American Medicine - Evil and Malevolent Coding (E/M)
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:
- the number of question types in the history of illness,
- the number of systems (eyes, ears, heart, lungs) reviewed in the general review of systems
- the number of past history facts reviewed and included in the note (such as family, medical, and surgical history)
- 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)
- the time spent in counseling the patient
- the level of complexity of medical decision making (which itself depends on three separate categories of complexity which must be assess 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:
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.
February 28th, 2007 at 9:56 pm
Just think this is what I am going to school to learn.. *whew*. I do know that they say HIT is one of the bigest growing professions in the area. I also think alot of it depends on the Ins companies. HMO’s are alot worse the PPO I do believe. I don’t know the answer. I do know that I don’t want the govt to be in charge of all ins cause then it would be worse then HMO as far as them telling us what we can and can not do for care. I have heard some real horror stories about people not being able to get test done etc through Medicare and such. I also know I hear alot of Docs saying how they are no longer taking Medicare so I doubt they would be liking the idea of Govt controled ins.
I do know I always thought I had an amazing doc now I just think she is a saint;)
February 28th, 2007 at 10:59 pm
Great post, this.
I’ve taken a little bit of each approach in my practice - I’ve sropped all but one or two well-paying plans (but keep medicare because it’s just wrong to drop it, even though so many of my colleagues are). This has allowed me to see a few less patients every day without a loss in income, and lets me spend the time I need to give good care. I use a lot of time based billing for things like Menopause management, PMS, depression, PCOS, sexual dyfunction, etc that require a lot of conversation. I bring these patients in at the end of the day so I won’t be rushed, and keep track of the time. I use a click and point template rather than cut and paste in the EMR, so I can’t overdocument by mistake.
The only “gaming” of the system I do is when a ptient comes for what she calls a “routine” or “annual” check up, but then I find problems that require treatment. If I am not in her plan, I ask her which way she is more likely to get reimbursed for my visit- preventive or problem visit. Given I have done both, I could code either way, it’s legit and works for the patients and for me. (I don’t bother carving out the problem and preventive portions like I do in Medicare because most plan have no idea what to do with that kind of bill. )
Your posts are SO well-written, by the way. I really enjoy your blog.
February 28th, 2007 at 11:05 pm
This is a great summary of our coding system! If I could provide you with the solution in a few paragraphs, I’d be a Nobel Laureate. There are many good people who propose very different solutions… but my personal opinion is that enhanced IT is the best way through. In theory, automating a lot of this coding process, as well as providing accessible price transparency, e-services (to keep folks out of the doctors offices when they don’t need to be there), as well as a network of tools and services to help people prevent disease or manage their chronic problems would solve a lot of our problems. This is the approach that advocates of the new IMP (Ideal Micro Practice) primary care model advocate.
Now, that still leaves the folks who are too ill, uneducated, or too poor to participate. They do need a safety net. Most say that a government sponsored system would be appropriate for them (and obviously that’s what we have now in Medicare and Medicaid), though I worry about the sustainability of this system with higher volumes of aging boomers. IT does have a role to play here too, as many companies are competing to design automated/electronic home monitoring devices for the elderly so that if they’re decompensating, we can catch them earlier on and send help so they don’t end up in the ER. Again, if Medicare and Medicaid were fully IT enabled (with EMRs, automated coding and payments, ePatient services, etc.) it could save itself a lot of money.
March 1st, 2007 at 1:32 pm
You are all trying to butter me up. I am too much of a free-market guy to favor a one-payer system. I agree with Val that there may need to be a bigger “safety net” for those with no coverage (perhaps even for all inpatient care). It interests me that TBTAM does not get rid of Medicare. How many of these patients do you keep compared to the self-pay? It seems that most get rid of it first because of all of the rules that come along with accepting Medicare. We have been able to succeed in our practice despite accepting most insurances, but I am sure it is different than in NYC.
In future posts, I will touch on the idea of the “medical home” as put forth by the AAFP, ACP, and AAP. This sounds similar to the IMP - is that true, Val?
March 1st, 2007 at 10:35 pm
The “medical home” is the AAFP’s (and other primary care physicians) concept of centralizing care through an individual team leader (the PCP). What we’ve observed over the years is that patients are seen by a smorgaasbord of specialists, most of whom do not share information. This results in decreased quality of care due to repeat testing, duplicate prescriptions, and piecemeal diagnosis and treatment with only a superficial understanding of who the patient is and what he/she really needs. The argument is that if these patients had a medical home (a team lead who could help coordinate their care) they’d be much better off.
I do believe that the AAFP is correct, but I am not convinced that returning to a “gate keeper model” is the right application of this idea. I believe that patients should have an Internet-based medical home, complete with coaches, disease management programs, physician email service, a PHR, and an insurance advocate system. Their primary care physician (and their specialists) should be invited to their home base to review their lab tests, vitals, and general self reported progress with disease management. The docs can give them some tips, and schedule in person meetings only as needed. (This is what Revolution Health is trying to create.)
Consumers have to drive this - because then we docs will follow. I doubt that docs will initiate this eHealthHome.
Now, the IMP concept is not so much about a medical home as it is about radically reducing overhead via IT, so that a physician can see fewer patients and still make a decent salary. Quality of care is enhanced by the luxurious 45 minute/patient H&Ps, and everyone enjoys the process so much more.
Hope this helps to explain what I was getting at… Keep up the great work, Rob. TBTAM is right - you’re an excellent explainer/writer!