Author Topic: Help with Coding Requirements for 99334 and 94760  (Read 5812 times)

Podiatrist

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Help with Coding Requirements for 99334 and 94760
« on: May 01, 2019, 11:26:26 PM »
Hello, new to the forum and in need of some help and insight

I am a podiatrist and work for a company that provides services to long term care facilities.  I have worked for other companies providing similar services and they always used 99304/99307 for coding for our services in addition to the procedure codes 11720/11721.  I was always instructed that to bill 99307 I had to find a new problem.  This current company uses 99324/99334.  Are these appropriate for assisted living/adult day care/independent living centers when the correct POS code is used in addition to 99324/99334?  Also, every established patient they advise using 99334 in addition to the procedure code 11720/11721.  By my understanding, to bill an E/M code (99334) for an established patient a new and separately identifiable problem needs to be present.  We are always following up, for the most part, for the same problem which is mycotic toenails (11720/11721)  So every established patient irregardless of a new problem is being billed 99334 and 11720/11721.  This seems wrong to me but I am very "green" when it comes to billing and coding.  This seems like over-billing.  Is it?  Am I missing the details of how this code can be used?  The company has been in business for 8 years and without an audit by my online investigation but this just seems outside of what my previous employment has instructed.

Also, just today, we were asked to bill all patients 94760 (for pulse ox) in addition to 99324/99334 and then our procedure codes.  Our assistants use a finger pulse ox.  First off, taking the pulse ox by my understanding would be standard collection of vitals included in the E/M code and so to use 94760 would be an attempt at unbundling, despite the reimbursement being nominal and likely to be denied, so why do this?  Additionally, to bill this code the chart would need to have documentation for its medical necessity of which there is none for podiatry as obviously I am treating feet and anything respiratory is out of my scope of practice.  I am very confused by this tactic.  What is going on here that I am missing?

I don't want to sway opinion, but I will admit the company seems to be run very sloppily and by people who really don't understand the intricacies of health care billing/coding and just plan regulation and oversight.   

I really would appreciate any information and clarification good and bad.

Thanks

Michele

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #1 on: May 02, 2019, 05:28:53 PM »
An E&M can be billed if there is a separate and identifiable reason for the E&M from the other services being performed.  If you do not have access to the patient's chart (which most billers do not) you would not be able to verify that and have to go on what is given to you.  The 99307 is not for "new problems" but if an exam is needed separate from the other services.  So as long as the patient's condition warranted that E&M separate from the 11720-11721 then it would be appropriate. 

The 99324/99334 is the E&M code for domiciliary or rest home visits.  Since it is the patient's home 12 would be appropriate.

As for the 94760 it certainly can be billed separately if appropriate but I would question why the podiatrist is doing it.  We have billed for podiatrists who go into skilled nursing facilities but they never did a pulse ox.  Most insurances consider it as part of the E&M.

You are in a tough position because as the biller if you are aware that things are being billed inappropriately you are just as liable.  I understand providers want to be reimbursed for all they are entitled to but it does sound like what you are describing may be crossing the line.  Have you expressed your concerns to them?  I would advise them that you are concerned they will be flagged for an audit with the way things are being billed.  Maybe they are unaware of the guidelines for billing a visit with every 11720-11721?

In any case if you are concerned, then you do need to make sure that what is being billed matches the services being performed and what is indicated in the chart. 

