[BrianL99]

Originally Posted by golfing eagles

S
OK, that's your basis. My basis is using, documenting and reviewing these codes for 35 years. Please don't even think about equating the two.

It's clear that one of the crippling aspects of healthcare in the USA (& perhaps elsewhere), is way to much time is spent on documentation, management, paperwork and tailoring care to meet obscure insurance criteria.

It's unfortunate, that our healthcare system has been highjacked by regulators, insurance companies and lawyers (who bill the same, whether they're in court or sitting on their butts, "thinking").

[biker1]

I have seen the term "long visit" on EOBs from visits to The Villages Health before (pre Medicare age).

I also had a Medicare insurance question about two years. I had several conversations with my PCPs billing folks, my Supplemental Plan, and Medicare itself. The question was "why did an annual visit (to essentially go over blood work) count towards my Part B deductible and carry a $20 copay? I was under the impression that these "wellness visits" were covered 100%." The only person who was able to answer the question was my PCP. What she told me I found interesting. She stated "if you come in for an annual visit and don't have any issues to discuss then it would be coded as a "wellness" visit and would be covered 100% without impacting my Part B deductible and being charged a copay. If I discuss any issues bothering me (i.e. my knee is getting worse) then it gets coded differently and would count towards my Part B deductible and might have a copay (I have Plan N)". Who knew ...

Originally Posted by golfing eagles

Short answer to first question: THEY DON'T. There is no "long visit" There is extent and complexity of visits. Here is the CPT description and documentation requirements for 99215:

[golfing eagles]

Originally Posted by BrianL99

It's clear that one of the crippling aspects of healthcare in the USA (& perhaps elsewhere), is way to much time is spent on documentation, management, paperwork and tailoring care to meet obscure insurance criteria.

It's unfortunate, that our healthcare system has been highjacked by regulators, insurance companies and lawyers (who bill the same, whether they're in court or sitting on their butts, "thinking").

And that is EXACTLY the problem. Kudos! The coding system encourages documentation over patient care. It siphons off time from patient encounters to entering data.

Why? Because the bureaucrats, regulators and lawyers don't know enough about medicine to be qualified to apply a band-aid, so they have to reduce everything to bean counting.

This is my main reason for retiring 10 years ago---I always stated that when I was spending more than 50% of my time on paperwork, I was done---and the regulators managed to achieve that goal.

[golfing eagles]

Originally Posted by biker1

I have seen the term "long visit" on EOBs from visits to The Villages Health before (pre Medicare age).

I also had a Medicare insurance question about two years. I had several conversations with my PCPs billing folks, my Supplemental Plan, and Medicare itself. The question was "why did an annual visit (to essentially go over blood work) count towards my Part B deductible and carry a $20 copay? I was under the impression that these "wellness visits" were covered 100%." The only person who was able to answer the question was my PCP. What she told me I found interesting. She stated "if you come in for an annual visit and don't have any issues to discuss then it would be coded as a "wellness" visit and would be covered 100% without impacting my Part B deductible and being charged a copay. If I discuss any issues bothering me (i.e. my knee is getting worse) then it gets coded differently and would count towards my Part B deductible and might have a copay (I have Plan N)". Who knew ...

"I have seen the term "long visit" on EOBs from visits to The Villages Health before (pre Medicare age)."

If it was there, it was not an official CPT term or criteria----I've already posted those criteria and there is not term "long"

As for the rest of it, it is even more complicated than the answer that was given.

If your appointment was scheduled as the annual wellness visit:

If you then bring up another problem, the proper procedure is for the physician to complete the wellness visit, close the note and start a new note on the problem. The she is supposed to bill for both with the appropriate CPT codes and the "problem" visit may be subject to a copay.

