Reinhard Wolfgang Beel, C'E'C, C'D'T'

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Reinhard Wolfgang Beel, C.E.C, C.D.T.
Business Manager Consultant

• Administrative Consultant
• for Endocrine Offices
• 49 Brookwood Avenue
• Carlisle, PA 17015
• Tel [phone] (Cell)
• Tel [phone] (Business)
• Fax [phone]

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CODING FOR MAXIMUM REIMBURSEMENT

• U/S (Ultrasound)
• FNA (fine needle aspiration)
• DEXA (dual energy x-ray absorptiometry)
• Nerve Conduction Study
• ABI (ankle brachial index)
• Fundus Photography
• Counseling
• POC (point of care) Testing
• Insulin Pumps and CGM (continuous glucose
  montoring)
• Shared Medical Appointments

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ULTRASOUND EQUIPMENT
Single Most Profitable Piece Of Equipment In An
Endocrine Practice

• Costs between 15.000 - 60.000
• Reimbursement approx. 103.50
• MC 2009 fee-schedule for U/S.
• Reimbursement approx. 134.55
• MC 2009 fee-schedule for U/S guidance for FNA

Reference CMS Fee-schedule PA 2009
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U/S EQUIPMENT
RETURN ON INVESTMENT

• Average reimbursement for U/S or U/S- Guidance
  approx. 115.-
• U/S Equipment cost approx. 60.000/115 522
  Studies
• 522/24Month22 U/S per month
• 22/20 work days 1 U/S per day
• ROI with 1 U/S per day 2 years
• Last 12 Month 784 U/S and 182 FNA

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DEXA SCANNING
How Many Patients Do You Have That

• Are post-menopausal?
• Have a history of fractures?
• Have long term steroid use?
• Are over 50 years old?

How Many DEXAs Do You Order?
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DEXA SCANNING

• Reimbursement was reduced this year at request
  and after a study performed by CMS (with only
  radiologists), resulting in a reduction in RVU
  values by more than 50.
• A study performed by multi-specialties revealed
  that the RVUs where at the correct value in past
  years.
• Is there a hidden agenda by radiologists to
  reduce DEXA performance by other specialties?

Nevertheless, the performance of DEXAs in your
office can bring in revenues, since the rule
is S/He Who Has The Patient Does The Service!
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NERVE CONDUCTION STUDY
How Many of Your Patients With Diabetes Have
Diabetic Neuropathy?

• In most states, nerve conduction studies can be
  performed by a trained medical assistant (MA)
  while the patient is in the office
• Excellent reimbursement (from 100-350)
• Code according to what nerves are stimulated
  (ex. 95903 and/or 95904 in multiples)
• Make sure the company you deal with is reputable
• Be certified in reading and interpreting results
• Document correctly
• Excellent patient care procedure

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ABI

• ADA suggests checking anyone at risk for PAD
  (over 50, diabetic, hypertension, dyslipidemia or
  with other indications of PAD)
• Insurance companies request ABI done on patients
  at risk for PAD (send letters)
• Doppler can be purchased for less than 1000
• Reimbursement approx. 120
• Return on investment with the first 8 patients
• Do not use DM (250.xx) code alone
• ABI code 93922
• Can be done by MA

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FUNDUS PHOTOGRAPHY

• Possibly lease camera
• MA is trained to capture photo (no interpretation
  involved by MA)
• Have interpreted by local Ophthalmologist (create
  more work not take it away)
• Use non-dilated photo (less liability)
• Reimbursement PA Medicare 70.70
• Code 92250

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COUNSELING

• Remember counseling can be billed by time (if
  more than 50 of the time was spend counseling)
• Time determents the level of visit
• 99215 is the correct level if 21 minutes out of
  40 was spent counseling.
• 99406 3-10 minutes and 99407 gt10 minutes should
  be used for smoking cessation

2009 CPT published by AMA
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POINT OF CARE TESTING

• BNP (TZD-CHF), GLU, HbA1c, Lipid Panel,
  Microalbumin, Urinalyses
• CLIA waived tests
• Machine and reagents must be bought to bill for
  the test
• Results with in 5 10 minutes
• Payment between 5 and 50 depending on test
  performed
• Some equipment is free with reagent rental

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Insulin Pumps

• Have a Certified Pump Trainer on staff
• Contract with the pump companies for
  reimbursement of pump training.
• Utilize DSMT and MNT to get the patient ready for
  the pump (carb counting)
• Management and follow-up visits are E/M visits

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CURRENT CGM BILLING

• 99212-99215 (EM) Patient Evaluation Session
• Comprehensive medical hx
• Review of past glucose monitoring
• Evaluation of A1c and glucose control
• Review medication regimen etc.
• 95250 Patient CGM Initiation session
• Pt wears CGM device for minimum of 72 hours
  includes training, hookup, calibration, removal,
  and download
• 95251 Physician Interpretation and Report
• Physician reviews and interprets CGM data and
  generates report

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FAQs REGARDING 95250 / 95251

• Can an RN or CDE bill 95250?
• An RN or CDE can provide the services of 95250
  under proper physician supervision, and the
  physician can bill for those services.
• What documentation is needed to bill 95251?
• Provider should contact their payers for specific
  coverage criteria. It is our understanding that
  physicians should document analysis and
  interpretation. CGM reports should be printed and
  included in patients medical record.
• Can a CDE or RN bill 95251?
• No. 95251 is a professional code only billable by
  an MD, NP, CNS, or PA (as appropriate).

