EP 15: Billing & Coding Basics (Non-Scary Edition)

This episode of NP Launchpad breaks down billing and coding basics in a clear, approachable way, helping nurse practitioners build confidence in one of the most intimidating aspects of clinical practice. Featuring special guest Wendy Wright, a nationally recognized NP leader and business owner, the conversation delivers expert insights on reimbursement, documentation, and common pitfalls. Listeners will learn how to accurately code visits, maximize revenue ethically, and avoid costly mistakes early in their careers. Whether you're a new grad or looking to sharpen your financial acumen, this episode offers practical, real-world strategies to succeed in today’s healthcare landscape.

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Transcript

Voiceover 0:01

Welcome to NP Launchpad, presented by Fitzgerald Health Education Associates, the podcast created for newly graduated nurse practitioners navigating the transition from school to clinical practice. Hosts Jason Gleason, Christopher Gleason, and Vanessa Pomarico-Denino deliver real talk, real experiences, and practical guidance to help you succeed from day one. So if you're ready, let's jump right in.

Vanessa Pomarico 0:33

Hi everyone, and welcome to this week's episode of Billing and Coding. And tonight I am joined by my co-hosts, Jason and Christopher. Hi you guys, how are you doing?

Jason Gleason 0:44

We're doing terrific.

Vanessa Pomarico 0:46

I just want to uh make mention to that this we've been talking about this for the last season and all of this season, about how Christopher was gonna be soon to be Dr. Christopher Gleason. And so now I get to introduce him as Dr. Christopher Gleason. So congratulations, Christopher.

Jason Gleason 1:03

Thank you, I think. Now I I have to say, Vanessa, what Christopher does not like people to know, though. He is now gonna be known as Doc C.

Vanessa Pomarico 1:10

Doc C Doc Copy.

Jason Gleason 1:12

And I keep telling him because you're known as Doc C now, you should open up an STI clinic. That's still not happening.

Vanessa Pomarico 1:16

There you go. That is absolutely not what we're speaking about tonight, Doctor.

Jason Gleason 1:22

No, it's not what we're doing. Come on. We cannot change the topic.

Vanessa Pomarico 1:27

So I am really so excited that we are joined by Dr. Wendy Wright tonight. She's the owner of Wright and Associates Family Health Care in New Hampshire. She is a successful businesswoman. Um, she's an author, she is a national and international speaker, and we're so delighted to have you here with us tonight, Wendy.

Wendy Wright 1:46

Thank you so much, Vanessa. It's so good to be here. Thank you, Jason and Christopher, for hosting me.

Jason Gleason 1:52

Thank you. We're delighted to have you.

Vanessa Pomarico 1:54

Uh just as a reminder, if you have any um uh questions for us, all you have to do is email us at nplaunchpad @fhea.com, and we may answer one of your questions in a future episode on air. And please remember, just as a quick disclaimer, that this is for your education only. We're here as your friend and your colleague, and really not here to offer any solid legal or clinical advice. There are professionals that actually do that. So we're gonna jump right in because we have so much that we need to cover tonight, our hot topic discussion on billing and coding and where do we begin? So, Wendy, what do you see as the biggest differences between physician and nurse practitioner billing?

Wendy Wright 2:37

There really is none, to be honest with you. I'm gonna make it short and sweet. The codes are the codes. And so, in whether you're a nurse practitioner, whether you're a physician associate, whether you're a physician, what you bill out really should be the same. The difference is what you reimbursed. So we're gonna talk about that based on federal statute, based on states that often follow Medicare regulations. But at the end of the day, there's a code. And so in my clinic, let's say it's a 99214, for instance, we set a we set a billable uh amount to that service. The way we do it is we take our highest payer and we we take that amount that they normally pay and we add 10% onto that, and then that's the charge that we bill out to every insurer. What they choose to pay us is based on the contractual uh uh based on our contracts that we have with those insurers. So at the end of the day, there's really no difference than that, nor should there be a difference.

Vanessa Pomarico 3:42

Exactly. Very nice. So so how does NP scope of practice really impact billing capabilities across the state? So for so for example, like telehealth. You know, we have people, I know people here in in Connecticut that um do telehealth, but they do it across the country. Can you speak to the NP scope of practice and the the impact on billing capabilities?

Wendy Wright 4:04

Yes, I can. And NPs in general do not have compact licensure, which means you must be licensed in the state in which the patient is sitting. So I have a number of colleagues who do telehealth throughout the country. They're licensed in 32 states. Wow. So for us, when we do Yeah, um, so when we do telehealth, the morning of the telehealth visit, my team reaches out, front desk person, calls them and says, Hey, just want to verify your information. We want to ensure that you're in the state of New Hampshire physically during the time of that telehealth visit. And number two, we want to make sure that you not only have audio, but you have video because many of the insurers today are not paying unless you are able to see someone through a video. Or if they do pay, for instance, it's a $25 reimbursement. And for me, we can't sustain a 30-minute visit with a patient and get paid $25. We just can't do it. So we want to ensure that their insurance is valid. We collect their copay before we even see them or their deductibles. And then what we do is we ensure, and then when I get on the line, I say I need to ensure that you're willing to see me on telehealth and that too, you are in the state of New Hampshire because I am only legally licensed here. So that is a real big issue in terms of scope of practice. The other thing I would say to you, Vanessa, and I want to make sure I can get through all of your questions tonight, is that if an NP is not able to prescribe certain medications, one of the criteria that change often changes the code from a three to a four is your ability to prescribe at that visit, whether it's telehealth or in person. And there's actually you get it, you get basically um an upcharge, if you will, if that's a high-risk medication. So in my EHR system, I select, you know, this is a chronic problem. I ordered five tests, and this is a high-risk medicine. Something like maybe a lithium, for instance, that's high risk, or uh even warfarin is a high risk or an opioid. It kind of upcharges that visit and helps to move that visit from a three to a four. So in states where NPs are not allowed to prescribe certain medications, i.e. anoreptic meds, there are states where NPs can't prescribe any weight loss meds or schedule two drugs for ADHD, that really can influence billing as well.

