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Help with Coding Requirements for 99334 and 94760

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Podiatrist:
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:
 
--- Quote ---she also stands behind charging every established patient a 99334 whether there is a new problem or not.
--- End quote ---

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."
--- End quote ---

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.
--- End quote ---


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

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?

Podiatrist:
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:
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:
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.
--- End quote ---


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.
--- End quote ---
, it absolutely is your concern, because it is your name on every claim.

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