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NEGOTIATING FOR PAYMENT

• Determine the payer(s) based on the number of
  beneficiaries you see

• Dont call the 800-number
• Do call your provider representative
• Do call the medical director
• Do call your local or state medical societies

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SHARED MEDICAL APPOINTMENT (SMA)

• In the past, access was ensured by adding space
  and new providers
• Declining reimbursement for services demands
  greater productivity
• Shortages in key specialties
• Even higher levels of demand
  for the best providers

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SHARED MEDICAL APPOINTMENT OVERVIEW

• Bill as individual appointments (E/M Visit codes)
• Code according to level of care delivered and
  documented
• Do not bill for counseling time (time on the
  clock can only be used once for counseling)
• Prior to visit, all patients and support
  personnel sign a patient privacy release (HIPAA
  compliance)

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SHARED MEDICAL APPOINTMENT
Add additional services during the Shared Medical
Appointment

• Random Glucose (82947) every visit
• HbA1c (83036 or 83037) up to 4 per year
• ABI
• Fundus Photography (92250) 1 per year
• Lipid Panel (80061) 1 per year
• Set up DMST group visit with SMA (bill on
  separate claim if ADA recognized DSMT Education
  Center)

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DO THE MATH! WIN-WIN for PHYSICIANS and EDUCATORS
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IT ALL ADDS UP!

• Lets put it all together.
• A PATIENT CASE YOU ALL CAN RELATE TO

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PATEINT CASE EXAMPLE

• 51-year-old male referred to your office by PCP
  for suspected thyroid nodule and DM. He has a
  documented history of HTN and dyslipidemia. The
  patient had noticed his shirt collars are
  becoming tight.
• Glucose, HbA1c, and lipid panel by finger stick,
  with POC Devices performed. Records are reviewed
  and physical exam reveals a palpable left thyroid
  nodule as well as retinopathy, HbA1c 8, GLU 210,
  BP-150/90, LDL 150. An U/S is performed and
  confirms the nodule. You perform a FNA under U/S
  guidance. The slides are evaluated under
  microscope for adequacy of samples, packed up,
  and sent to the pathology lab for evaluation. DM,
  BP, lipids are addressed appropriately. A Fundus
  Photo is done to evaluate retinopathy, an ABI is
  performed to evaluate PAD. TSH and FT4 are
  ordered, drawn, and analyzed in your office lab.

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PATEINT CASE EXAMPLE

• The following is coded as diagnosis
• Thyroid Nodule 241.0
• Diabetes Type 2, with Retinopathy, uncontrolled
  250.52
• Benign Essential Hypertension 401.9
• Dyslipidemia 272.4

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• THE FOLLOWING PROCEDURES ARE CODED
  PA MEDICARE
• 99244 -25 Separately identifiable E/M visit
  179.55
• 36415 Blood collection 3.00
• 82947 Glucose Assay (Lab level Analyzer)
  5.48
• 80061 Lipid Panel 18.72
• 83036 HbA1c 13.56
• 93922 -59 Extremity Study (ABI) 112.95
• 92250 -59 Eye Exam w/Photo, Fundus Photography
  70.70
• 76536 -59 Separately identifiable
  Procedure 103.50
• 10022 Fine needle Aspiration under U/S
  124.32 guidance
• 76942 Ultrasound guidance for Fine Needle
  172.69 Aspiration
• 88172 Immediate cytohistologic study to
  determine 49.89 adequacy of specimen
• 84443 TSH 23.47
• 84439 FT4 12.60
• TOTAL 890.43

2009 Physician Fee-Schedule
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SOME RULES TO FOLLOW

• Must have 2 or more DX codes to use Mod. 25
• Several nodules can be billed separately
• Use Mod LT, RT And 51 Multiple Procedures
• Some procedures will be paid at 50
• 2 and more U/S can get paid with Mod 59
  Separately Identified Procedure

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The most important ways to maximize
reimbursement

• Code and document correctly
• Code all services done and documented
• Add additional services according to standard of
  care (ABI, POC Lab Tests, NCS, Eye Exam, DEXA)

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ABOVE ALL ELSE

• RE-WORK REJECTIONS
• RE-SUBMIT CORRECTED CLEAN CLAIMS
• UNTIL THEY ARE PAID