In The Eyes of Medicare, You are a 99223

What the hell does that mean?

Well. It means everything.

And it means nothing.

It is the vast land of numbered codes, the mystery of billing that every physician must grasp, or at least their office staff, in order to get payed for services provided.

To remain a viable business of providing "health care".

To remain relevent.

It is called coding. How I get paid.

And as much as I love it (because I'm good at it, really good at it), it is a ridiculously difficult and arbitrary. So difficult and vague that often times audits by Medicare often result in multiple different opinions by Medicare themselves, by their auditors.

It is a system of confusion.

And I'm am here to say. It is absolutely insane. 100% insanity. It is the system of codes, which all insurance ( Medicare/Medicaid/private insurance) use to determine "level of care".

To determine who much your time/surgery/procedure is worth.

How much you get paid.

It is, in the end, the most important, life sustaining element for physicians, because coding determines your income.

And because of that, let the games begin.

It is the futile attempt to bring rings of value to medical service.

Services which are so vastly different and unique for every patient.


I will attempt to walk you through an example of the payment system, and how it relates to relative value units (RVU's) and ultimately how that affects physician reimbursment.

The number of codes is massive. For all imaginble procedures, encounters, surgeries. Any possible health care interaction.

Hospitalist medicine is limited (thank goodness) in the types of codes we use. So I only have to remember a few.

95% of my billing is based on about 20 codes.
3 Admit codes (99221,99222,99223)
3 follow up codes.(99231,99232,99233)
2 critical care codes (99291, 99292)
5 consult codes (99251-99255)
5 observation codes (99218-99220, 99217)
2 Discharge codes (99238, 99239)

There are a few others, but these 20 codes determine my very financial existance.

Medicare says so.

Imagine a surgeon. A primary care doc, a proceduralist. Every single interaction has a code there are codes for codes, modifiers for codes, add on codes, dissallowed codes. V codes, M codes. It is endless.

Thousands of them.

And you have to get it just right. Every time.

Or you don't get paid, or you are accused of "fraud".

It is an immpossible feat. The process of taking care of patients has turned into a game of documentation. And it has affected medicine drastically. That will be blogged later.

Let me walk you through a 99223, the code for the highest level admit for inpatient care. A level "three".

There is no actual law, as I understand it, on the Medicare books that definitely defines the requirement for the codes. There are generally accepted "guidelines." 1995 and 1997 "guidelines". Even the guidelines from different years are different. And you are allowed to pick and chose from both.

More silliness.

The following is my understanding of what Medicare requires to bill a level 3 admit, a 99223.. You must have every one of them or it's considered "fraud", "overbilling", "waist", pick your NYT's tag line.

1)HPI: The history of present illness. It requires 4 elements (character, onset, location, duration, what makes it better or worse, associated signs and symptoms) or the status of three chronic medical conditions.
2)PMH: Past medical history. It requires a complete history of medical (medical problems, allergies, medications), family (what do your parents ail from), Social (do you smoke or shoot up cocaine?) histories.
3) ROS: Review of systems. A 12 point review of systems which ask you every possible question in the book. Separted by organ system.
4) A comlete physical exam: With components of all organ systems.
5) A high complexity of "medical decision making". This one is great. It is broken down into 3 areas and you must have 2 of 3 components as follows. Pull out your calculator.
5a) Diagnosis. 4 points required to get high complexity. Self limiting, established stable, established worsening, new problems with no work up planned and new problems with work up planned are each defined a different point value and some have maximum additive amounts, and some don't. Add up the points to get your total
5b) Data. 4 points required for high complexity. different components are worth different amounts on such things as reviewing or ordering lab, reviewing xrays or EKG's yourself, discussing things with other "health care providers" (which I have never been able to define.), reviewing radiology or nuc med, obtaining old records etc. Each element is worth a different number of points. Add up the points to get your total.
5c) "Concepts" I call this the basket. Predefined, sometimes vague medical process that are defined as "high risk". Such as close monitoring of drug levels, de-escalating care, severe exacerbations with threat to "life or limb" changes in neuor status.

And you must have 2 out of 3 components of high risk for medical decision making for #5.

This is coding in a nutshell.

A 99223.

It is Medicare Medicine.

To get payed, I must document what Medicare says I must in order to care for the patient. They are telling me what is important. They are Dr. Government.

This is ONE PATIENT. ONE ENCOUNTER. ONE DAY.

The Rules are different for inpatient followup, discharge codes, critical care codes, observation/admit same day codes.

The rules are all different.

And I have to do this for every single patient I see. Every day. Over 2500 times a year.

And I am expected to get it right 100% of the time.

I am good at coding because I took the time to learn the rules. I know exactly what I'm doing. But it took me along time. I would say a good 2 years to really grasp it.

And that is with a limited arsenal of 20 codes.

Imagine trying to do this with an outpatient arsenal of 100's of codes.

This is the state of medicine. I carry around cards that help me. There are multi billion dollar industries that do coding, submission, denials, software. It is built on the premise of Medicare's rules.

Not medical care. And it adds billions to the system in lost productivity.

You're doc may be running late in the office because they are busy documenting what Medicare says they must in order to get paid.

The subject of coding is enormous and will try and turn it into a multi part series.


Chew on this for awhile. This is "quality" medicine in 2007.








It is something most doctors fear. Most doctors dread. And most doctors don't understand.

The system is insane.

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