Jason Gleason 6:32

Vanessa, those are some great questions. And Wendy, what insight you're offering all of us, including our audience out there, and I'm learning stuff from you just from the get-go here. I do have a question for you, kind of off script, not related to our topic tonight, but so important because frankly, you are a legend among NPs. A young legend, I must say. But you're a legend because you've done so much in your career and you have such a career left to do, right? And so you're not only a clinician and an author and a researcher and a national speaker and an educator and just a hero among us. But at what point in your career, probably early in your career, did you decide, you know what? I love being a clinician, but NPs can do so much more. What was the driving force to become not just an NP in clinical practice, but a brand, an ecosystem? What was that driving force for you?

Wendy Wright 7:22

1996, Dr. Margaret Fitzgerald nominated me to the board of directors of NPACE, and I came on to NPACE. I had no idea what I was doing. You should talk it's a CE education company. That really catapulted my career, and I saw what NPs were doing, and I was so lucky in 1997 to be nominated to by uh NPACE to attend a speaking weekend, if you will. There was an educator, many of you know her, Eleanor Lopez. She was a speaking coach. She was there. There were 10 experienced NPs who spoke and 10 novices. I was one of the novices, and we were paired with people like Mimi Secord, Peg Fitzgery, then Elaine D. Simone, like movers and shakers in this country. And and we were coached, and then they became our mentor. And I will tell you, that single-handedly changed the trajectory of my career because my thought was if I can survive this weekend, I threw up all weekend in the bathroom all weekend. It's a thing to talk to a group, but it's to talk to your colleagues who are sitting there like stop moving, stop using your hands. I mean, it was really grueling. And at the end of the day, I thought, you know what? People believe in me and they're seeing something in me that I didn't even know was there. But what I did know, Jason, and all of you is that I could outwork anyone. I have drive. I grew up poor. I grew up worried about food about I'm never ever live that way again if I can do anything about it. And so, you know, they they saw something in me, and I took the opportunity that was presented to me and just said, I'm gonna put my head down. And one thing led to an next. And if you would see me when I was this 24-year-old kid becoming an NP, what are you gonna do with it? I'm like, I'm gonna work in an NP office or in an office. I didn't know any that my career, you know, any of those paths that my career would take. I'm just so blessed that people saw something in me.

Jason Gleason 9:29

And what an inspirational life story. Did you always want to become a nurse or an NP from a younger age?

Wendy Wright 9:34

Always, age four. I knew I was a nurse. Age four, it never ever wavered. Wow. My my childhood provider was a physician associate from Vietnam, and my adolescent provider was the first nurse practitioner in the nation to open up a family practice. Back in the time in the 70s, what NPs didn't prescribe. So I saw that role from such a young child that I never wanted to work in the hospital. I did it because I had to. Back then, you remember all of you, we had to put our time in. You didn't go to any school until you did your duty. I hated the hospital. I hated it so much, but I did it because I knew that that's what I had to do to that next step.

Jason Gleason 10:18

That is incredible. That's incredible. And within that, here's an important question for you. Did you have the Fisher Price nurse and physician kit with the stethoscope and the shrimp as a kid?

Wendy Wright 10:29

Oh goodness. I don't know that I did. I wasn't much of a player, to be honest with you. I hated games, but I had every every nursing book catalog. Does that count? I have a lot of parents, and I got all my books, including Nancy Drew, and all of those were all cataloged. You know, my parents never went to college, and my parents folk uh knew that the only way for me to to make something into a skate artillery was to really go to college and they mortgage their trailer to get me there. So I just I just feel like you know, everything I'd have is a blessing and it's icing on the cake. And if it were over today, I'd be sad, but I have no regrets about where this path has taken me. I'm then so blessed with this slide.

Christopher Gleason 11:14

That's awesome.

Vanessa Pomarico 11:14

I absolutely on that note, I just have to put a little plug in. If you have not read Wendy's book, uh, she wrote a book about her life, and I have read it twice now. I just have to put a little plug in. It is available, I believe, on Amazon, right? It is. Um, cycle. Yeah, it was it's an amazing read. So um everybody should read it. It is so inspiring, and there's so many stories that I I could talk about, but it will take away from our billing and coding. But back to billing and coding. Back to billing and coding.

Jason Gleason 11:50

Yes, indeed. Thank you for that insight and what an inspirational story, Wendy. I can't uh I honestly can't wait to pick up your book and read it. I bet it's gonna be a terrific read. And and like Vanessa said, we definitely recommend everybody out there pick it up. I'm certainly going to. So um here's another question for you, and back to our topic on billing and coding. You know, can you talk a little bit about what is incident two billing and when is it appropriate and when are you taking a lot of risk in using that?

Wendy Wright 12:16

Sure. So incident two is a is a code basically, or it's a it's a term that we use to be able to bill under someone's someone else's tax ID. So an example would be I work alongside a physician, and instead of me billing this out as my tin, I allow that physician to bill out on my behalf. So when I first became an NP, every one of my visits was billed out under a physician. Why? Because back 34 years ago, I was in Massachusetts, they didn't credential NPs. We were an unknown entity. So we had no idea what I was able to bill because everything went through the physician, right? And was attributed to that physician. So here's the deal with incident two. I hate it. Because it makes us invisible. And you know what? There are three criteria that have to be present in order to bill out incident two. One, the patient must be an old patient, not age, but they have to be established. Two, the physician must be on site. So if that physician is on vacation, incident two is out the door. Wow. Three, it must be an old problem. So that patient, how many of you, any of you, see a patient who doesn't bring up something new during a visit?

Christopher Gleason 13:36

Never, every time. Every time, right?

