One of the most common questions we receive when training nurse practitioners in the nursing home is, “how do I maximize the level of billing for the visits.”\u00a0\u00a0<\/p>\n\n\n\n
The best way to maximize reimbursement for your medical visits is to follow Medicare guidelines.<\/strong><\/p>\n\n\n\n
1. Bill for the level of work that you do<\/strong><\/p>\n\n\n\n
2. Document all the components for the level of visit<\/strong><\/p>\n\n\n\n
3. Make sure your visit meets the requirements for the level of visit you are billing.<\/strong><\/p>\n\n\n\n
4. Do not under code because you are worried about an audit<\/strong><\/p>\n\n\n\n
5. Utilize add-on codes such as advanced care planning when medically appropriate<\/strong><\/p>\n\n\n\n
Unfortunately, there isn’t some magic way to increase the level of visit. Yes, some providers bill higher-level visits on average. There really should be more medically complex patients to justify the higher level if this is the case.<\/p>\n\n\n\n
The truth is, many providers under-code the visit. Most likely, the under coding occurs because of a fear of failing an audit of their notes. However, if you properly document the level of risk and meet the components of the exam, you will pass an audit with the insurance companies.<\/p>\n\n\n\n
It would be best if you made sure that your medical decision-making is determined on two out of three MDM elements. Your progress note needs to clearly show the medical decision-making done in the assessment and plan. <\/p>\n\n\n\n
According to the American Medical Society<\/a>, Physician\/other qualified health care professional time includes the following activities, when performed:<\/p>\n\n\n\n
All visits will require a history and physical exam. The extent of history and physical examination is not an element in selecting the level of codes. <\/p>\n\n\n\n
One of the main things that determine the visit level is the number and complexity of the addressed problems. Include all of the issues that are addressed in your progress note. This will help increase the level of medical complexity.<\/p>\n\n\n\n
Therefore it is important to document the ICD 10 codes for all the symptoms and actual problems addressed. If the patient has fatigue, make sure to include that in your diagnosis list. Just remember that all the symptoms are not necessarily “conditions.”<\/p>\n\n\n\n
When you have multiple symptoms, there is a higher likelihood that the patient is experiencing something that is higher risk. If there is a higher risk to the patient, then the medical decision-making will be higher. <\/p>\n\n\n\n
If you don’t document the symptoms, how will MedicareMedicare and the insurance companies know what is going on?<\/p>\n\n\n\n
One component of determining the level of the CPT code is determining the risk for complications. Determining the risks includes the morbidity or mortality of patient management.<\/p>\n\n\n\n
According to the AMA, the level of risk is based upon the consequences of the problem(s) addressed at the encounter when appropriately treated.<\/p>\n\n\n\n
Risk also includes MDM (medical decision making) related to the need to initiate or forego further testing, treatment, and\/or hospitalization.<\/p>\n\n\n\n
Remember that the patient can still be at high risk even if the possible outcome isn’t death. The patient could end up with a life-altering event. <\/p>\n\n\n\n
The alternative could be true with serious events that don’t necessarily lead to life-altering events or death as a risk factor. An example is certain cancers treatments have low-risk side effects (serious illness, low-risk profile for the treatment) even though it’s treating a very serious condition. <\/p>\n\n\n\n
You should always document medications that require monitoring by the physician or practitioner in your notes when appropriate. Many drugs can have serious side effects with toxic levels. When you identify these side effects it can increase the level of visit. <\/p>\n\n\n\n
Unfortunately, just documenting monitoring for therapeutic effect only does not increase the level of the visit. Even monitoring of glucose levels could be interpreted as monitoring for therapeutic effect. <\/p>\n\n\n\n
You want to focus your documentation on avoiding the adverse outcomes of the medication, such as severe hypo or hyperglycemia. <\/p>\n\n\n\n
Just because you document something doesn’t mean it increases the level of complexity of the visit. <\/p>\n\n\n\n
Simply documenting that the patient is going to dialysis and will manage labs doesn’t add a layer of complexity. However, your progress note needs to tell the story, so it is good to include these points.<\/p>\n\n\n\n
Charting a bunch of labs and studies that are not related to the problem or reason for the visit do not count towards the level of complexity.<\/p>\n\n\n\n
Many medical providers feel the need to add a bunch of “fluff” to their progress notes. Just because you use many words in your note doesn’t mean the visit is more complex.<\/p>\n\n\n\n
Documenting a review of systems and physical exam components that have nothing to do with the reason for the exam also doesn’t increase the level. <\/p>\n\n\n\n
For instance, you see the patient because they have an ingrown toenail but do a full system review. No extra credit for documenting on all the exam components when they are not required. <\/p>\n\n\n\n
Sometimes documenting the above information is warranted when it shows the provider’s thought process and how they came to a decision regarding the diagnosis and plan of care. <\/p>\n\n\n\n
How can you know how to maximize billing without understanding the requirements for each of the CPT codes in the nursing home. If you are going to bill for each level, you will need to know the criteria for each. <\/p>\n\n\n\n
There are three CPT codes used for admits to the facility. With medical visits, these visits are done by the doctor assigned to the patient. They include 99304, 99305, and 99306.<\/p>\n\n\n\n
CPT Code 99304<\/strong> is a detailed visit with straightforward medical decision-making. <\/p>\n\n\n\n
How long is a CPT code 99304? 25 minutes<\/p>\n\n\n\n
CPT Code 99305<\/strong> is a detailed visit with straightforward medical decision-making. <\/p>\n\n\n\n
How long is a CPT code 99305? 35 minutes<\/p>\n\n\n\n
CPT Code 99306<\/strong> is a detailed visit with straightforward medical decision-making. <\/p>\n\n\n\n
How long is a CPT code 99306? 45 minutes<\/p>\n\n\n\n
CPT Code 99307: <\/strong> is a straightforward medical exam with a problem focus. The patient is either stable, recovering, or improving.<\/p>\n\n\n\n
How many minutes does a 99307 visit take? 10 minutes total time. <\/p>\n\n\n\n
CPT Code 99308<\/strong>: is for patients that are not responding or have minor complications. This CPT code is an expanded problem visit and is focused.<\/p>\n\n\n\n
How many minutes does a 99308 visit take? 15 minutes of total time.<\/p>\n\n\n\n
This CPT code is used for patients who inadequately respond to treatment or have developed a minor completion. <\/p>\n\n\n\n
CPT Code 99309<\/strong>: is used for patients with significant complications or new problems.<\/p>\n\n\n\n
How many minutes does a 99309 visit take? 25 minutes of total time. <\/p>\n\n\n\n
This CPT code is used for patients requiring a detailed medical examination with moderate complexity. The patient has developed a significant complication or a significant new problem.<\/p>\n\n\n\n
CPT Code 99310<\/strong>: is for a Significant new problem requiring immediate attention, high complexity visits. CPT code 99310 is for unstable patients or patients that have developed a significant new problem requiring immediate medical attention.<\/p>\n\n\n\n
How many minutes does a 99310 visit take? 35 minutes<\/p>\n\n\n\n
CPT Code 99315<\/strong>: This is a discharge code used for visits that take less than thirty minutes. <\/p>\n\n\n\n
CPT Code 99316<\/strong>: This is a discharge code used for visits that take more than thirty minutes. <\/p>\n\n\n\n
CPT Code 99318<\/strong>: is used for the annual exam of patients ad is a comprehensive exam with low to moderate decision-making complexity. The patient is usually stable, recovering, or improving.<\/p>\n\n\n\n
How many minutes does a 99318 visit take? 30 minutes. <\/p>\n\n\n\n
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