Newly graduated physicians may find themselves dealing with a foreign process, billing. The amount of training for billing while in residency varies widely. Some programs have only brief discussions while other programs have residents do some of the billing. I was lucky in that my residency program had us rotate through 4 different hospital systems. In two out of the four, the residents were responsibility for entering in the diagnosis and bill for level of service. The attending would then go in later to co sign the orders, notes, and confirm billing. Each bill is then assigned an RVU or a Relative value unit. Medicare uses RVU’s to base reimbursement rates per procedure or document. Other insurance companies then adjust their reimbursements accordingly based on Medicare reimbursement rates.
I didn’t fully appreciate learning about billing while in residency till I started my current job. My contract, like many other physicians, is heavily RVU based. This means that how I bill will determine how many RVU’s are assigned to that encounter. This subsequently affects my take home pay. If I do not bill correctly then that is money lost from my paycheck. This is the one drawback to a salary based heavily on RVU.
Learning the Basics and Frequently Used Codes
No matter what profession a physician chooses there will always be the most frequently used billing codes for that practice. Lets take a look at the five most frequently used codes from my last week.
- 99232 Subsequent hospital care expanded problem focused (1.39RVU)
- 99233 Subsequent hospital care detailed history (2RVU)
- 99223 Initial Hospital Care, comprehensive history (3.86RVU)
- 99239 Hospital discharge >30 min (1.9RVU)
- 99220 Initial observation Comprehensive history (3.56RVU)
The difference between a level 2 and 3 visit is 0.4 RVU’s. Doesn’t sound like much but when I have 20-25 follow-up encounters per day, that can add up to large amounts of money over a period of a week. The biggest complaint that physicians have with my group is being down coded, meaning that they billed a level 99233 but their documentation did not support this bill. As a result, their bill get changed to a 99232 and they lose 0.4 RVU’s.
This past month with my job was a good example of when these loses can add up to real money. At the end of the year the company did an audit of our bills. Any over-billing was down coded and this money was money out of the physicians next paycheck. Some of the physicians in my group missed 2 whole paychecks as a result of incorrect billing. Now we are talking serious cash.
Learning to Bill for Services Rendered
Most physicians with my group use the same codes that I use most frequently. The one difference is that unlike some, I also billed for services that I am also rendering. For example, lets say I admit a patient with chest pain. The standard of care would be to do a history and physical plus look at the EKG. Of course I looked at the EKG and interpreted it. The next step is to document it in the note correctly and submit the bill for a service that was already preformed.
Additional Examples of Bills for Services Provided for Hospital Medicine
- 93010 EKG with interpretation
- 99406 Smoking cessation 4-10 min
- 99291 Critical care evaluation (4.5RVU)
Documentation is key
Forgetting to put in the correct phrase or time requirements may end up meaning that the bill could end up down coded or not accepted at all. There are too many nuances for each code and each specialty. This is why its important to find a mentor early and learn how to bill before its money taken out of your pocket. Residency and fellowship are a perfect opportunity to learn how to bill appropriately. You might find yourself saving thousands of dollars or obtaining billing for services that were being rendered anyway without having to learn the hard way.
Billing the government or an insurance company is serious business. Submitting bills for higher level than what services are either rendered or what documentation supports, is fraud. This post is not encouraging people to learn how to make as much money as possible by bending the rules.This post is mean to highlight how learning how to bill early can save new physicians thousands of dollars in loss bills. Always bill for only services provided and ensure that documentation supports the level being billed.
For those still in training, does your program provide any instruction on billing? Graduated doctors, did you have any experience with billing before being an attending?