Wendy Wright 13:39

So it that's what it'd be an example of an incident two. Patient comes in for a follow-up with hypotension, physicians saw them, physicians on site, that's all they bring up to you. You make no changes in their their treatment because everything is going great. That's an incident two potential. You know what that gains us? 15% more than physician than we would have gotten. On a typical Medicare reimbursement, let's just use $100, for instance, that gives you an additional $15. You know what? 95% of my visits would never qualify. I don't have a physician on site, so none of my building is ever incident to. And at the end of the day, there's a big push to get rid of it because it's used fraudulent, right? I know a lot of practices that every NP is filled out incident to that that just goes out through the physician's number. And I see NPs and need to understand what's being done on your behalf because at the end of the day, your name is on that. And it can result in Medicare exclusions. Medicare is the first place that this got set up. And I think they're the really the ones that tend to use it most often or enable incident two. Uh, I know that there's a big push to get rid of it because a lot of people think it's being used inappropriately.

Jason Gleason 14:56

And what are the penalties when you use it inappropriately? Have you had colleagues over the years that have gotten in big trouble?

Wendy Wright 15:01

Yeah, there I have had a colleague who was audited for incident to Billy, and they gave them an ultimatum. You either disenroll or you reimburse us every ounce of money that you build out inappropriately. You know, I don't know about you, but there are three people I never want knocking on my door.

Christopher Gleason 15:19

Yeah.

Wendy Wright 15:20

The Board of Noursting, the IRS, and Medicare, right? Yeah, totally. Totally. You just don't want that. And I think for $15. And here's the other thing. I once heard Jan Towers from AANP say, if you're truly doing an incident to incident two visit, your visit should never be more than a 99213 because you're not changing anything. All right, not brought up anything, and you're addressing one issue. So at the end of the day, how many of my visits are fours? My bell curse sits over the four because no one comes in for one issue. No, they're gonna list this long in primary care. So I encourage people to really know what's being done on your behalf because you're liable. And two, I'm not a big fan of incident two, no, nor are many people.

Jason Gleason 16:06

It's just not worth it, it doesn't sound like. You know, yeah, worth the risk.

Wendy Wright 16:10

That's my opinion.

Jason Gleason 16:11

You know, you've worked with a lot of NPs over the years and you've mentored a lot of new NPs and NP students. Talking about risk, what are the biggest mistakes you see new NPs making when they launch into practice?

Wendy Wright 16:24

Are you asking me in tons of billing? As far as billing.

Christopher Gleason 16:30

As far as Billy.

Wendy Wright 16:31

Many, yeah, great. So many new NPs have very limited education about billing and coding in their programs. I was just out at the University of Wyoming and I was teaching billing encoding to the students because they feel like it's really important that these students not only have a course on it, but since their first clinical experience, they make the students choose a level of billing with every one of their patients that they see in the clinics or in standardized patients. I think that's important. That's unheard of. Yeah, it is unhearding. I think many of us were told you never want to bill over a three. If you bill over a three, you're gonna get audited. And you know what? Bring it on.

Jason Gleason 17:12

Right.

Wendy Wright 17:13

Bring it on. If you're asking me to do the work that I do and I'm documenting that work, then you are paying me for it. Absolutely. You know, I don't know about you, Vanessa, but if I go to my hairdresser and say, I'm not paying you over blah, blah, blah, she's gonna say you're not getting your highlights and your lowlights, and you're not getting your cut today, and you're not even getting a blowout. So at the end of the day, if you want me to do the work, I should be paid. So the work that I do. And a lot of MPs are too scared to do that.

Vanessa Pomarico 17:45

Right. And I completely agree, Wendy. When I am precepting students, I teach them about billing and coding because they're not getting it in school. And then they graduate and they go out into the world and they haven't, they don't know what they're talking about. And you kind of get a crash course, you know, that first month that you're in, you know, in practice, uh and the students, you know, at least my students, when they leave me, they've got a a bit of an education of what constitutes a three, what constitutes a four.

Wendy Wright 18:12

I think that's huge because you know what, Vanessa, when you were a nurse, you got a paycheck. And it didn't matter what you did, your check was your check. As I tell the NPs, you eat what you killed. I mean, that doesn't sound good, right? But the end of the day, you reap what you sow. If you're sitting back and you're not doing work, and you don't care if you get vaccines, and you don't care if you get A1C's when it's supposed to be done, you're not gonna get the same pay as the person who is down the hall for you, who's doing the things that need to be done. And so in my clinic, the way we set it up is I don't use RDUs, and I know we wanted to talk a little bit about this, but I think RDUs reward people who are new, who are doing lots of procedures and new patients. They penalize people like me who see the older, dizzy, fatigued patients. Oh, yeah. Because there's not a lot of RDUs that go with that because they're not as labor intensive, if you will, or they're not procedure driven. So I the way it works in my clinic is if you you after your first year, because we I run a fellowship in my clinic, after your first year, you're expected to collect three times your salary and benefits in collection. And if you don't, if you do that, your manner raises five thousand dollars every year. And that's meant to keep pace. The new grads always set the pace for for pay. It's the experience people who get short circuit. So I want to keep my experienced people by bumping them up five grand every year. But we just had someone who went above her numbers times 100%. So her raise was ten thousand dollars that year. Wow. So that's how it rolls. If you're above, you get whatever percent above you are, of that 5,000, add it on. And if you're below, you get blessed. So choose what you will if you want to work hard and make sure people get the care that they deserve, and you want to make sure you don't just say to me, You only get one problem in this clinic. Um, then you're not, you know, you're you're gonna get pancakes of the work you do.

Jason Gleason 20:18

Yeah, right. Can we come and work for you?

Wendy Wright 20:21

Absolutely. I just offered Vanessa a job. If she ever retires, come on out.

Vanessa Pomarico 20:28

She's she's making it very, very enticing.

Jason Gleason 20:31

I bet she is. I bet she is. Yes, indeed. Well, I'm gonna turn over to Christopher now. I know he has some questions for you as well.

Christopher Gleason 20:39

So, my first question for you, Wendy, is what constitutes fraud versus an honest coding error?

