PookieMD's Blog: Where Physicians Learn About the Business of Medicine

We’ve talked before about billing for phone visits.  Only a few insurance companies will actually reimburse for this, but there are benefits to keeping track of calls.  Here are the rules.

The basics:

• Telephone service applies ONLY to established patients that initiate the call.
• If the patient is seen with in 24 hours after the call, the telephone service code is NOT reported.
• If the call is about a previous E/M service (e.g. a previous visit) within the past 7 days or post op period the code can not be used, as the phone call is considered part of the previously reported E/M work.

Sounds pretty useless, right? Medicare does NOT reimburse for phone calls BUT will allow the physician to “consider” this in determining the level of the E/M code at the next visit. So, it does make good sense to document those calls, and consider them at the next visit.  FYI: telephone codes for physicians (99441-99431) and non-physician practitioners (98966-98968).

Thanks modernmedicine.com for the tips!

One of the hospitalist groups I work for has a coding specialist that examines our charts to make sure we are following the coding rules.  They read through our notes and compare them to what we coded.

Here are the things that I have gotten dinged on:

• Not putting the family history.  Sometimes it doesn’t apply (like in a 90 year old!) but according to the consultant I should list it any way.  Well, okay, easy enough.
• Forgetting to put my total time. (Duh.  Sometimes I’m just an absent minded professor!)
• Forgetting to put who asked me consult and why.  She reminded me that a consultant asking me manage a medical problem does NOT count as a consult, and that I couldn’t even bill and H&P–just another rounding code.

Ridiculous stuff the coding consultant said:

• She told me to spell out HEENT in my notes etc.  She said this will soon be unacceptable.
• She told me I couldn’t put ROS after the HPI.  To me this is the most logical place–usually the ROS is directly related to the HPI.  I have taken the great step since residency of moving the ROS after the HPI.  Sorry, but I ain’t changing!

Take away: put in the family history, document your time and remember who asked you to see the patient.  Will improved coding make that much difference? We’ll see-I doubt I’ll get paid more, but maybe my chances of getting audited will go down.

 As the Wall Street Journal announces that decreased reimbursement for physicians appears imminent under the Health Care reform that President Obama is pushing, it is time to make sure that your practice is maximizing collections.  So how do you know if your billing company is a bull dog or a pussy cat?

• Check the days in accounts receivable.    Current national average for all practices is 43 days.  The longer it takes to get your money, the more kittenish the billing company!
• Check gross and net collections.
• Check encounter averages: i.e. the amount billed vs. the amount collected.
• Check bad debt amount and amount turned over to collections companies.  Transferring 2 -3 % of  Accounts Receivable to collections is reasonable.    One practice I know of was NOT aware that their billing company was writing off a whopping 30% of the accounts receivable!
• Check references from other physicians.  Make sure the billing company has been in business for several years. 
• Benchmarks to check: total AR in the 31-60 day category should not be greater than 15 % of monthly charges, AR in the 61-90 day category should not be greater than 10% of monthly charges and AR in the 91-120 day category should not be greater than 7% of monthly charges.
• Exceptions to benchmarks: practices that are academic, hospital based, or have a significant portion of medicare/medicaid/workers comp will have longer time in AR.

The practice I mentioned in which the billing company was writing off a 30% of the AR now does their billing in house.  I don’t necessarily recommend this as billings/collections is complicated and requires dilligence and great understanding of the draconian coding/insurance morass we currently find ourselves in. 

Lesson: look carefully at what your billing company is doing, and apply benchmarks to judge the company’s effectiveness.  Don’t let your hard earned money go in to the insurers pockets!

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There’s a new hired gun in town, and it’s name is RAC.  Yup, pardner, Recovery Audit Contractor.  This new breed of watch dog is charged with auditing your medicare claims, sniffing out over payments and noncompliance of every practitionerin the United States (and Puerto Rico, for those who care.)  The expanded RAC will be in your neighborhood sometime this year.  These government hired contractors are paid by percentage of overpayments  found.  That’s right, the more errors they find, the more money they earn.  Suffice to say they will be highly motivated to find your documentation, coding and compliance errors.

