Another great excerpt from Movin' Meat
My take on why it costs you $500 just to say hello to the ER.
A 48 year old walks into the ER with the sniffles.....
Here we go...
Your illness is not an illness. It is an alphabet soup.
It is a 3 or 4 or 5 5 digit number (the more specific the decimal point, the more your doctor has pinned down the specific diagnosis). The World Health Organization owns the ICD codes
International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10)
These are the codes for which Movin' talks about.
The AMA (American Medical Association) on the other hand owns the CPT codes (Current Procedural Terminology) and will sell you a copy for $102.95.
In 1983, the government mandated the use of the CPT system to report services for Part B of the Medicare program. Three years later, it extended the requirement to state Medicaid agencies. Today, CPT is the preferred system of coding and describing healthcare services for private insurers, as well.
These are the codes that physicians actually submit to the insurance company to prove they actually did a service.
These CPT codes were further delineated into E&M codes (Evaluation and Management).
But because these explanations often used vague words, Guidelines were developed to help physicians determine what level of service they actually performed.
There are 1995 guidelines and 1997 guidelines.
These are the 99223 codes and other "levels of service" that determine how much your doc gets paid.
What do you think so far.
When your doc submits their claim to get paid, they must document their ICD codes to prove you actually had a complaint or a disease, and that you just didn't come to the docs office to talk about the BIG DANCE.
Then they must spend lots of time documenting based on rules and regulations from impossible guidelines and hope they get it right, so they aren't accused of fraud
This is just the physician part of your ER visit.
And every physician must do this, from the ER doc to the radiologist, to the pathologist to your internist and family practioner.
And this doesn't even include all the hospital rules and regulations.
That's a whole other ball game. A HUGE other ball game, with a whole alphabet soup of its own.
Remember that 48 year old with the sniffles that walked into your ER?
The $500 visit?
Why do we pay so much?
It's layer after layer after layer of bureaucracy. Every layer justifies another layer.
I belong to a list serve that does nothing but ask questions all day long about how to code this and that. These are coding experts in doctors offices and hospitals asking other coders for help on how to code.
Who pays for all that?
We all do.
A layer that the Medicare National Bank requires everyone to follow to get paid. They justify the existance of a cost structure out of control.
You want to know where your money is going?
I'll tell you where it's going.
It's going to pay for rules and regulations that are created out of the need to control all aspects of your care.
6 Outbursts:
I think it was Winston Churchill who said something along the lines of "Paperwork is the embalming fluid of a bureaucracy. It gives the appearance of life where none really exists."
I think that quote about sums up what our health care system has basically become. Just a corpse embalmed with lots and lots of paperwork.
By the way, how can I subscribe to that listserve so that I too can try to unravel this E&M coding mystery? (I'm not completely certain, but I think I've at least identified the language the rules are written in as being some ancient form of Sanskrit!)
The list serve is less involved in actual E&M coding. It asks more important questions like
These are actual examples:
"Does anyone know the code for a umbilical polyp removal? It was infected if that helps."
"Dr. A sees pt in hospital, pt. gets worse Dr. B comes on board spends 85 mins of critical care. How can I bill for both docs?"
"Does anyone know if you can code for an ear wash with an office visit when you are not an ENT? We use a lavage system by the nurse."
"Anybody out there work with family medicine residency programs? I have a quick question, but I know it's late on a Friday afternoon....If any of you bring on outside preceptors, any idea on what you might pay them? Do you do it by the hour or half day? thanks"
"Pt was seen in an Adult Day Care am I correct in using POS 99? The claim was billed with 99 POS and the consultation was denied but 11720 was also done on same day billed with same POS and that was paid. Please help!"
"This is the scenario-pt sees PA on first visit, even a couple subsequent visits. Then she starts to state patient seen under the supervision of dr.x. If the MD never had an appointment with the patient, isn't this pt to be billed under the PA always?"
"Modifier 25 is correct. I was told at a seminar that the diagnosis for the Smoking Cessation 99406 should be the medical condition that is adversely affected by the smoking or the condition is being treated with a therapeutic agent whose metabolism or dosing is affected by the tobacco use. You are not to use 305.1 alone. I see that you also used 272.4 and 733.00, so if those conditions are being affected by the smoking, it should get paid. I would appeal."
This goes on day after day after day. It fills my inbox with garbage. But I like skimming over it to remind me who ridiculous the system of caring for patients has become.
We all pay for this
Not to quibble with technicalities, but the AMA, not the WHO, owns the ICD-9 and CPT codes. They get hefty royalties from commercial entities that use them for financial gain. Otherwise, great post and I'm in full agreement.
independent urologist:
read here:
http://en.wikipedia.org/wiki/ICD
I think I was correct.
The actual questions from the list serve are REALLY effective at highlighting the bureaucratic nature of what we have to do. So painful and so poignant. Thanks for this!
-"Then they must spend lots of time documenting based on rules and regulations from impossible guidelines and hope they get it right, so they aren't accused of fraud"
I understand your perspective and complaints regarding the documentation process and for the most part I agree with you. From a revenue perspective, that's all we have to justify claims payments. I constantly have carriers down coding 99213's to 99212's. The only way I can justify the coding we use is through the documentation. That's just one simple example. I have a doc who refuses to adjust his documentation style, and guess what happens to his claims? However, I understand where he's coming from (much like your complaints) but this is the game.
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