Wendy Wright 20:45

I really, I mean, I'm not an attorney and I'm not the FBI or Medicare, but I guess I would say to you, it's not unusual for us to make a mistake on a code here or a code there. But all you have to do is pick up the new, uh pick up a newspaper these days, and you're seeing NPs, physicians upcoding visits, driving up what's called their RAF score, the risk is destroyed score. So I don't know if you all see this in your EHR, but in our EHR, those hierarchical category codes, those high risk codes, all add up to give you what's called a risk score. And the higher the risk score, the more the actuaries set aside money in that insurance company to provide care for that high-risk patient. I think Medicare averages the average risk score for a Medicare patient is a one. When you see patients who are two, I have a patient who's a five. Like those people are really sick, and those are the people that cost the system a lot of money. But the higher you drive those codes up, the more money they set aside. And if you're in value based care, that money can come back to the clinics at the end of the day. So what we see is people coding things that don't exist, not taking Away codes that have gone away and keeping those codes, those risk scores higher. I always tell my team, I never for one doll want you to manipulate a chart. I don't care if we go, if I go without pay, I want you to be honest with the codes you put in because that can really impact us. So organizations have people working on, you know, making sure these codes are right. And if they're right, they belong there, right? But they don't belong there if that's truly not a diagnosis that that patient has. So one off here and there, we all make mistakes on coding. And uh, but if it's a persistent pattern where emails have been sent out to drive, you know, make sure in your coding X, Y, and Z. That's really where fraudulent comes in.

Christopher Gleason 22:51

Sure. Okay. So uh I'm uh kind of on that topic one day. I'm kind of curious what documentation is essential to support billing levels?

Wendy Wright 22:58

Yeah. So it it depends upon how you're billing, Christopher. So if you're billing based on time, the time regulations have really changed over the last since 2021. You must document the timing spend with that patient and it must meet or exceed. I'll I'll clarify that in a second. It must meet or exceed the minimum requirement for that level. Now, years ago, you may remember that in order to build based on time, 50% of the visit needed to be in face-to-face counseling. In 2021, that went away. And here's what it looks: if you want to build based on time, it's the prep time that you put in for that chart, it's the time you saw the patient, it's the time you spent reviewing records, it's the time you spent documenting every ounce of the time you spent taking care of that patient on the day of their service. You can count that toward the time spent. So if it takes you 20 minutes to document some of my complex patients, take a long time. You can now do that. Yes, but here's the key it has to be done on the date of service. So for MPs who don't get their work done on the day that they see the patient, you have now knocked yourself out of the ability to build based on time. Everything or Vanessa, you and I were talking about this, prepping our charts ahead of time. If we prep our charts ahead of time on the day before, you can't count any of that time for time spent.

Christopher Gleason 24:30

Wow.

Wendy Wright 24:31

It has to be done the morning of or the day of that that you see that patient. Does that make sense? So that time spent, I created a quick text for my tuning, and it basically says this visit was uh is being billed based on time. And I will only do that. For instance, I had a patient come in with leg pain. I was evaluating her, and during that leg pain intervention a few weeks ago, I listened to her heart. Her heart is all over the place. I thought, oh my goodness. Well, I got him a KB, 125 beats a minute, high ventricular response rate. She's an atrial fit, calculated her Chad score, got her started on an anti-coagulant, referred to her cardiology. That visit, my time was over 50 minutes. Oh, yeah. I'm not taking a four, so that visit. No, I'm taking a five with a modifier and an EKG and blood work that I've ordered because you know what? I did the work. And you know what I did? I kept that woman out of a $5,000, $10,000 ER visit. Yeah. Because otherwise, I can have sent her to the ER. So I don't feel badly when it's something like that or chest pain and it's potentially life-threatening. I'll just fill it out based on time. I just will switch it if I think it if it helps it rates out to be a four, I'll switch it to time if I know I've spent the time. Now, if you're doing medical decision, oh sorry. One other thing. If it's based on medical decision making, no longer does review of systems matter. No longer does chief complaint or HPI or even physical examination matter. What matters is your brain. How many diagnoses, the risk of those diagnoses, how many labs you order, whether you prescribe a drug, whether you talk to someone else, all of that goes into calculating it. That has to be documented.

Christopher Gleason 26:20

Well, wow. That's some that's some great, great information, Wendy. And I think now I'm going to turn it over to Vanessa for some questions from her.

Vanessa Pomarico 26:27

So under that same guideline, uh, you know, what you were just talking about, do you have any key documentation tips that can help our listeners today justify those higher-level visits?

Wendy Wright 26:41

Well, certainly the time, that that is definitely, you have to document that number in there and create a quick quick text. But here's what I would say to you. I used to say in the old billing guy finds, if you make sure you're including three to four diagnoses in a visit, you're probably guaranteed to get a level four. No longer. If those three or four are mild issues or minor issues, like a sore throat and an ear pain, that's never gonna get you a four. What often gets you a four is a couple with acute visit uh complaints, one stable problem. So I always tell the MPs, don't give me sore throat with ear pain. If that patient is hypertensive and you looked at their blood pressure, that deserves to go into your plant and you comment that their blood pressure is stable. If they've got asthma and they've got an upper respiratory infection, you drop asthma in and you comment this is stable.

Jason Gleason 27:38

Nice.

Wendy Wright 27:38

And then uh, and then so I think three to four diagnoses at least, and they can be multiple chronics, particularly if chronics are worsening. And then when you prescribe a drug, and I've noticed this because my EHR system calculates out visits for it. I just click on buttons and it'll tell me the level of that visit. But I will always double check, make sure it's accurate. Sometimes I actually don't think it's accurate, and I'll down code it because I feel like, you know, this was a visit that really didn't deserve a four. But at the end of the day, I think one should prescribe a drug prescription, and that includes injections like immunizations or uh foridol or any of those drugs. That often bunks that three to four diagnoses from a three up to a four. Wow.

Vanessa Pomarico 28:26

Wow, great.