 
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Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #2 on: May 02, 2019, 10:34:30 PM »
I am actually the provider, podiatrist, of this original post.  We don't get much for billing/coding education.  Much of what I have learned/know is from working for companies that have been internally auditing my charts and then offering their assistance/knowledge.  I have moved on to this company and they are using the 99324/99334 E/M codes whether the patient is seen in an A/L, I/L or adult day center etc.  It's always 99324/99334.  Also, they tell me EVERY established patient should be billed a 99334 even when I am following up for the same problem which is mycotic toenails in most cases.  This does not line up with what I have been told in the past.  Namely that another E/M code is only applied when attending to a new problem.  So following up for mycotic toenails but patient now complains of heel pain let's say.  Ok so now we can apply an E/M code in this case as a new problem for an established patient.  This company blankets every established patient with a 99334 code.  So by your explanation, it goes along with my gut feeling that this if VERY incorrect billing.  How have they not be audited for this.  They have been in business for 8 years and employ about 20 podiatrists all that tow the line and apparently I am the only one that is questioning their tactics as informed by administration.  So in other words, I should be concerned, I know legal advice cannot be offered.  But from a professional billing/coding standpoint, this should be concerning is what I gather?  I literally don't think they really have a billing department as I am always told when I present questions/emails to the "billing manager" that she does not cover "clinical" issues and my questions are always answered by the COO of the company.  I know red flags all over.....

The whole pulse ox thing makes no sense to me as described, it is collection of vitals and therefore incorporated into any E/M.  I am not complying with their suggestion on this.


Michele

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #3 on: May 03, 2019, 11:06:51 AM »
I answered you PM you sent.  Hopefully that will help!
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kristin

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #4 on: May 03, 2019, 03:49:32 PM »
What the company you work for is instructing you and the other podiatrists to do is most definitely wrong, and eventually an audit will happen, it is just a matter of time. Unfortunately, I have heard your exact situation numerous times over the years, from other podiatrists employed by mobile companies and group practices.

SNF/ALF/ILF podiatry services are a part of the OIG work plan almost every year for good reason. The OIG and CMS are well aware that fraudulent billing is high among podiatrists, especially as how it relates to services at ALF/SNF/ILF. This is why I say it is just a matter of time before the company you work for is audited. Medicare puts out Comparative Billing Reports, and if the provider/company/practice doesn't get in line with others in their area/the nation, that is usually when a RAC audit is initiated. Commercial insurances who have Medicare Advantage plans do the same thing.  Other circumstances that can prompt an audit are patient complaints to the insurance company/state insurance commission, and Qui Tam cases, to mention some others.

Often, companies like the one you work for issue blanket billing mandates, such as what you describe with the 99334/99324 and 94760, and sadly, most of the providers go along with it, either because they have never taken the time to educate themselves properly on billing and coding, or because they just don't care, and need the money, or they do know it is wrong, and still do it to stay employed and not rock the boat. 

Kudos to you for refusing to go along, questioning their tactics, and for educating yourself, but I feel staying employed by them puts you at risk, and you should be very concerned. Unless you personally submit your own claims to insurance (every claim has your signature on them, stating that the claims are true and accurate) you have no way of knowing WHAT they are billing out for you. They could be adding E/M codes and pulse ox's and anything else, without your knowledge. Then an audit happens, you think you are fine since you know you have been billing correctly. But the next thing you know, YOU owe Medicare for services you never knew were being billed under your name, and it just gets worse from there. 


CMS and the OIG are very clear in their publications on the subject matter of fraud. Anyone can find this information on the internet, as well as through other methods. Every doctor/biller/coder/practice manager/company compliance officer should read these publications, and fully understand the information they provide. If they need further help, there are individuals such as healthcare attorneys who can assist them.

As far as your concerns about what they are telling you to bill, when each encounter stands on its own, and thus the coding/billing has to reflect that:

1. Pulse ox 94760 is out of your scope, and is generally included in E/M even if it was within your scope. I can't think of a single insurance that will pay for this code when billed by a podiatrist, and it does nothing but raise red flags with the insurance. So your company is practically issuing Medicare an invitation to audit them by billing it out. But they just see it as a potential extra few dollars per patient in their pockets, is my guess, and can't see the actual long-term ramifications.

2. NH/SNF E/M codes are 99307-99310 for podiatrists (you cannot use 99304-99306, since you are not the attending doctor). They are only used in NH and SNF's. You cannot bill a 99324 or 99334 for patients in a NH or SNF. Even if your company changes the POS to be something else that a 99324 or 99334 IS allowed for, Medicare cross-references the facility listed where the services were provided, and will deny E/M codes billed with wrong POS, or that don't match what they have on file. So again, they are just inviting Medicare to audit with that tactic.