If it was booked as a visit for a specific problem:

And the physician states "while you're here let's also do your annual wellness visit", that is a violation of the rules and would subject her to paying the wellness visit back

Kind of dumb, predicating two different billings on the original reason for scheduling the visit, but those are the dumb rules

[ThirdOfFive]

Originally Posted by golfing eagles

And some other estimates are as high as $105 billion. But I think we need to clarify what is being loosely thrown around as "fraud". I believe the definition of fraud is intentional misrepresentation (legal dictionaries agree). If I believe my SUV is in good working order and sell it to you, and it turns out it's a lemon, it is NOT fraud. If I knew and concealed it, THEN it is fraud. If I believe I correctly documented a patient visit as a 99214, but CMS disagrees, IT IS NOT FRAUD. It's only if I knew it didn't meet the criteria and billed that code anyway that I committed fraud.

Now that the definition is clear (sorry to the hundreds of posters that are accusing TVH of "fraud"), there is the question of what is included in that $60-105B estimate:
First there is outright fraud, medical practices that were set up for no other purpose than to bill Medicare millions for unnecessary work or services that were never performed. These are usually fly by night clinics owned by somebody with a bogus medical degree from the Caribbean that pays winos and homeless people cash and a bottle of thunderbird to come to their clinic and have "tests", or just say they did. They are usually gone by the time CMS catches on, and doing the same thing under a different name. California, Arizona and Florida are notorious for these.

Then there is gray zone "fraud". Coding aggressively but not necessarily having the documentation to support the submitted codes. If this is intentional it might be fraud, but like I said, it's a gray zone. And believe me, I can turn even a 3-minute visit for a sore throat into a 99215 (highest level of office visit) if I was so inclined. How is that possible? Because it is no longer important what you doctor does, only what he writes. Thank the bean counters at CMS and insurance co. as well as lawyers for that one. The result, for some less scrupulous physicians, is that they would rather spend 2 minutes with the patient and 10 minutes documenting that visit--far more lucrative.

And then there is "overbilling" or "miscoding" or "computer error" or "misinterpretation of ICDM-10 and CPT" or whatever you want to call it. This is devoid of intent, and also subject to interpretation of the vague guidelines.

So, what are the safeguards?
For the fraudulent practices, it involves CMS and DOJ identifying them, usually because their billing is way more than similar sized legitimate practices. But again, they have a tendency to disappear off the grid until they re-emerge elsewhere.

For the aggressive coders, CMS knows the bell curve of CPT E&M charges and can identify anomalies. They would then ask the practice to submit 25 or 50 progress notes for review to see if the documentation supports the coding, and pay the practice a "visit" if they are out of compliance. For one group of cardiovascular surgeons in Syracuse, that visit was by the FBI with M-16s in full body armor while their waiting room was packed with their patients.

For the other 95% of practices that wants to play by the rules, it starts with internal chart review. In our group of 6, we just reviewed each other's notes and coding. In large practices like TVH, they have outside consultants that perform that task. And this is where the TVH case get murky. (Hypothetically), those outside consultants told TVH that they were in compliance with the rules. Also, hypothetically, later reviewers disagreed. And like all practices they also had to send CMS charts to review periodically, so I don't understand how any "overbilling" didn't come to light years ago. Now, and to appease certain others on TOTV, I will term the following "conjecture". The chart review at CMS was conducted by low level staff who either didn't catch it or more likely also thought it was legitimate. But with all the hoopla with Humana and UHC as well as a very large number being thrown around, it caught the attention of a higher level bureaucrat, and probably one with even higher ambitions.

From my experience, if CMS finds what is overbilling in their opinion, you can appeal or just give them some money back. But I don't think anyone wants to try to give $361M back. Of course, we don't know exactly what period of time might be involved, if that number is accurate, and whether or not it includes interest and penalties, which would be negotiable.

I just want to reiterate that no one on TOTV, including myself, knows what happened. And it will take time for this to all settle out.

In the meantime, I agree we are in a mess. TVH has 50,000 patients. Already at least 2 doctors are trying to leave. We don't have enough physicians for our population as it is, and any mass exodus will spell trouble. And not only for patients of TVH---those patients will start flooding other practices, and those that can't find a new PCP will end up in urgent care and ER's. In turn, anyone with a real emergency may be walking into a logjam. So let's hope they get acquired or bailed out before it's too late and table the recriminations until we know the population will be cared for.

Many thanks for your informative, factual post. It should help folks better understand just what a complicated maze Medicare is. It certainly did me.

