I recently blogged about the insanity of CPT® medicine by describing how physicians earn a living. Medicare's rules are an attempt to create a defined value of service. What is that encounter worth? Why is it a CPT® code 99223? The rules are 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 half an hour writing a novel if you don't get paid for it. The global surgery fee and how surgeons document their follow up notes is the classic example I have given.
I have practiced medicine unaware of anything but the insanity of current coding requirements. By necessity, I have accepted E/M coding as the only truth out there. I have made conscious decisions to be good at it. It is something that took me hundreds of hours in the last several years to learn. I am self taught in all respects.
In general, doctors areso afraid of getting it wrong that they error on the side of caution. They simply do not grasp all the details that E&M guidelines say you must meet to qualify for a certain level of service and subsequent payment..
I hear it all the time. Doctors simply do not understand the rules. 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, they should submit a bill for a a level 4. The rules Medicare stated in their guidelines allowed 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 follow the lead of 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.
As payments for services shift upward and 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 incompatible. For years doctors were, and still are, too afraid to submit appropriate charges 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 by claiming they are fraudulently submitting work that they didn't do.
Now there are claims the computer assisted documentation of work is fraud. This is the documentation that Medicare wants and demands of doctors for them to get paid. Doctors are investing in technology that is able to accurately decipher the vague guidelines established by our very own Medicare.
My understanding of the audit 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. The assumption is that you must be committing fraud because you fall outside the bell curve distribution. Forget the fact that maybe the whole bell curve is shifted downward and that every doc under bills for fear of getting audited.
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. Worrying about whether we bill to many level 2s or level 3s, instead of worrying why doctors are leaving at the hands of the RVU system. This process is doomed for failure. See much more in my lectures on hospitalist coding and my list of resources.
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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