Wendy Wright 28:27

When you talk to someone else, oh the one other thing, Vanessa. A lot of people don't always do this. So let's say a wife comes in because the husband has uh major neurocognitive disorder, something like an on-sounders disease, right? And you're getting history from the wife, you document that in your note, accompanied by history from wife, you actually can get credit because you're taking a history from someone else. Or if you call someone in a different center, like if you've ever picked up Fun Kong GI, said, I've got this person with ulcerative colitis, you treat them, they're having a slayer. What can I do to keep them out of the ER? Can you walk me through this? You can actually get credit for that and it bunts that level of code appetite.

Jason Gleason 29:12

Very nice.

Vanessa Pomarico 29:13

Wow, excellent. So, really, the documentation, you know, we always say this, you know, going through school and with our new grads, to make sure that they document essential documentation, but to make sure that it's concise. And it's for these reasons, because if you ever get audited, you know, three years from now, I don't know about the rest of you, I can't remember what I did this morning.

Jason Gleason 29:35

Oh, yeah.

Vanessa Pomarico 29:36

Let alone if I get audited. So it's really important that your documentation is very concise and very precise just to justify those higher level visits.

Wendy Wright 29:47

Just like the IRS, Vanessa.

Vanessa Pomarico 29:49

Exactly. Exactly.

Wendy Wright 29:51

You can't, you know, say I deserve this amount of money back. You better have good documentation to support it, right?

Vanessa Pomarico 29:57

Do you feel that nurse practitioners are leaving money on the table because they're under coding, Wendy?

Wendy Wright 30:02

Absolutely. Not a question in my mind, you know what, how I know this. My sister and I started a forensic fix. And uh, so what we do, my sister's a biller coder. And so what we do is we uh we go into practices and we audit their level of coding. We're working with a physician group right now that brought us in, and even the physicians are under coding because they're like, oh, this is at three. When the reality is most of their visits are at four. I did a practice in Texas, 60% of their visits were accurately coded, and most of them were undercoded or they left money on the table. They forgot things like vaccination administration, they forgot to bill for the pelvic exam that Medicare now pays a fee for to uh to enable you to have a chaperone and to pay for the supplies of a pelvic exam. So there are things that unless you keep up with this coding, people are leaving a lot of money on the table. You and I talked about this earlier. G2211. This is a code paid out to primary care by Medicare. You can bill this at every visit, other than at physicals or transition into care visits, but this can be at every visit, and it tells Medicare I'm the primary care office of Lecard. We are monitoring and following these people, and it's it's something like on average $17 per visit. Wow. But you know what?

Jason Gleason 31:28

Adds up.

Wendy Wright 31:28

I have a thousand Medicare patients. That's right. That adds up over time. Now the problems have to be moderate to severe. It can't just be a Medicare patient lesson know how fishes, but have you met both I haven't?

Jason Gleason 31:44

Not at all.

Wendy Wright 31:44

I haven't. Most of my Medicare patients have more than 20 diagnoses on their chart.

Jason Gleason 31:50

So, Wendy, you know, when you think about coding, I think what is often missed as well, and tell me if I'm correct, you know, you bill for the visit, but then all the the side codes, like for tobacco cessation education or that for exam for that patient with diabetes, you can take credit for those as well, right? And get jumped up on the pay you're gonna get.

Wendy Wright 32:07

Absolutely. Forty something dollars for counseling on smoking cessation.

Christopher Gleason 32:12

Oh, wow.

Wendy Wright 32:13

Now it's a 15-minute minimum for that reimbursement. Wow, 15 minutes? That's a long time.

Jason Gleason 32:21

That is a long time, right?

Wendy Wright 32:23

Uh but if you're doing it, same is true for alcohol, screening for substance use disorder and counseling about alcohol as a sanction. There are codes that you can bill that out. Now, here's what I tell people: there are lots of codes that get asked this all the time. Can I bill for a telephone call? Yes, you can. Doesn't mean you're gonna get paid for it. You can certainly bill, but you but most insurers don't pay for that. They don't pay for portal messages, although I think they should because the portal is taking us all down. Um but and at the end of the day, you can bill for almost anything. Most people don't get remote for a lot of these other codes. But yeah, smoking cessation, counseling about end of light. All right, doing their DPOA or you know, validating their DPOA in living oil. That can all be billed out as well for an end-of-life discussion.

Jason Gleason 33:17

And those codes are in addition to the visit code itself.

Wendy Wright 33:20

Absolutely, in addition to the visit code themselves. And many times I'll see a patient who I'm doing a physical on them. I see a mole, I don't like it. I'll say to them, you know what? I want to get this biopsy. I've got a few minutes today, let's do it. I know that I have two insurances in my in my state that don't allow me to do this. They're not gonna pay for that surgical procedure. So I just say to the patient, your insurance won't allow me to do it with you today, but let's get you back on the schedule.

Jason Gleason 33:47

Oh, okay.

Wendy Wright 33:47

And we'll bring you back. But most of them, I'll modify the visit, I'll do a procedure code for punch biopsy or shave excision, and I will do their well visit and a visit. The other thing, uh, a procedure. The other thing people don't realize is that the majority of your patients who come in for well visits bring a list of 50 items. They're they think this visit doesn't cost me anything. I'm gonna save everything up until that visit. And so for us, what we do is we say we're happy to work with you to try to address as many of this as we can. But we have we have a notice published in every room on our website in the waiting room that if you bring items beyond preventive care to a well visit, we have the ability to modify your visit and fill out a charge for that additional additional thing you brought to the table. Because people just save it all up and I want them to. Right. That's our motto of care is I want to address as much as I can that day. Yeah, but you can't ask me to add on additional color highlights and low lights to look cut and expect that I'm not gonna have to pay for that.

Jason Gleason 34:56

Yeah, right, absolutely. Bottom line. Right? So the person out there that, you know, looking at the tobacco cessation education code, for example, could somebody out there, if they want to put a class together, like a group education class, invite like 20 people that use tobacco and have a class for 15 minutes, they could they bill for that in a group setting?