So what’s a good doctor to do?  (No, throwing your hands up in despair isn’t one of the options!) Remember first that it is the physician’s responsibility to make sure documentation is up to snuff, coding is appropriate for the level of service, and that billing meets CMS guidelines. 

• Be prepared. There will be automated reviews and/or requests for chart review.  Chart review is usually initiated when an automated audit doesn’t provide sufficient information to resolve the issue.
• Know there is an appeals process, but not a simple one. It is the standard Medicare A and B appeals process.
• Consider auditing your own charts before the RAC attack begins. Find and correct errors before you get audited.
• Check the link to see when RAC will arrive in your region, and create a time line to insure compliance.
• Know what the RAC is looking for: duplicate services, services that were not indicated, uncovered services, incorrect coding.
• Respond in 45 days to medical records requests.  (BTW–the RAC is required to pay for copies of records.)
• Know the penalties:  interest will be charged on amounts owed back to  the Feds for over payments.

So, add this to your  burgeoning to do list.  As if medicare payments  weren’t small enough!  The biggest losers are hospitals that rely on Medicare A. Next up is, of course, the primary care doc. How many specialists rely heavily on Medicare?

For more info visit Medicare Update written by Health Care Attorney Michael Apolskis.

My trusty health insurance, for which I pay handsomely, (yes, I am self-insured) sent me an email titled, “Calls could cost you.” It states that calling your physician may cost you. I quote:

“Many times people call their doctor to ask a question, resolve a concern, or ask about a referral. Traditionally, doctors haven’t charged to answering these questions. In certain cases, that’s changed.

New rules have been established that allow doctors to charge for telephone consultations in some circumstances. To be a billable call, the patient must not have been seen by the doctor for a week before the call or within 24 hours after the call. If the doctor provides services that could have happened at a regular office visit, then the doctor can submit a claim. The doctor must let the patient know the call isn’t free and that he or she intends to bill.

If the doctor does submit a claim to Humana, we’ll treat it as if the doctor filed a claim for an office visit. So if your benefits have co-payments for an office visit, you’d owe the doctor your co-payment for an office visit. If your Humana plan has a deductible, we’ll apply the allowable claims costs to your deductible. You’ll pay the allowed charges, unless you’ve met your deductible.

These rules don’t apply to most calls people make to their doctor. But Humana wants you to know that under current national rules, doctors can bill both Humana and their patients for some telephone visits.

It’s important to know that calling your doctor could cost you in some circumstances. If you’re aware of the rules, you could save yourself some money.”

Hmmm, this is interesting. What patients should you manage over the phone? What are the legal ramifications? Ethically, what is involved in charging for phone calls?  God forbid, are we behaving like lawyers? I don’t know about you, but I always prefer to see a patient rather than prescribe over the phone. I know some patients absolutely refuse to come in, “I don’t have time,” but I am loathe to diagnose and prescribe over the phone.    (And these are the patients I think are most likely to sue-they seem to be looking for a way to work around the system.)

My take-
If a patient is ill they need to be seen.
If you are going to bill for phone calls, and it is certainly justified in some cases, be impeccable in your documentation.
Establish criteria ahead of time of what sorts of phone calls you will bill for, and what cases ABSOLUTELY must be seen in the office.
Teach your staff how to triage calls.

Following are the codes for phone calls.  (From From the January ACP Internist, copyright © 2008 by the American College of Physicians.)  If anyone is doing this, I would love to hear back as to which insurers are reimbursing, and how you determine which patients are appropriate to be managed by phone–e.g.  coumadin management? 

99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
99442: 11-20 minutes of medical discussion
99443: 21-30 minutes of medical discussion

As to liability, here are some guidelines from CRICO/RMF, the medical malpractice company for the Harvard Medical Community.  (http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/telephone-technology/faqs.aspx#Q31)

“Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.”

Good luck with this!  I think that coding for phone calls has a lot of potential for good and bad, and would tread lightly.  And just to make you smile, I got an automated phone call from Humana while I was writing this, encouraging me to visit their web site, where I could get medical advice “tailored for me.”  Shoot, who needs an MD?  Just throw up a web site with generic advice and call it a day!