[ThirdOfFive]

Originally Posted by Kerry Azz

They wanna play the morse family must pay, the family acted together to conspire to commit what we all know was a crime, they should be charged with the RICO ACT! They strong arm the stores and restaurants in the villages and healthcare prosecute them to the max.

So saith The Court Of Public Opinion.

Thankfully this issue will be settled by courts of law.

[golfing eagles]

Originally Posted by ThirdOfFive

Many thanks for your informative, factual post. It should help folks better understand just what a complicated maze Medicare is. It certainly did me.

And for the really sad part----that's just the tip of the iceberg. Think of the maze from "Harry Potter and the Goblet of Fire" and expand it to 4 spatial dimensions

[biker1]

The term "long visit" was used on the EOB from either the Supplemental Plan or Medicare, don't recall which as I gets EOBs from both. Apparently, the term "long visit" is an interpretation for the patient ???? At least one was, by the way, a long visit because I was discussing some treatment options that were complicated (the pre-Medicare visit)

The appointment was for a "wellness" visit. The conversation eventually moved to "this is bothering me, any thoughts?". I find it more of a curiosity than anything as I would hit my Part B deductible anyway and the co-pay is only $20. Thanks for the explanation.

Originally Posted by golfing eagles

"I have seen the term "long visit" on EOBs from visits to The Villages Health before (pre Medicare age)."

If it was there, it was not an official CPT term or criteria----I've already posted those criteria and there is not term "long"

As for the rest of it, it is even more complicated than the answer that was given.

If your appointment was scheduled as the annual wellness visit:

If you then bring up another problem, the proper procedure is for the physician to complete the wellness visit, close the note and start a new note on the problem. The she is supposed to bill for both with the appropriate CPT codes and the "problem" visit may be subject to a copay.

If it was booked as a visit for a specific problem:

And the physician states "while you're here let's also do your annual wellness visit", that is a violation of the rules and would subject her to paying the wellness visit back

Kind of dumb, predicating two different billings on the original reason for scheduling the visit, but those are the dumb rules

[Aces4]

Originally Posted by golfing eagles

Short answer to first question: THEY DON'T. There is no "long visit" There is extent and complexity of visits. Here is the CPT description and documentation requirements for 99215:

What Does CPT Code 99215 Mean?

CPT code 99215 is specifically used to document a comprehensive evaluation and management service for established patients. To qualify for this code, the visit must meet the following criteria:

Comprehensive History: The patient’s history must be well-documented, including a detailed assessment of their medical condition, family history, and social history.
Comprehensive Examination: The physical examination should be thorough, covering all systems related to the patient’s presenting problems.
High Complexity Medical Decision-Making (MDM): The physician must demonstrate a high level of decision-making. This involves analyzing multiple diagnoses, reviewing test results, and determining complex treatment options.

Using this code appropriately ensures that healthcare providers are compensated for the time, effort, and resources required to manage complex patient conditions.

Documentation Requirements for CPT Code 99215
Proper documentation is key to successfully using CPT code 99215. It is essential that the documentation captures all three critical components: history, examination, and decision-making. Here’s a breakdown of what’s required:



Comprehensive History: This must include an extended history of present illness, an extended review of systems (ROS), and a complete past, family, and social history (PFSH). The history should be documented thoroughly to reflect the patient’s complex health status.
Comprehensive Examination: The physician must document a detailed examination of at least eight organ systems or body areas. All pertinent findings, whether normal or abnormal, should be included in the documentation.
High Complexity MDM: The documentation must show a high level of decision-making, including multiple management options, a thorough review of test results, and an assessment of patient risks and benefits for each treatment option considered.

Please point out, right from this excerpt from CPT, the word "long"

Now, as an aside, CPT does make statements that ARE NOT PART OF THE CRITERIA such as "this visit will typically take a physician xxx minutes to complete", which is a suggestion/guideline, but not part of the requirements. Also, when the strict documentation guidelines do not fit the service, there is a way to document time spent---the most obvious example is psychiatry where 50 minutes is spent "just talking", but bedside management in an ICU setting can also be billed by time.

