430
This is why many clinics will limit the number of diagnoses you can list on your
charge tickets for billing purposes to 4.
Pillar 3b: Data (Both Amount and Complexity Considered)
For surgeons, it is often tough to get to a high-level visit based on data. Different
activities are assigned “points.” A level 5 visit requires four points, a level 4 visit
three points, a level 3 visit two points, and a level 2 visit one point. The activities
that earn points are a bit deceptive. There are five ways to earn one point: ordering
or reviewing a lab (but you still only get one point even if you do both and review a
gazillion different labs), ordering and/or reviewing radiology report (again only one
point even if you review several reports and order several new ones), ordering and
reviewing “other” tests (EEG, EKG, PFT, echo, cardiac catheterization, noninvasive
vascular studies), doing a discussion of test results with performing physician, and
making decision to obtain old records or obtaining history from someone other than
patient. There are two ways to earn two points: personally review a film, specimen,
or tracing (again only two points if you look at six different films and specimens and
tracings), and review and summate old records or obtain history from someone
other than the patient.
The thing to remember here is if you personally review a film, specimen, or trac-
ing, it is possible to get to a level 5 visit.
Pillar 3c: Risk (This Is the LeBron James (King) of Billing)
Risk is the trump element and should be the basis for your billing when in doubt.
Table 23.3 lists minimal-, low-, moderate-, and high-level risks which designate
level 2, 3, 4, and 5 visits, respectively. Note the table is split into three columns of
presenting problem(s), diagnostic procedure(s) ordered, and management options
selected. If you can obtain one bullet in high risk for any column, you can bill level
- Thus, it is worth reviewing the table and seeing where things you commonly do
fall in the table.
Noteworthy level 2 categorizations include gargles – you should definitely make
an effort to recommend gargles soon. More seriously, noteworthy level 3 categoriza-
tions include recommending over-the-counter drugs or treating two or more self-
limited problems or one stable chronic illness. Wait, What? I said diagnoses (pillar
3a) were determined by number of problems?!? Indeed there is overlap between 3a
and 3c, and this definitely adds to the confusion.
Noteworthy level 4 visit includes prescription drug management or opting for
minor surgery with risk factors or opting for major surgery without risk factors. This
sentence should prompt two questions.
Q1 What is the difference between minor and major surgery?
A1 Global period (a procedure with a 90-day global period is considered major);
< 90 day global is minor. A vasectomy has a 90-day global which means you get
paid only once for all the work you do in relation to the vasectomy for 3 months.
T.S. Köhler