423day!!! Now for those who want to get technical, there is something called subject
to billing which is beyond the scope of the brief chapter.- Billing on time when there isn’t that much time in a day. If you are billing on
time alone (which can be done with minimal documentation – minstrels are
rejoicing), it is pretty easy to add up the numbers – 6 hours of “face-to-face”
timed billed in a 4-hours morning clinic will probably raise some suspicion
(minstrels unemployed). - Billing for consults when there is no documentation to support a consult request.
Consult notes differ from new patient visits in only three key ways:- It says at the request of Dr. X, I was asked to see this patient for problem Y.
- It says report to Dr. X at the bottom (and correspondence occurred).
- Most important there is a retrievable consult request form in the medical
record somewhere. It cannot say transfer of care; it has to say consult from Dr.
X. This component is most often missed.
Billing tip – Develop a system with your office staff that ensures this document
from the consulting provider is available and retrievable at the time of the appoint-
ment. Some clinics go so far as to not seeing the patient if this consult form is not
completed. When completed, it guarantees an average 30% increase in revenue per
encounter (see Table 23.2).
- Billing both procedure and E & M code in the same visit (use of a 25 modi-
fier). Remember that any procedure you perform has some inherent counsel-
ing built into it (that’s why it pays so much more). If performing a cystoscopy
for blood in the urine, a urologist cannot charge both a procedure and a visit
by explaining the normal landmarks during the exam. However, if bladder
cancer is found and this leads to a new discussion, it is appropriate to use a
modifier and charge for both. I make a point to let the patient get dressed
from their procedure (patients never remember anything you tell them if
they don’t have pants on), perhaps have the bladder cancer discussion in a
different room, and start a whole separate note detailing that portion of the
visit. - Billing at a high level because you wrote a lot and the patient was very “stress-
ful.” Here again, ignorance bears its ugly head – a 5-page note is only billable on
its weakest section. Time and time again, I’ve seen overbilling from deficiencies
in the history portion of the review of systems (ROS). Residents excel at missing
a complete ROS. - Billing established patients at high levels when medical decision-making
required is low. This is super important. As you read on, you will later on be
delighted (dare I say tickled pink) to discover that established visits require only
two-thirds of the basic components of billing. A great way to commit fraud is to
take a level 5 history, do a level 5 physical exam, make a level 2 decision (like
prescribe gargles), and bill level 5 – more on this later.
23 Evaluation and Management Documentation, Billing, and Coding