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Help with Coding Requirements for 99334 and 94760

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Podiatrist:
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:
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. 

 

Podiatrist:
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:
I answered you PM you sent.  Hopefully that will help!

kristin:
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.

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