Wendy Wright 35:16

Well, there's a group charge. There is a group charge for those things. And I don't do those in my clinic. Yeah. I I know that there are people that do it, so I don't want to speak out of turn, but I know that there is the ability to bill out services in a group if you bring them together for education, etc.

Jason Gleason 35:35

Okay, good. But but again, be sure that you know what the code is and to meet the criteria for those group education sessions.

Wendy Wright 35:42

Absolutely. Absolutely. Because if you're audited, you've got to defend that this was an appropriate post.

Jason Gleason 35:49

Yeah. So I can't invite 500 of my patients that smoke and do a class for 500 people.

Wendy Wright 35:54

You certainly can. You just may not be paid adequately for it.

Jason Gleason 35:57

Yeah, I won't get reimbursed at all.

Wendy Wright 35:59

You know, it's but there are comings out there because I know a lot of people do group diabetes education. And so I I think it's worth investigating if that's something that's important.

Christopher Gleason 36:10

Sure. Sure. Anessa, you got any more questions?

Vanessa Pomarico 36:15

Um Jason, you got a couple more there, or you don't have to Oh, I do, yeah.

Jason Gleason 36:19

I'm I'm kind of the host among us three that's off topic, and it uh that's often the case, Wendy. My apologies. No way, I wouldn't believe that for a minute. They put up with me for all these episodes. But here's another question for you. For the NP out there, whether they're new or they just want to start their own practice, what are some of the biggest myths that you thought, you know, well, it would be so easy to start an independent practice, but then you find out that it is not as easy as you thought it would be.

Wendy Wright 36:46

Sure. I'm gonna stick with the billy and coding because Jason, that's another podcast for a different. Okay. I'll stick with the billy and coding. Number one, I always thought if you go to an insurance company and you say, hey, I want to do business in this state, I want you to credential me. I thought that they had to. They absolutely can do not. As I work with NPs around the country, there are states where they'll say the blues won't credential me. United won't credential me, Aetna won't credential me. And I know that they need providers in this area, but they just won't do it. So I think that, you know, the old saying, if you build it, they will come. That's not necessarily true. You want to do your homework before you start out and find out what insurers in your state will credential you. Sure. And then what are the rates for your reimbursement? Because Medicare reimburses us 85%. That's federal statute from 1996. I'm old enough to remember that in 1995, we got zero dollars for Medicare. So during the Clinton administration, who by the way, his mother was a nurse anesthetist, uh, he passed or helped to pass that, allowing us to bill Medicare and get reimbursed for it. We settled for 85% because 100% of zero is zero. So the thought was anything is better than nothing and we're no longer visible. But, you know, a lot of the insurers now follow Medicare. So they said, well, that's what Medicare does. So we're gonna pay you the same, you know, 85% of what we would pay a physician. Very fascinating. I have uh I have data because I am the chief clinical officer of duet technologies and we're helping nurse practitioners open, sustain, negotiate, grow, et cetera. People in the RM clinics. All right. So we have data that we took to the state legislature in New Hampshire because the insurers said we're paying NPs the same amount as physicians. And we said we cried foul. You're lying. Oh, yeah, it is absolutely not true because now we're working with all of the NP clinics in the state. There are NPs, every NP clinic is in the bottom one-third of reimbursement for independent own practices. So compared to physicians, there are NPs that are getting paid $100 when physicians down the street are getting paid $300 for the same level of service.

Jason Gleason 39:09

Wow.

Wendy Wright 39:10

So that is the reality for NPs, particularly who own their own clinics. I'm an N of one. No one will talk to me as an N of one. That's why we at Duet break all the NP practices together because now we represent 25,000 patient lives. And guess what? Yeah, people are going to talk to us now.

Jason Gleason 39:28

Wow.

Wendy Wright 39:29

And so that's just in New Hampshire. We're well over 25,000 patient lives, but we now represent 250,000 patient lives uh at Duet. And we're helping NPs to be able to sustain. I cleaned my toilets for years. My mom cleaned our toilets for years, so then we could do the care that we wanted to provide because the reimbursement was picker.

Jason Gleason 39:54

Oh shit.

Wendy Wright 39:54

Terrible. Yeah. I always say, I love my hairdresser. I keep using that analogy. She truly, she truly for hours gets paid more than I do on a lot of our bases. And I love my hair. If she ever watches this, she's gonna kill me. But she'll probably make my hair like turn some funny color. But at the end of the day, it is the reality. And uh so because we're at the mercy of whatever they decide, and you're not supposed to talk to Babby, you're supposed to share your numbers. That's that's a real big issue.

Christopher Gleason 40:25

Yeah, yeah. So, Wendy, I'm kind of curious. In in today's day and age, what do you think a what role do you think AI is going to play in coding and billing?

Wendy Wright 40:33

Huge. It's already playing with usual.

Christopher Gleason 40:36

Is it?

Wendy Wright 40:36

I don't know if you've heard that there are a couple of insurers now that are running claims through AI, and AI is telling them that the code was over overveiled based on what was what was seen in the diagnosis. And so they're automatically down coding it and they're paying a reduced rate without even looking at Edwin's notes. We're already staying at our clinic. We're hearing it from NPs around the country that their visits are being down coded. So what we're doing is we're sending a letter to these insurers and saying, we want and let us submit our documentation. We've been able to reverse. We've only had three or four of these episodes happening in our clinic, but our biller is watching this like crazy because AI is the source behind all of this. But let's turn it around. Yeah. Throw your throw your notes into AI. We use AI in our clinic. AI looks through all of our documents that come in, it summarizes all of our documents for us, and uh then it gets reforwarded to the MPs. All they have to do is just quickly look over the summary, make sure it's pretty accurate, and sign it off. Like AI is really the future, but it ha but it's being used by some of these companies to damp bully miss it.

Jason Gleason 41:54

Sure. Yeah.

Wendy Wright 41:56

But I think it'll be a great audit tool for all of us. Pop your visit and tell me, tell me, is this coded the way it's supposed to be? Right. I could print, I could take my notes, throw it up there and say, tell me what the uh what the code should be for the level of this visit in an established patient.

