Out of curiosity - anyone on here using G2211 in Epic? I managed to find the G2211 code and make a button for it, but if I click the button with a 9921x code it won’t let me close the note and tells me that it needs to be associated with a specific diagnosis (but it is?). My billers have no idea how to help with this, and the IT people seem confused also. Apparently I’m the only person trying to use the code at my practice…?

 

[Mehena]

We have a separate epic code built at the bottom to click in addition to the standard codes. No issues encountered with closing the notes.

For follow ups through April this year, I'm at ~35%/30%/35% for 99213-5.

Mine is a lot lower. Do you mind sharing examples of your follow up encounters that falls in 99213?

 

[MD46]

Out of curiosity - anyone on here using G2211 in Epic? I managed to find the G2211 code and make a button for it, but if I click the button with a 9921x code it won’t let me close the note and tells me that it needs to be associated with a specific diagnosis (but it is?). My billers have no idea how to help with this, and the IT people seem confused also. Apparently I’m the only person trying to use the code at my practice…?

Try using it as addon or modifier

 

[gutonc]

We have a separate epic code built at the bottom to click in addition to the standard codes. No issues encountered with closing the notes.

Mine is a lot lower. Do you mind sharing examples of your follow up encounters that falls in 99213?

I see a TON of benign heme. I work in a rural area with a fair number of NP/PAs doing primary care. They tend to refer anyone with any sort of abnormality on a random CBC. These usually result in a couple of follow ups at least, all of which require only reviewing a CBC and sending them away. I also inherited a patient panel full of people who'd had cancer 10-15 years before and were being followed "just in case". I've been there almost a year so most of them have been discharged from the clinic.

 

[osprey099]

I see a TON of benign heme. I work in a rural area with a fair number of NP/PAs doing primary care. They tend to refer anyone with any sort of abnormality on a random CBC. These usually result in a couple of follow ups at least, all of which require only reviewing a CBC and sending them away. I also inherited a patient panel full of people who'd had cancer 10-15 years before and were being followed "just in case". I've been there almost a year so most of them have been discharged from the clinic.

Is there a way you can wiggle these benign hemes into a 99204 or 99214? If you're seeing them for Hgb of 10 and you address that, but then also list several of their other problems like:

HTN - well controlled, continue lisinopril
DM - continue metformin
HLD - continue atorvastatin
Etc etc

Could you theoretically bill for a higher level if you did the above since technically those additional problems increased your "critical thinking time"?

 

[guildsman]

Is there a way you can wiggle these benign hemes into a 99204 or 99214? If you're seeing them for Hgb of 10 and you address that, but then also list several of their other problems like:

HTN - well controlled, continue lisinopril
DM - continue metformin
HLD - continue atorvastatin
Etc etc

Could you theoretically bill for a higher level if you did the above since technically those additional problems increased your "critical thinking time"?

According to CPT rules you have to actively manage a problem to include it in the MDM problem's addressed for the points (be the actual prescriber for those conditions or referring to a specialist to co-manage, or influence your decision - chemotherapy -> Anemia, monitoring). You also cannot order a test in one visit and use another visit to review it for counting for complexity points (FAQ: Scoring Elements in the E/M Guidelines). Those visits for follow-up likely fall into 99213 based on time essentially (20 minutes).

 

[gutonc]

Is there a way you can wiggle these benign hemes into a 99204 or 99214? If you're seeing them for Hgb of 10 and you address that, but then also list several of their other problems like:

HTN - well controlled, continue lisinopril
DM - continue metformin
HLD - continue atorvastatin
Etc etc

Could you theoretically bill for a higher level if you did the above since technically those additional problems increased your "critical thinking time"?

They all start out as 99204s, but most wind up as 99213 follow ups. It’s not that big of a deal though. I double book them in a 20 minute slot, spend 5 minutes total on each one (including the note), and still have time to prep for the next patient while running on time.

But as @guildsman pointed out, unless you’re actively managing those issues, or they impact the problem you see the patient for, you can’t just make a random list of the patient’s PMH and meds and bill a level 5 follow up.

