Saturday, August 25, 2012

Codes the Government Misunderstood

     Every now and then I discover a medical code that has sneaked into the compendium under the radar.  Medical codes are slippery things.  Insurance companies are constantly adding and subtracting payable codes without much fanfare.  Medicare is the worst culprit, and Medicaid is close behind.  The government loves complexity, and the rest of us get entangled in it.
     There are many new codes, but they tend to be specific to certain insurance carriers.  For example, W9881 used to be the code for a well-child exam--but only for Medicaid patients.  Q0091 used to be a code for obtaining a Pap specimen during a gynecology exam--and at first could only be used for Medicare patients, then became acceptable for Blue Cross, and of late may no longer be okay to bill to Blue Cross.  Keeping up with coding rules is like tracking  a whirlwind.  The incessant circulation of new and retired codes accounts for Medicare's coding "guidelines" totaling more than 200,000 pages--and it's why Medicaid has a completely dissimilar 200,000 pages of coding rules.  Blue Cross, Aetna, Tricare, CMS, Champus, and dozens of other insurance carriers have their unique sets of criteria for billing.  It's a source of endless frustration for medical providers, most of whom relegate the task of billing to outside companies, thereby sacrificing revenues in exchange for simplicity.  Billing companies do not go to the trouble of chasing down insurance company denials.
     Last year I discovered two codes that corresponded to services we had provided patients--but not billed.  It makes sense, when this happens, for me to back-code for the work I've done once I confirm that it's considered a compartmentalized service, separately payable.
     Doctors should make it a policy to hunt down new codes because otherwise we miss out on legitimate revenues.  I keep abreast of codes by reading practice management journals which have columns dedicated to coding.  There are newsletters about coding, too, but most of them have not been worth the subscription cost, as they reiterate what I already know.  The coders who write them don't report new G-, W-, Q-, A-, and L-codes that are added by specific insurance companies, or undrape codes for niche services.  These expensive publications must be compiled by non-physicians, because they give me the impression of people who are observing the world of  medicine from outer space.
      Three codes I discovered last year were 99441, 99442, and 99443.  They represent charges for telephone sessions with patients.  Every day dozens of patients phone to go over lab test results, discuss side effects of medicine, ask if certain symptoms warrant a visit, or get advice about how to manage early signs of illness without a full-fledged exam.  It makes sense for insurance companies to pay for telephone "visits" because they cost much less than appointments, and save trips to the emergency room.  Blue Cross and other private insurance companies have calculated the overall gain for them by paying nominally for phone calls, and therefore decided to cover telephone visits about clinical situations.  Some insurance companies, similarly, have added e-mail correspondence to the list of covered services. I didn't learn about this additional source of revenue until many months after the telephone codes had been approved for coverage.
     Therefore, once I knew about the telephone codes I asked several front-office staff to cull charts for patients whose insurance carriers covered telephone visits.  Their charts already contained written documentation of telephone calls, because we document every communication with patients.  (An exception is calls to schedule appointments, which don't qualify as telephone "visits").  We billed the 99441-99443 codes for those dates of service all at once, as soon as we had located the notes in the charts.  It is acceptable to "back-code" for services like this as far back as three years.  We billed for documented phonecalls for the prior fourteen months--back to the time when the codes were approved for payment by some insurance carriers.  There were enough to make the data collection worthwhile.
     Medicare and Medicaid don't pay for telephone visits, instead instructing providers to roll phone time into the next office visit.  A concession to family doctors, in the mid-1990's, allows us to bill for the time we spend with patients (if more than 50% of a doctor's time is spent counseling a patient, then coding should represent this time, rather than the exam and analysis required to treat the patient).  Auditors don't acknowledge this when they review our charts, considering it an anomaly, even though I am careful to document, "More than 50% of this visit consisted of counseling about...."  Such is the hypocrisy of the insurance reimbursement system.
     Blue Cross and a few other companies do pay for telephone visits, so the back-coding we did last year was above-board, resulting in small but measurable payments in due course.
     I also billed retroactively for G0396, a code that designates alcohol or substance abuse assessment.  My staff identified documentation that proved we had performed this assessment on patients, once I learned that a separate billing code covered it, and we transmitted the charges correctly.
     Medicaid does not cover the G0396, but it does cover contraceptive counseling--so I may be able to bill for the provision of this service, if the documentation in our patients' charts justifies it, and if there aren't restrictions on its use.
     Last month two FBI agents questioned one of my past employees, now an eighteen-year-old college student.  She worked part-time at my clinic during her last two years of high school, and she was one of the employees who pulled charts for the retroactive billing.
     The agents met her as she was leaving a class at Florida State University, and said:  "We need to talk to you about Dr. Colasante."  When they asked if she had been asked to do "special projects" they were referring to her assistance one week identifying documentation in the charts of telephone calls and substance abuse assessments.  There was no wrongdoing associated with this task, and it was a legitimate project.  Did we bill when we hadn't provided a service?  Of course not.
     Most doctors don't have time or the inclination to search out codes that might improve reimbursement for the work they already do.  It is odd a doctor's time should be fragmented by insurance companies into separate categories:  smoking cessation counseling, diabetes counseling, substance abuse, telephone visits, emergency services, after-hours appointments, and stabilization of critically ill patients are all supposed to be coded and paid as separate items, even though they are part of the "visit."   Unless physicians keep up-to-date with these codes, they will be under-paid for the work they do.  I keep abreast of codes as they enter and leave the various insurance formularies, and I use them in every case if a patient's visit warrants it, and I have enough documentation in the chart.
     I hope the FBI agents review all my charts, because they'll see that every charge correlates with a service for that patient on the correct date of service.  Maybe retroactive billing for legitimate services is their idea of money laundering.

    

1 comment:

  1. Wonderful blog & good post.Its really helpful for me, awaiting for more new post. Keep Blogging!









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