Jason Gleason 42:12

It's exciting and maddening at the same time.

Christopher Gleason 42:14

Is that right?

Jason Gleason 42:15

Truly.

Christopher Gleason 42:16

True.

Vanessa Pomarico 42:16

Yeah.

Christopher Gleason 42:17

Some great information, Wendy. I think I'm gonna turn it over to Vanessa now.

Vanessa Pomarico 42:20

So we do have some um audience engagement questions that we have gotten. So I'm gonna I'm gonna address this to you, Wendy, and then um I always say that Jason and Christopher are the princes of the VA system because they don't have to do a lot of what we have to do out in the private sector. But Wendy, what's one billing mistake you learn the hard way?

Wendy Wright 42:42

That's a good one. One billing mistake we learned the hard way. I guess to look back and see how many visits we undercoated and left money on the table. I I mean, it's never coming back. My analogy to the MPs is it's like a Marriott. You don't sleep in the bed, you've lost that night, right? Marriott's lost that night. If that bed goes unslept in, you're you can never go back and say, hey, you underpaid me. So I think that that's the issue is making sure, like I told you, my sister is a bell or coder. She literally is cockey carry. She doesn't leave a dollar on the table, and she's not afraid to go after any penny because her thought is, you know what, you guys work really hard for this, and this is what the NPs are paid on. This is what their raises come from. I don't want to be that authorist that never goes out and collects money. And as so the other thing I would tell you is having worked in forensics, NPs need to know what's being done on your behalf. Because if you have trappy collections, you're gonna pay the piper for that. Because at least in my clinic, we have very little money. I think right now I looked at our our patient responsibility balances. We're running at 14,000. Right now, we're a five million dollar a year entity. That's very little amount of money on the table. And that's because our team works so hard. And I think people also recognize, you know, we're independent. And when you're independent, I don't know if you're all aware, but there's a facility fee that gets attacked on if you work in a hospital. So hospital billables are three times that of private offices, and their collections are three times because they're given a facility fee, and that's meant to take care of the uninsured and the underinsured and people who don't pay their bills. I maintain my patients don't always pay their bills either. Why are you paying us so much less? So my patients have become very savvy. What they say is I don't want to go to that specialist over at wherever. Because you know what they do? When they bail out my when they order my labs, they tell me they want me to go to the hospital. They tell me they want the ultrasound out at the hospital. And you know what that means? They're all going to be billed out at hospital rates, which are three times higher than some of these low-cost centers. So that's a very long-winded answer. But people would become really savvy because now you and I have deductibles. I do.

Jason Gleason 45:18

Oh yeah.

Wendy Wright 45:18

And and people are savvy with that.

Vanessa Pomarico 45:22

Well, what's something you wish you learned uh in your nurse practitioner program about billing? Besides all of it.

Wendy Wright 45:30

Right. You know, I I don't even remember learning much about it at all. But I I think billing and coding, I think you need a foundation. But I also think you need to do it. And I think you need to have people. I'm telling you, my sister sends out messages and says to the team, please stop billing pesplanus. Why, you might ask me? Because it's a podiatry code. So every time you put pes plainus in your diagnosis codes, we get denied. I never do stuff like that. I don't know. She said, please, please call it foot pain. If you just put foot pain, get flat seed, we're gonna get paid on it. But if you have pes planus, where you put presbyopia, we don't have presbyopia. If you put that, that's an ophthalmology code. You automatically deny we it's denied. Now in our EHR system, when I finish a visit, it goes to the billar and it's scrubbed in a house. And so what that means is the computer says, You need to make this code more specific. This code is gonna deny your claim. Like it gives you things that before it goes out to the clearing house that you clean up. Otherwise, you're gonna get in denial because every denial costs the practice ten to fifteen dollars in work time, in resubmission time. And so I wish I had known coding and billing better, but I think having a foundation and then having to use that, every NP in my clinic is taught how to bill and code from the day they start my clinic. And we asked them to bill and code the visit, and our mentor who they're assigned in the first year double checks their billing and coding for the first year to ensure. And then we have our coder who's obviously checking before anything goes out the door.

Jason Gleason 47:21

Very nice.

Vanessa Pomarico 47:22

So so the rule of thumb is here all of our listeners, everybody wants to go work for Wendy.

Christopher Gleason 47:27

Exactly.

Vanessa Pomarico 47:28

Because not only will you get a fellowship, but you're gonna learn how to build the right way. Well, these are absolutely amazing tips, Wendy. Um, we do have some resources to share on air, and the audience can find these in the show notes. Uh, so the one of them is Carolyn Buppert. She has uh a training module online. Another one is the NursepractitionerOnline.com. They have seven resources for nurse practitioners to decode primary care billing and coding. And then there's also the McGraw-Hill Access APN billing and coding, and all of these again are in the show notes. Well, this brings us to our favorite part of our podcast, Wendy. It's called Fact or Fiction. So I'm going to ask the questions. I'm going to start with you, Christopher. If you spend more time with a patient, you can always bill a higher-level visit, fact or fiction.

Christopher Gleason 48:16

Fiction.

Vanessa Pomarico 48:17

Right, exactly. Um, remember that your documentation has to support your total time and your activities, as Wendy had discussed. All right, Jason, nurse practitioners always get reimbursed at 100% of the physician rate.

Jason Gleason 48:31

Factory. Oh, I wish that was the case.

Vanessa Pomarico 48:33

Fiction. Fiction. Right. It's as Wendy had mentioned, we get reimbursed 85%.

Wendy Wright 48:39

Um at least for Medicare.

Vanessa Pomarico 48:41

At least for Medicare, right. So Wendy's.

Wendy Wright 49:02

So it's doable. So it's doable. And you know why? Because the insurance said physicians aren't showing up to take care of these patients. NPs are. And we want to reward the quality of work that they're doing. So it is doable. It doesn't have to be 85%, but it requires all of us working together to negotiate on behalf of NPs.

Jason Gleason 49:23

And have the courage to ask for what we deserve, right?