Two other points that I will try to make politely:

1) "Yeah, may be slightly over a billion... follow all the threads regarding this."

Yep, social media, the place to get all the facts. If it's on the internet, it must be true???

2) "ten seconds of thyroid neck check, (didn't even have to swallow water this time), and was advised to reschedule in a year. That is my basis."

OK, that's your basis. My basis is using, documenting and reviewing these codes for 35 years. Please don't even think about equating the two.

I think some minds are so closed to reality that they can only see their limited perspective perhaps due to bias from their occupation. I've had enough exposure to medical claims and physicians charges to know nothing is perfect, physicians are human and temptations are real. I could throw 3 or 4 laughing idiot icons on to finish this but I think I'll pass.

[golfing eagles]

Originally Posted by Aces4

I think some minds are so closed to reality that they can only see their limited perspective perhaps due to bias from their occupation. I've had enough exposure to medical claims and physicians charges to know nothing is perfect, physicians are human and temptations are real. I could throw 3 or 4 laughing idiot icons on to finish this but I think I'll pass.

Whatever.

[Aces4]

Originally Posted by golfing eagles

Whatever. But that does justify the “laughing idiot” icons

In one mind anyway... whatever.

[golfing eagles]

Originally Posted by Aces4

In one mind anyway... whatever.

Ok, I'm sorry I wasn't clear. This is not a debate. This is me educating people how the system works and hopefully some of them listen. Their choice. But if they want to know what happens in reality, at least I've shown them. To those with "closed minds", res ipsa loquitur.

[Aces4]

Originally Posted by golfing eagles

Ok, I'm sorry I wasn't clear. This is not a debate. This is me educating people how the system works and hopefully some of them listen. Their choice. But if they want to know what happens in reality, at least I've shown them. To those with "closed minds", res ipsa loquitur.

The "system", Medicare, indicates payment for a "long visit" which I indicated in the earlier post per Medicare guidelines exists. Then educating would include this vital information and the fact that some Drs. or their offices do bill this for charge when it has not occurred in any form. And yeah, " the thing does speak for itself".. if critical thinking is applied.

[golfing eagles]

Originally Posted by Aces4

The "system", Medicare, indicates payment for a "long visit" which I indicated in the earlier post per Medicare guidelines exists. Then educating would include this vital information and the fact that some Drs. or their offices do bill this for charge when it has not occurred in any form.

I don't get it. I posted the criteria for just one E&M code, the highest level 99215. I can post others if anyone wants. I threw down the challenge to show me the word "long" anywhere in the requirements. Guess what? IT ISN'T THERE. If someone has seen the word long on their EOB, they are either hallucinating, or it is some sort of attempt to explain the code to an amateur, but it IS NOT AN OFFICIAL TERM. This is the third time I've had to reiterate this, it's really not that hard.

Now we have a new accusation----"some Drs. or their offices do bill this for charge when it has not occurred in any form." If true, and I very much doubt that it is, that would be an example of outright fraud. So naturally the person who posted that has irrefutable proof of their accusation? Of course they do,

[Aces4]

Originally Posted by golfing eagles

I don't get it. I posted the criteria for just one E&M code, the highest level 99215. I can post others if anyone wants. I threw down the challenge to show me the word "long" anywhere in the requirements. Guess what? IT ISN'T THERE. If someone has seen the word long on their EOB, they are either hallucinating, or it is some sort of attempt to explain the code to an amateur, but it IS NOT AN OFFICIAL TERM. This is the third time I've had to reiterate this, it's really not that hard.

Now we have a new accusation----"some Drs. or their offices do bill this for charge when it has not occurred in any form." If true, and I very much doubt that it is, that would be an example of outright fraud. So naturally the person who posted that has irrefutable proof of their accusation? Of course they do,

I've got my EOB right in front of me, "Doctor's office visit, long", but you are unable to accept any truth so maybe those reading this thread followers will realize the truth isn't always told by doctors. AI: the codes are based on the total time spent on the day of the encounter and the patient's status as new or established. For established patients, codes range from 99212 (shorter visits) to 99215 (longer, more complex visits).