** Note: This post is part of a series of posts on my blog Musings of a Distractible Mind.

The Problem

In previous rants posts, I discussed the problems within the US healthcare system and some potential solutions. One thing that is not often discussed as being a major problem is the system by which medical billing occurs. Most non-medical people assume that the billing process is straightforward. Nothing could be further from the truth.

Code Confusion

There are several types of codes that doctors need to have for each visit:

• ICD Codes - An extensive list of diagnoses along with numeric codes linked to them (mainly for billing purposes).
• CPT Codes - Another extensive list - this one of medical procedures, such as laboratory tests, immunizations, surgical procedures, and office visit codes. These are also used mainly for billing purposes.
• E/M (Evaluation/management) codes - Technically, these are a type of CPT codes, but refer to the office visit and its level of complexity - this is the primary billing code used. It is accompanied by modifiers if there are special circumstances on the office visit.

While the extensive list of ICD and CPT codes is an excessive burden on physicians, for which nuances of incorrect coding can cause rejection by the insurance companies, the evil thing I want to address here is the E/M code. Really, this seems on the surface to be the simplest of the bunch. There are only about 20-30 E/M codes that are routinely used (compared to the over 8000 ICD codes). Yet the devil is in the details.

Driven to Document, Driven by Fear

You see, what you get paid for an office visit is not based on what you do at that visit, it is based on what you document. The more you can document, the higher you can bill.

So why not just document all visits at a high level so you can bill more? The main reason is that the rules are quite complex - requiring the provider to count:

1. the number of question types in the history of illness
2. the number of systems (eyes, ears, heart, lungs) reviewed in the general review of systems
3. the number of past history facts reviewed and included in the note (such as family, medical, and surgical history)
4. the number of systems examined on the physical exam and the number of details about specific systems (such as what the lugs sound like, what the chest wall looks like, what the chest wall feels like, and what the respiratory status of the patient is)
5. the time spent in counseling the patient
6. the level of complexity of medical decision making (which itself depends on three separate categories of complexity which must be assessed and documented)

It takes a long time to document these, and any mistakes could potentially come back to haunt you. If you are caught billing at a higher rate than your documentation supports (regardless of what you actually did at the visit), you could be found guilty of defrauding the insurance company (with Medicare being at the head of the list).

How to Cope - Playing the Game

There are several responses to this situations by physicians:

• Undercode to avoid the accusation of fraud
• Use EMR to document more and bill at a more appropriate level
• Code at the higher level without documenting higher and risk audit, jail, etc.
• Stop accepting insurance and just accept cash up front based on your own criteria
• Do other things besides office visits - such as surgical procedures, labs, x-rays, or other procedures that pay much better than the office visit. The pay for EKG with interpretation is nearly as high as that of the decision making that the physician makes that may save the life of the patient.

Undercoding - The safe route

Most physicians choose the first option, to undercode visits - code them at a lower E/M code than the visit itself merits to avoid the risk of an audit or worse. Studies show that a substantial percent of visits are not coded at a high enough level.

Overdocumenting - Using BS to bill better

One of the solutions to this is to use an electronic medical record (like mine). These programs often include tools to properly match the coding to the documentation and suggest how to document in a way that would result in better codes (and better pay). The problem with this is that it results in every note being far more verbose than is useful to the physician. Often when looking for information in the chart of a patient whose physician uses an EMR is like trying to find a number in the phone book. Most of the information is not there for any other reason than to placate the E/M gods.

The result of all this is a constant "gaming" of the system to get the most of the system by documenting unnecessarily. Physicians on EMR simply have a better way of putting a lot of BS in a note so they can bill higher. Yet even the EMR physician is under some stress, because if you bill enough higher level visits, you show up on Medicare's database as an outlier and are much more prone to an audit. Since the rules are enough subject to interpretation, it is probable that the vast majority of charts can be found to have some notes that are not consistent with their billing level - constituting again Medicare fraud. If someone wanted to catch and convict any physician on Medicare fraud, they probably could.

Notice that I have at no time in this discussion discussed the quality of the care given. It does not matter if you are saving lives, saving money, preventing disease, or deeply touching the lives of the patients. It all hinges on what you put in your record, and not whether you do the right thing.

Refusing to game - Taking the risk

Some physicians just roll the dice and bill at a level above their documentation. This is not necessarily because they are greedy and are trying to cheat the system, they often feel they are simply billing at a rate that is justified by what they did at the visit and don't want to play the game. Yet these physicians will be the first to "face the firing squad" if there is a crack down on fraud. This is a shame, because they are often doing good medicine; they simply refuse to play the billing game.

Quitting insurance altogether

All of this has caused there to be a growing trend of physicians to stop accepting insurance at all. In a previous post on the state of healthcare in America, I responded to a comment by someone stung by the fact that many doctors in her area were turning to this option. This may be a good solution for the physicians, but it leaves the patients with a difficult decision: either pay cash and have the doctor you want (and this may cost quite a bit out of pocket), or change physicians to someone who accepts insurance.

While this may be a viable option for physicians in certain circumstances, it would cause the entire system to collapse if adopted by a substantial percent of physicians.

Do "profitable" procedures

To some extent, this is a strategy taken by most physicians. We have a bone density machine, EKG's, Lung function tests, and a variety of lab tests we do in our office. We also have physicians who do injections, cut off skin lesions, etc. that are quite profitable when compared with doing routine office visits.

There are several problems with this approach as well: first, the insurance companies have noted that these procedures are causing them to pay more out and so are monitoring them much closer to assure they are being only done when needed. This results in more conflict between the insurance carriers and the physicians over what is necessary and what is not.

The second problem is that it puts the physician in the position of ordering tests on the basis of what is profitable, and not necessarily what is in the best interest of the patient. The ethical standards of the physician are pushed to decide when a test is appropriate and when it is not - even if it would hurt the bottom line of the practice.

Solution?

What is the solution? To avoid making this post too long, I will stop here and see what my readers think are good solutions. How do we change the system from one that is full of fear, accusations, gaming the system, and inefficiency? How do we become more efficient? How do we reward less care?

I have my thoughts on this, but I want to hear what others have to say.