Wendy Wright 49:26

And to have the data to back it off, right? You could say one thing, but until you show those numbers and until you show what we've been able to collect, it really uh that's why I publish every single year the work that we're doing in our clinic to just contribute to the body of knowledge around nurse practitioner like led care.

Vanessa Pomarico 49:46

Wendy, where do you publish these findings for our audience?

Wendy Wright 49:51

So I just did two op-eds in uh JNP with Elaine D. Simone, the editor. So A-A-N-P, if you go there, you look at the journals, we have two op-eds, and we've started to publish some of our quality metrics.

Vanessa Pomarico 50:06

Nice.

Wendy Wright 50:07

Our next plan is to look at uh cost. But I was just looking at some of our documents today from the state of New Hampshire, the NP practices there. Our inpatient care is down 32% from the market for patients who are being managed by nurse practitioners. Our outpatient care is about 25% below the market rate. So insurers love this data. You got to put your money where your mouth is. You bet. And I think I think that that really speaks volumes. There's this whole myth out there that we cost the system more because we don't know what we're doing. It's a bunch of bull crap. And we're gonna show that it's a bunch of crap. Good for you.

Vanessa Pomarico 50:46

All right, our last factor fiction. Wendy, this one's for you. You can build what if I get it wrong? I don't think so. You're the you're the expert guru in the house, right? All right, you can build incident, you can build incident two services even if the physician never sees the patient. Factor fiction.

Wendy Wright 51:05

That is fiction. It has to be a patient that you are following up from a physician visit. Fiction.

Vanessa Pomarico 51:14

Thank you. So for our mail drop, make sure that you email your questions to nplaunchpad at fhea.com. Again, that's nplaunchpad at fhea.com. And we have two on-air questions here. Are telehealth visits billed at the same rate as in-person visits, Wendy?

Wendy Wright 51:33

So the answer is you bill them out at the same rate or whatever you charge, but they may not reimburse you at that rate, depending upon the different insurance companies. With COVID, it was amazing. Everything we billed out came back at the exact rate of an in-person visit. But some of the insurers, depending upon the state you're in, are starting to drop the reimbursement for telehealth. And I think it's a real tragedy because for so many of our patients, so much can be done on telehealth. I don't think it's an in-person substitute. I mean, I don't think it takes the place of in-person care. We showed in a diabetes study that we published that patients that were seen by a telehealth had worse A1Cs, worse weights, worse blood pressures, because you can lie about that. Right. Oh yeah. I can't see it. But at the end of the day, I think for people who have social determinants of health, who care for gased, who don't have time to offer work. I have patients who go out at lunchtime and do their telehealth visit in their car with me. I think that's huge. I think it's huge. So you bill it at the same rate, but they may not pay you at the same rate.

Vanessa Pomarico 52:43

Sure. Excellent. And this question you actually had answered previously about can time spent documenting after the patient leaves the office count toward your billing time?

Wendy Wright 52:53

You betcha. It should count toward your billing time as long as you complete it that day. So those of you who don't get your charts done on the day you see the patient and you have 50 opening counters in your box, you need to get your stuff together. You need to get those charts done. Standard of care is really within 72 hours of the visit that everything should be signed off. We call that timely filing, if you will. Um, and remember one other thing about billing many insurances put a cap on when that charge has to be correct and in their in their clearing house. And so if you don't do your charts and there's something wrong with that charge and you don't finish it off for two weeks, and then it goes out, it's got the wrong address or the wrong ID number. Guess what? We have to resubmit it. And some of our insurers have a two-week timely filing. That means you've now worked for free. None of that money will ever come back to your clinic. Wow. Medicare allows a year. Most of my insurances have 30 days of timely filing. And that's really tough. Really tough. So it's why we all need to get our stuff done. More reasons than that to get our stuff done, but we need to get it done in a timely manner to make sure you're paid for the work you do.

Vanessa Pomarico 54:03

Absolutely. And who can remember the next day? I certainly can forget about it.

Wendy Wright 54:11

I can't even remember what I did an hour ago, let alone two weeks ago, right?

Vanessa Pomarico 54:17

Well, as a special appreciation to all of our listeners, we'd like to share some special savings with you. If you visit the FHEA.com website and you use the code launchpad20, you'll get an additional 20% discount off of all of our continuing ed library, which is huge. And there's plenty of things that Wendy has a lot of continuing ed in our library, but launch pad 20 for 20% off as our way of saying thanks for supporting the show. Well, we're going to do our landing checklist. We have some three take-home tips for your homework. Um, what we want if you wouldn't mind, if you would please drop us five stars if you think we deserved it. Hit follow, tap subscribe, and more importantly, please share our podcast with your NP colleagues, your fellow students, your faculty, your friends, and your family. And please make sure that you stay in touch with us and email us at nplaunchpad at fhea.com. Wendy, thank you so much for such an amazing podcast. We loved picking your brain about all things billing and coding. I'm I'm we could sit here and talk with you for another three hours about it.

Wendy Wright 55:31

And Jason and Christopher, if they want more information on billing and coding, I have a one and a half hour lecture up on the Fitzgerald Health Continuing Education. It walks through all the medical decision making, all the time and the requirements, the modifiers, the procedure codes. Please check that out. I think you'll find it really, really helpful for your career.

Jason Gleason 55:51

That's wonderful.

Vanessa Pomarico 55:52

Well, thank you again for joining us tonight, Wendy. We really appreciate it.

Jason Gleason 55:56

Wendy, we appreciate it. We hope to have you back. This would be great.

Wendy Wright 55:59

Listen, you can invite me, but you've got to make it a little earlier. This is really my bedtime.

Vanessa Pomarico 56:06

Thank you again. Take care, everybody. Until next time.

Wendy Wright 56:09

Until next week, see ya. Bye bye for now.

Voiceover 56:12

Bye now. You've been listening to NP Launchpad, presented by Fitzgerald Health Education Associates. Like, subscribe, and share. And for more tools to power your NP career, visit FHEA.com.