3. ALF/Custodial care/Rest Home codes are 99324-99328 for new patients, and 99334-99337 for established patients. These are not to be used for private residence/home visits, and certainly not NH/SNF visits. Whether or not you use one of these codes, and what level code you select, is based entirely on each separate DOS, and if you met 3/3 elements of the code for a new patient, or 2/3 elements for an established patient. You absolutely cannot assign a "one code fits all" be it a 99324 or 99334, and in many cases, especially for established patients, you will not assign an E/M code at all. So for your company to tell you to do this "blanket" code selection is the third invitation they have issued for an audit.

4. Independent Living codes are the same as Home visit codes, since the patient is in a private residence/apartment. Those codes are 99341-99345 for new patients, and 99346-99350 for established patients. They are always billed with POS 12, for Home. Again, code selection is based on meeting the required elements. You do not bill any of the codes I mentioned in #3 above for IL visits, contrary to what your company is telling you to do.

On a personal note, because I have run a podiatry practice for the last 26 years, and do side billing/coding work for several other podiatrists, it really ticks me off that situations like what you describe, and that I have heard about over the years as I said above, give the ENTIRE profession a bad name. They are literally the bad apples ruining it for you, and the many other podiatrists I know who are ethical.









« Last Edit: May 03, 2019, 03:52:36 PM by kristin »

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #4 on: May 03, 2019, 03:49:32 PM »

Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #5 on: May 07, 2019, 09:41:48 PM »
So after questioning their 94760 tactics this is the email I received from their billing manager and supposedly CPC.  I trust everyone's opinion on here much more than I am trusting this individual as she also stands behind charging every established patient a 99334 whether there is a new problem or not. 


Good Day,

I wanted to make sure everyone understood where I stand as far as capturing all revenue possible from the standpoint of compliance (record every thing performed) to ensuring reimbursement.

The pulse ox is considered included in the E/M based on the RVU's.  However, there are a few insurance companies that pay for it.  As a matter of exact fact... AHCCCS pays $3.16 cents and Health Net pays $3.43

It is important to document and charge for every thing that a provider performs.  Whether or not it is being billed out, billed out with a zero charge or not is our business concern, nothing for a provider to question or worry about.

 I have done it myself and trained where I know it is possible and of course it makes perfect sense that the provider would also list the medical necessary diagnosis first.  I mean I own a health care billing company, it is always how it has worked.

I hope this helps.  We need to charge for the pulse ox if it is performed and truthfully it should be.


PMRNC

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #6 on: May 08, 2019, 10:13:12 AM »
 
Quote
she also stands behind charging every established patient a 99334 whether there is a new problem or not.

Right there would be a red flag for me if in your shoes. If they put that in writing, add the orange jumpsuit to the red flag.

Kristen mentioned the pulse ox being out of your scope..that's true, it should not be billed seperately. I personally would use this email and any other documentations of their methods you explained and get out of this contract. They say:
Quote
"The pulse ox is considered included in the E/M based on the RVU's.  However, there are a few insurance companies that pay for it."

LEGALLY speaking what they are doing is fraud..coding and unbundling for the sake of increasing revenue not billing appropriately. Nevermind the snarky remark of telling you it's
Quote
"nothing for a provider to question or worry about.

Quote
I mean I own a health care billing company, it is always how it has worked.

So do I but no, that's not how it's always works. They are not taking into account proper coding for the scope of your licensure, they are "routinely" billing codes (99334) regardless of documentation. You have enough there to decide if it's worth it to stay with them. 

Out of curiosity... do they Code from documentation first before billing or do you give them coding encounter?
Linda Walker
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Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #7 on: May 08, 2019, 11:09:17 PM »
They do not code from documentation.  I do not even think they look at our documentation.  I literally think they just bill verbatim from the "super bill" in our EMR without evaluating documentation content as I asked when I will have some internal audit of my charting as I have had at other employers and they said they do not do that and I also asked is my documentation meeting the codes and they said if your super bill reflects what you feel is appropriate then the coding is appropriate.  I have not been billing the 99334 on any patient for 6 weeks now and have not had anyone ask my why.  I have no clue what is going on.

