I blogged here about the insanity of the billing rules. The rules Medicare put into place as attempts to create a defined value of service. What is that encounter worth? Why is it a 99223? The rules are complicated, extremely complicated, and often times vague and arbitrary. I know having 3 different Medicare auditors evaluate the same note could potentially get 3 different opinions as to the level of service that it qualifies for.
The result of the rules determines how doctors document. And ultimately how much they are paid. You won't spend 1/2 an hour writing a novel if you don't get paid for it. Global surgery fees and how surgeons document their follow up notes is the classic example I have given.
Dr Rich graciously took the time to explain E&M coding and the history of this devil. Head on over to the E&M link I provided and you will understand how complex it is and why it is so difficult to grasp.
Dr Rich is correct. I have practiced medicine unaware of anything but the insanity of current coding requirements. I have accepted it as the only truth out there. By necessity. I have made the decision to be good at it. It is something that took me hundreds of hours in the last several years. Self taught in all respects. And non-reimbursable.
If this doesn't scream of lost productivity than it's time to refresh your economics class.
I might add one other thing to Dr. Rich's comments. Doctors are in general so afraid of getting it wrong, that they error on the side of caution. They simply do not grasp all the minute details that E&M guidelines say you must meet to "qualify" for a level of service/payment.
I hear it all the time. Doctors simply do not understand the rules. And they bill on the side of caution. They under bill. They are afraid of an audit.
If in doubt, bill down.
That is a universal theme I always hear.
Guess what happened when doctors started buying computer documentation programs that did a lot of the documentation calculating for them.
They shifted their billing patterns upward. The programs told the docs instead of billing a level 3, you can bill a level 4. The rules Medicare stated in their guidelines allow doctors to bill that level 4 and the computer program said so.
Technology is always better. Right?
Guess what happened. The bean counters started realizing that they would have to pay doctors more. Private insurance companies always follow the lead for Medicare as far as reimbursement.
However, when they saw their docs billing more level 4s, some attempted to "create" new blended codes where a level 4 becomes a level 3-4. You can see where this is going. Level 4s get paid less, level 3's get paid more.
And as the payments for services shift upward the pot of money remains fixed.
The Medicare National Bank will ultimately pay less for more.
While patients continue to demand more for less.
These two realities are incompatable.
How ridiculous. How unfair. For years doctors were (and still are) too afraid to get their due for fear of a Medicare audit for submitting "fraudulent claims." The moment the Bell curve of coding shifts upwards there is an outcry that doctors are using the computer data entry as a way to get more money. They are fraudulently submitting work that they didn't do.
That the computer assisted documentation of work is fraud. The very documentation that Medicare wants. That it demands to get paid.
How about get what they have always been due but were afraid to ask for.
How about investing in technology able to accurately decipher the vague guidelines established by our very own Medicare.
Our very own group of docs was audited by Medicare. We had outliers. Our Bell curve was shifted.
My understanding of the process is very superficial. I believe that Medicare has data on all the codes all docs submit. For me, the ratio of level 2 to level 3 followup codes. For outpatient docs, the ratio of level 3 to level 4 to level 5 clinic codes.
Medicare has their own Bell curves, regional distributions that compare you to other docs in your community. If you are billing more level 4s than other docs in your community, than you are an outlier.
You must be committing fraud. You just bought yourself an audit. You are a suspect by numbers.
Forget the fact that maybe the whole bell curve is shifted downward, that every doc under bills for fear of getting that distracting audit.
Forget the fact that some docs may actually understand the rules well enough to know that they should be billing higher levels, more often.
For hospitalists, our patients are sicker (at least in my community). Our severity of illness is higher when compared to other internists and FP's in my community. I have the data to back that up.
Taking care of sicker patients leads to higher billable codes.
But the Bell curve doesn't factor that it. It just sees higher billable codes.
It doesn't factor in the fact that I have taught all 18 internists in my group the basics of great accurate coding. The minimum requirements to achieve a billable claim that isn't considered fraud in the eyes of the Medicare National Bank.
We passed our audit with flying colors. And when they tried to audit us again, we justified our billing practices based on our history with the previous audit. Agreeably, the audit was aborted.
We won.
But really we all lose. The whole system of care. Worrying about whether we bill to many level 2s or level 3s, instead of worrying why primary care is dying at the hands of the RVU system. Pitting doctor against doctor in the search for reimbursement. It has been a LOSE-LOSE government innovation from day 1.
It will only be a matter of time before it kills procedural specialists and surgical subspecialists.
The delayed gratification will move toward banking, Wall street, lawyers, technology, engineering, Silicon Valley. All fields competing in a market economy for the same brain power. Health care strapped in a socialist reimbursement model and straddled with a market economy cost structure.
Doomed for failure.