 

[NewYorkDoctors]

though you could list a ton of problems and if it falls under your purview or domain and you are actively managing it (even if it's just assessing a labwork, tweaking a med, something basic seeming to a doctor) even to a little degree, then it could work. I know that's what I do.

my default template has

1) what the eventual diagnosis is
2) Dyspnea - which postulates on non-pulmonary etiologies of dyspnea
3) Cough - which postulates on non-pulmonary etiologies of cough
4) Nonspecific findings of lung imaging - which mentinos that 2mm granuloma seen incidentally is no big dea
5) Snoring / OSA - comment on the possibiltiy of OSA and epworth score and whether i am ordering sleep study or not
6) encounter for immunization - reviewed their immunizations for Tdap (pertussis relevant to lungs), pneumococcal, influenza, COVID, and RSV vaccines. if PCP is not able to get this done, I will get this done for the patient (though I give professional courtesy for that 90471 to the PCP first and foremost)
7) encounter for screening for malignant neoplasm of lungs - discuss if they meet LDCt screening criteria
8) encounter for prophylaxis - this is less used but if its patients on immunosuppression and usually has to do with PCP prophylaxis need
9) GERD - if relevant - as this drives me nuts as a chronic cough etiology . I do actively manage patients GERD if they have chronic cough though

but no I am not mentioning their DM or HTN unless I am tweaking those meds. I cannot really justify and say "yeah they have OSA. they have DM too so I will code that."

Boom level 4 at least right there. the insurances have not given me any pushback

most of these are not things I am "waxing poetic about" in front of the patient. but it is something I thought about and wrote it down and planned for contingencies

 

[sloh]

though you could list a ton of problems and if it falls under your purview or domain and you are actively managing it (even if it's just assessing a labwork, tweaking a med, something basic seeming to a doctor) even to a little degree, then it could work. I know that's what I do.

my default template has

1) what the eventual diagnosis is
2) Dyspnea - which postulates on non-pulmonary etiologies of dyspnea
3) Cough - which postulates on non-pulmonary etiologies of cough
4) Nonspecific findings of lung imaging - which mentinos that 2mm granuloma seen incidentally is no big dea
5) Snoring / OSA - comment on the possibiltiy of OSA and epworth score and whether i am ordering sleep study or not
6) encounter for immunization - reviewed their immunizations for Tdap (pertussis relevant to lungs), pneumococcal, influenza, COVID, and RSV vaccines. if PCP is not able to get this done, I will get this done for the patient (though I give professional courtesy for that 90471 to the PCP first and foremost)
7) encounter for screening for malignant neoplasm of lungs - discuss if they meet LDCt screening criteria
8) encounter for prophylaxis - this is less used but if its patients on immunosuppression and usually has to do with PCP prophylaxis need
9) GERD - if relevant - as this drives me nuts as a chronic cough etiology . I do actively manage patients GERD if they have chronic cough though

but no I am not mentioning their DM or HTN unless I am tweaking those meds. I cannot really justify and say "yeah they have OSA. they have DM too so I will code that."

Boom level 4 at least right there. the insurances have not given me any pushback

most of these are not things I am "waxing poetic about" in front of the patient. but it is something I thought about and wrote it down and planned for contingencies

What if the t2dm and being overweight impacts OSA?

 

[NewYorkDoctors]

What if the t2dm and being overweight impacts OSA?

well unless I am actively prescribing SGLT2 inhibitors and GLp1 agonists or doing the dietary talks myself then I can't really do a "drive by" and write "treat DM per PCP to help OSA."
i mean i can write that but i cant really use that for E&M purposes.
i mean im sure this kind of "gray zone" billing happens in the real world all the time . but by the book I have better things to do with my time then "nickel and dime a gray zone."

 

[sloh]

well unless I am actively prescribing SGLT2 inhibitors and GLp1 agonists or doing the dietary talks myself then I can't really do a "drive by" and write "treat DM per PCP to help OSA."
i mean i can write that but i cant really use that for E&M purposes.
i mean im sure this kind of "gray zone" billing happens in the real world all the time . but by the book I have better things to do with my time then "nickel and dime a gray zone."

Could do a perfunctory dietary talk haha. 20-30 seconds. Often these patients require nudges from more than one person/physician