Take the challenge. CPT: 99213-25, 77085 ICD-10: Diagnosis M81.0, Z79.52 The encounter is coded as 9913 as follows: History—The history of the present illness was extended. The review of systems was complete, and the past medical history was documented. This makes the history detailed. Examination—The examination was expanded problem focused. Medical decision making—The diagnosis was…
Avoid the Trap of Balance Billing
It is no secret that payers and providers have conflict as it relates to reimbursement rates for medical services, and there is another stakeholder, the patient, that plays an important role in the financial impact of healthcare reimbursement. Usually, patients are faced with unforeseen bills from their providers due to an unpaid portion of a…
Rheumatology Coding Corner Question: Office Visit with DEXA Scan
A 67-year-old female patient with Medicare returns to the office for a follow-up of her age-related osteoporosis. She states she has an achy pain in her left hip that lasts for 30–40 minutes in the morning. Currently, she has taken ibandronate sodium and alendronate sodium for the past year, and her pain level is a…
Rheumatology Coding Corner Question: Documentation Improvement
A 55-year-old female patient returns for her second infliximab infusion. Her temperature is 98°F, her height is 5’6″ and her weight is 151 lbs. She received 210 mg infliximab via infusion. The patient arrived at the clinic at 8:15 a.m. and left at 10:55 a.m. Can this encounter be coded correctly? Yes No A 38-year-old…
Rheumatology Coding Corner Answer: Documentation Improvement
Take the challenge. B—No. Although the documentation states the patient arrived at the clinic at 8:15 a.m. and left the clinic at 10:55 a.m., it does not document the actual start and stop times of the infusion. According to CPT, when reporting codes for which infusion time is a factor, use the actual time over…
Preparing for Increased HIPAA Audits Among Smaller Rheumatology Providers
Recent enforcement activities of the Department of Health and Human Services’ Office for Civil Rights (OCR) have shown an increase in fines and penalties assessed against smaller providers for failing to comply with the privacy, security and breach notification requirements of the Health Insurance Portability and Accountability Act (HIPAA). Historically, OCR has focused on larger…
Implementing Successful Care Management Programs for High-Cost Patients
As healthcare delivery increasingly moves from volume-based care to value-based care, providers are needing to adopt new practices to meet what is now commonly referred to as the triple aim of healthcare delivery—improving the patient experience of care (which includes satisfaction and quality), improving the health of populations and reducing cost.1 Among the most difficult…
Addressing the Rheumatology Workforce Shortage
In 2008, the American College of Rheumatology Workforce Study Advisory Group published a comprehensive rheumatology workforce analysis.1 It concluded: Based on assessment of supply and demand under current scenarios, the demand for rheumatologists is expected to exceed supply in the coming decades. Strategies for the profession to adapt to this changing health care landscape include…
Tips for Increasing Your Client Base
Recruiting new patients requires a multi-faceted approach. A rheumatologist must have a solid brand and marketing platform, as well as an active strategy to attract and convert new patients. This might involve embracing social media, having a website, developing a referral network, being involved in your community and nurturing existing patients. Your brand includes such…
Why Physicians Say Sick Days Aren’t Worth the Trouble
A recent JAMA Pediatrics article found that 83% of clinicians admitted to coming to work while sick and 95% admitted to knowing that it could be dangerous for their patients.1 “The decision to work sick is shaped by systems-level and sociocultural factors,” the study authors wrote. In speaking with rheumatologists on the matter, I found…
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