I just found out today when asked who our HIPAA compliance officer is that they do not have one and nor do they have any compliance/regulatory affairs officer.  I thought that was a requirement???

I am in contact with a lawyer as of today and her head was spinning with the details I was explaining.  I am actively seeking employment elsewhere and as of now the lawyer is asking me to remain with them until she can get her head around everything and then she will advise soon if the best option is to quit or to assist in a whistleblower action and in which case she would need further information from me. 

I have used the info presented here to the administration without revealing the source etc....basically presenting it as my "own" knowledge but it has had no effect on them


Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #8 on: May 08, 2019, 11:18:12 PM »
Thank you everybody who has provided info and content for this.  It is greatly appreciated for my own education but also for my current situation.  I am going to continue to post details to it as I gather them, I am actually surprised they (the company) are putting alot of this in writing via email to us.  It is almost like they are sealing their fate as it is in writing what they are asking us to do.  I can only guess that they are incredibly ignorant that what they are doing is wrong or so bold that it does not concern them. 

Please if there are any further questions of me please post and I will provide the answers/info I am aware of.  This is definitely an education by fire....

Thanks again

kristin

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #9 on: May 09, 2019, 11:00:29 AM »
Linda is absolutely correct:
Quote
LEGALLY speaking what they are doing is fraud..coding and unbundling for the sake of increasing revenue not billing appropriately.


And the supposed CPC who happens to be the billing manager is not only totally pressuring you and other providers to do this, she really seems to think it is perfectly okay because she personally has done this before and owns a billing company. Unbelievable! She is a certified coder and doesn't understand or follow one of the most basic rules of coding...you don't unbundle codes for higher reimbursement. Which in the case with the pulse ox for the two insurances she has found that will pay for them is peanuts. Just like I said in my original post...an extra few dollars. That will, as Linda said, have people ending up in orange jumpsuits.

An equivalent example (which is within your scope of practice) is if you were to perform an ID on a paronychia, on the left lateral border of a great toe. Even if you remove the nail border in the course of the ID, all you bill for is the ID, and not the partial nail avulsion, since that is included already in the ID. Based on her faulty logic, she would tell you to bill both, would slap a 59 modifier on the codes, and they would both pay, and it would be fraud. I use this example because nail avulsion codes are often the most fraudulently billed codes by podiatrists.

Since your attorney has advised you to stay put for the time being as she decides on a course of action, I would STRONGLY advise that you DEMAND this company provide you with all past and current reports showing EXACTLY what they have submitted on your claims to each insurance. You may have billed one way on the super bill in the EMR, but they could be adding whatever they like, as I said before. These reports are extremely easy to get from any billing software they may be using, and once you get them, you need to look for anything suspicious, and then cross-reference anything that looks wrong with the super bill in the EMR.

This is CYA time for you, because contrary to this comment from the billing manager:
Quote
Whether or not it is being billed out, billed out with a zero charge or not is our business concern, nothing for a provider to question or worry about.
, it absolutely is your concern, because it is your name on every claim.

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #9 on: May 09, 2019, 11:00:29 AM »

Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #10 on: May 09, 2019, 12:57:08 PM »
I am going to do that today Kristin.  Thank you for that info, that actually seems very important to my "case" and the lawyer at this point as not advised of that but we have only had one meeting, it was suppose to be a 30 minute consult and we ended up going for 90 minutes.  And is this information they have to provide if I ask, can they withhold it?  I assume they will deny my request but is there a statute anyone knows of or a ethic etc that they have to provide it.

To add even more intrigue to this story, I found out yesterday when I called Medicaid as I had a sample of patients I wanted to actually see what the claims were....I found out I am not even enrolled in medicaid with this company and have no active enrollment paperwork.  I then called Caremore and Humana and found the same.  Medicaid and Caremore are the bulk of the patients I see.  I have no clue what they are doing and how they are billing for services.  Could be billing under another providers info????  I didn't have any claim numbers so none of the insurances could process my questions further.

