First, I want to correct a misstatement I made in a recent column regarding incident to billing by an extender (Dermatology News, July 2016, p. 1) When an extender sees a patient for an established problem, they can bill at 100% if there is a supervising physician in the house, AND it should be under that supervising physician’s number – NOT necessarily by the physician who saw the original problem. This change was promulgated by the Centers for Medicare & Medicaid Services in the proposed rule, and everyone thought it was a done deal, but the billing remained unchanged in the final rule. Apologies for any confusion.
Coding
As all of you know, several years ago, CMS unilaterally decided (after an Office of Inspector General study) that consultations were really just new patient visits and stopped paying for consultations. Visits are now coded with new or follow-up patient evaluation and management codes. This is unfortunate, because a consultation pays more, and importantly, does not establish the patient as a patient in your practice for the next three years. If originally billed as a consultation, the patient can be seen back for another problem in the next three years, and be billed for a consultation, or a new patient as appropriate. Therefore, it is a big advantage to be able to bill for a consultation, assuming another doctor has asked your opinion and you call with or send them a report of your findings.
Just because Medicare says you cannot bill for consultations does not mean that all insurers are the same. The consultation codes are still in the CPT code book and your contracts with private insurers probably stipulate that the insurers must comply with CPT convention. In this case, you can bill your private insurers (including Medicare Advantage Plans, which are private insurers) for consultations when your documentation supports it. Be aware, that some of the more popular electronic health records that perform billing automatically default to a new patient visit, when a new patient consultation might be more appropriate.
While discussing evaluation and management coding, you should be aware that 97% of visits billed by dermatologists are level 3 or lower. This means that, even if your EHR can propel you to heights unimagined before, that it could become a problem. You cannot bill a higher level beyond what is medically appropriate. For example, you don’t usually need to do a full-body skin exam during an acne follow-up.
I’ll never forget the poor soul who explained to me that she was being audited “because all my visits were level 4 or 5, and the software agreed with it.” The software company (or the consultant) will not be sharing the joys of an audit with you. You can do a quick and easy check of your evaluation and management patterns, compared with others by checking either of the online Medicare databases, the Wall Street Journal’s “ Medicare Unmasked ” site or the “Treatment Tracker” for Doctors and Services in Medicare Part B, on the ProPublica website.
While you are there, check your procedure numbers against others. Are you a freeze-y king? Are you the shave master? There are often valid and justifiable reasons for unusual billing patterns. If you are an outlier, make sure you have a good reason to be there. For example, I am in the top 10% paid per patient visit in the state of Ohio. The reason is that I treat only skin cancer, and it usually involves surgery. The world is looking at these data. So should you.
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Write to him at dermnews@frontlinemedcom.com.