The result of the rules determines how doctors document. And ultimately how much they are paid. You won't spend 1/2 an hour writing a novel if you don't get paid for it. Global surgery fees and how surgeons document their follow up notes is the classic example I have given.
Dr Rich graciously took the time to explain E&M coding and the history of this devil. Head on over to the E&M link I provided and you will understand how complex it is and why it is so difficult to grasp.
Dr Rich is correct. I have practiced medicine unaware of anything but the insanity of current coding requirements. I have accepted it as the only truth out there. By necessity. I have made the decision to be good at it. It is something that took me hundreds of hours in the last several years. Self taught in all respects. And non-reimbursable.
If this doesn't scream of lost productivity than it's time to refresh your economics class.
I might add one other thing to Dr. Rich's comments. Doctors are in general so afraid of getting it wrong, that they error on the side of caution. They simply do not grasp all the minute details that E&M guidelines say you must meet to "qualify" for a level of service/payment.
I hear it all the time. Doctors simply do not understand the rules. And they bill on the side of caution. They under bill. They are afraid of an audit.
If in doubt, bill down.
That is a universal theme I always hear.
Guess what happened when doctors started buying computer documentation programs that did a lot of the documentation calculating for them.
They shifted their billing patterns upward. The programs told the docs instead of billing a level 3, you can bill a level 4. The rules Medicare stated in their guidelines allow doctors to bill that level 4 and the computer program said so.
Technology is always better. Right?
Guess what happened. The bean counters started realizing that they would have to pay doctors more. Private insurance companies always follow the lead for Medicare as far as reimbursement.
However, when they saw their docs billing more level 4s, some attempted to "create" new blended codes where a level 4 becomes a level 3-4. You can see where this is going. Level 4s get paid less, level 3's get paid more.
And as the payments for services shift upward the pot of money remains fixed.
The Medicare National Bank will ultimately pay less for more.
While patients continue to demand more for less.
These two realities are incompatable.
How ridiculous. How unfair. For years doctors were (and still are) too afraid to get their due for fear of a Medicare audit for submitting "fraudulent claims." The moment the Bell curve of coding shifts upwards there is an outcry that doctors are using the computer data entry as a way to get more money. They are fraudulently submitting work that they didn't do.
That the computer assisted documentation of work is fraud. The very documentation that Medicare wants. That it demands to get paid.
How about get what they have always been due but were afraid to ask for.
How about investing in technology able to accurately decipher the vague guidelines established by our very own Medicare.
Our very own group of docs was audited by Medicare. We had outliers. Our Bell curve was shifted.
My understanding of the process is very superficial. I believe that Medicare has data on all the codes all docs submit. For me, the ratio of level 2 to level 3 followup codes. For outpatient docs, the ratio of level 3 to level 4 to level 5 clinic codes.
Medicare has their own Bell curves, regional distributions that compare you to other docs in your community. If you are billing more level 4s than other docs in your community, than you are an outlier.
You must be committing fraud. You just bought yourself an audit. You are a suspect by numbers.
Forget the fact that maybe the whole bell curve is shifted downward, that every doc under bills for fear of getting that distracting audit.
Forget the fact that some docs may actually understand the rules well enough to know that they should be billing higher levels, more often.
For hospitalists, our patients are sicker (at least in my community). Our severity of illness is higher when compared to other internists and FP's in my community. I have the data to back that up.
Taking care of sicker patients leads to higher billable codes.
But the Bell curve doesn't factor that it. It just sees higher billable codes.
It doesn't factor in the fact that I have taught all 18 internists in my group the basics of great accurate coding. The minimum requirements to achieve a billable claim that isn't considered fraud in the eyes of the Medicare National Bank.
We passed our audit with flying colors. And when they tried to audit us again, we justified our billing practices based on our history with the previous audit. Agreeably, the audit was aborted.
We won.
But really we all lose. The whole system of care. Worrying about whether we bill to many level 2s or level 3s, instead of worrying why primary care is dying at the hands of the RVU system. Pitting doctor against doctor in the search for reimbursement. It has been a LOSE-LOSE government innovation from day 1.
It will only be a matter of time before it kills procedural specialists and surgical subspecialists.
The delayed gratification will move toward banking, Wall street, lawyers, technology, engineering, Silicon Valley. All fields competing in a market economy for the same brain power. Health care strapped in a socialist reimbursement model and straddled with a market economy cost structure.
Doomed for failure.
Next up will be how my 99223 is translated into an exact dollar amount via the RVU system and why and how this has killed primary care, and is now as Dr. Wes points out, is killing general surgery. And given time, all of medicine. The fixed pot says so.
I got the picture from here
1 Outbursts:
Based on "medical decision making" section of the coding rules, all coding is a judgement call. And therin lies the rub.
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