I want to kind of clarify some comments I made as they could be taken wrong in a few posts.  I have worked for the company for just over 2 months now.  The codes they apply were different than other places I worked.  I read the language of the 99335/99335 and stupidly self-interpreted it and it states "....a problem focused interval history..."  I figured "oh, we see the patients every 61 days for nail care when medically necessary and so that is an interval history, yes 99334/99335 can be used.:  My instinct never quite liked my answer I guess as I reached out via email to the billing manager after a few weeks and she overly enthusiastically said I was doing everything correct and it was just an odd phone call....smart she didn't put it in writing in hindsight.  So that raised my suspicion more and then I started looking for answers and went to multiple forum sites before finding this one and finally getting people to answer.....so thank you everyone.  Anyways, point being I was billing as instructed for about 3 weeks before I stopped and it either has gone unnoticed or they aren't willing to challenge me now that I have changed course for the last 6 weeks.  But I assume I'm on the hook for the past bills, I feel I should ask them to resubmit any claims prior to me doing this? 

Also, the lawyer asked to not play all my cards with the company yet so I have not revealed obviously the lawyer but also that I have firm documentation from this site on their tactics being wrong and so I am "using" the information as my "own" but I definitely want to credit everyone on here for their expertise and information.  Thank you for everything.




 

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #11 on: May 09, 2019, 01:00:38 PM »
Actually, now that I know that I am not enrolled on at least 3 insurance carriers I wonder if they have any reports for me?  I am still going to ask for the info you advised Kristen and there are some other insurances I have seen but just didn't have the time to call and check on.  Could get very interesting if I'm not enrolled in anything........

PMRNC

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #12 on: May 10, 2019, 09:48:10 AM »
I would ask for a full audit of all your billing/claims. Doesn't matter which carrier or whether contracted or not. I'd put your request in writing and date it with request for them to complete it within 10 days (seems reasonable).  One other thing to consider, even though you are employed by the group, as Kristen mentioned, your name goes out on claims where you rendered services. With that said you may want to clarify with the group the position of the billing company in regards to "coding".

This is just my opinion from doing this almost 30 years, and I've seen situations like this before, but whistleblower cases involving attorney's take forever. You should probably only worry about you right now and see if possibly you can get the group to "see the light". ;)
Linda Walker
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Podiatrist

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #13 on: May 10, 2019, 01:56:16 PM »
I don't like orange and definitely don't look good in it.

I am reaching out to them for the information on my billing/coding and to audit my claims.  We will see if they provide it/do it. 

My lawyer really isn't pushing for the whistleblower as it is time consuming and labor intensive but she is probably reaching out to the AG to file a complaint.  She  advised to keep trying to get policy in writing but I think they are starting to get a little scent of what I am doing.  She said to expect to get fired but I guess that could work in my favor in some manner, at least from a legal standpoint.

In the meantime....job hunting as quickly as possible.


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Re: Help with Coding Requirements for 99334 and 94760
« Reply #14 on: May 10, 2019, 02:06:43 PM »
Oh, and the company was asked to never return to a facility yesterday as many of the residents who are not their own POA anymore, signed consent to treat paperwork and other paperwork related to accepting hearing aids and glasses (I heard a few resident's who are legally blind were dispensed eyeglasses which will obviously do them no good and was not medically necessary)  Numerous families when they got the bills were confused as the designated POA was not informed of the need for these and word got out this happened to many people so the families all convened with the administrator at the facility and found that the consent forms were signed by "mom/dad" who has dementia/alzheimer's etc and therefore not there own POA.  So from top to bottom this place is a scam.  I can't believe they have made it 8 years without an audit/investigation, but it seems to all of a sudden be showing some cracks and it is probably only a matter of time.

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Re: Help with Coding Requirements for 99334 and 94760
« Reply #14 on: May 10, 2019, 02:06:43 PM »