K.I.S.S. Is All You Need.

The documentation game has killed efficiency in medicine.

I can assure you that myself, and just about every physician in this country, who doesn't want to be accused of criminal fraud walks into every single patient encounter with the following thought in their head

"What is the appropriate level of service that I can bill for today.

In my group, I am responsible for determining what I bill.

As a hospitalist, I have a very limited number of codes that I use.

I'd say 90% or more of my billable codes are based on less than 10 codes.

Every single billable encounter MUST have an assortment of the following components

HPI (history of present illness)

PMFSH (Past medical family social history)

ROS (Review of systems)

PE (Physical exam)

Data (xrays/ekgs/labs radiology etc)

Decision making (Low medium high)

To get paid, I must document correctly 15 or more times a day, the exact stated requirements for every single above stated component.

For 15 encounters a day, with 6 parts each, that is 90 potential error points per day.

Assume 200 shifts a year, and that comes out to 18,000 potential opportunities for me to commit "fraud".

18,000.

Amazing. And that's nothing compared to how many encounters the outpatient guys see.

Every encounter is treated the same.

Same requirements.

Same everything.

Why is that?

Why should a patient who comes in to get their diabetes checked out be charged the same as a patient with an acute medical problem that requires an extensive workup.

The whole system, established by the Medicare National Bank places equal emphasis on all encounters based on the number of underlying medical conditions, and how much "stuff" you order.

I know the billing game forward and backward. I know exactly what is required to achieve every possible level of service from critical care codes to the 3 hospital admit codes, the 3 hospital follow up codes, the 5 consult codes, the observation codes, the observation/discharge same day codes and the two discharge codes

I know them well enough, that I could pass every single audit 100% based only on documentation, even if I was way outside the bell curve.

But the question I pose is.

Why?

Why is the system set up based on a unified game of counting points, reviews, exam components and complexity.

Let me give you an example.

If I was a clinic doc with an EMR and I had my patients fill out a complete review of systems in the waiting room for all encounters, and my EMR comparison had my medications, allergies, medical family and social history all pre documented.

AND I had 4 documented chronic medical conditions, one of which included the monitoring of coumadin dosing levels, I could achieve a level 5 office visit, simply by doing a complete physical exam on the patient.

If those 4 conditions includes CAD, Hx of stroke, Afib, Diabetes, one could easily justify doing a complete physical exam on this patient every time. Multiple times a year.

Now, if this patient had no complaints and was simply there to get their labs checked for PT INR testing or diabetes, the ability to differentiate the intensity of service and "thought" required is lost in the rules of the coding game.

Does this patient need a level 5 visit?

Well, based on the established guidelines, a level 5 visits could be justified.

Every time.

That's the nature of the rules. The rules established by the Medicare National Bank in their guidelines of 1997 and 1995.

The rules don't differentiate the level of thought required to manage chronic medical conditions.

All conditions are created equal.

From diabetes to crohns to myasthenia gravis to multiple sclerosis to hypertension to hypercholesterolemia.

There is no differentiation on the nature of complexity of the disease.

There are many chronic medical conditions that require frequent monitoring, but not frequent doctor contact. These are the medical conditions that we spend multiple billions of dollars a year on.

These are the conditions that require a physician contact and extensive note of documentation, simply to get paid.

These are conditions that could easily be managed quickly and cheaply by phone or email.

Yet aren't, because they don't get paid for. And they bog down clinics.

When I was a resident, I had a patient, a morbidly obese female who came to my clinic every three months. She was a wonderful patient. She never missed an appointment. She had the triad of American fast food diseases

Diabetes

Hypertension

Hypercholesterolemia

Every three months was exactly the same.

No new complaints, labs looked great, a change here a change there. Come back in three months.

I call these visits the art of tinkering.

My job job is to tinker with the meds to reach "a goal" based on a number.

goal cholesterol

goal HgbA1C

goal blood pressure.

This is chronic disease management.

This is tinkering at its finest

On the opposite spectrum of medicine is the art of thinking.

The art of thinking requires a much higher level of intensity.

Differential diagnosis plays heavily in this aspect of care.

Patient complaints (symptoms) and objective findings (signs) play heavily in this aspect of care.

This is where history and physical play a crucial role in caring for an acute complaint.

This is Dr. House.

This is ER.

This is glorified medicine.

A game of 20 questions with the hope of finding the right answer.

This is where the complexities of the human body must be delineated by the education embedded in the the physicians mind.

This level of care should be reimbursed at much higher levels because it requires a much higher level of evaluation and interaction.

But the Medicare National Bank doesn't differentiate based on presentation of illness.

Only on how many points you can count up for the 6 different areas I spoke of above.

How would I do things differently?

I would abandon evaluation and management codes as they are currently set up. They do not differentiate between evaluation and management.

I would instead create only 2 possible classifications of codes for payment of services rendered.

1) Evaluation codes (Thinking codes)

2) Management codes (Tinkering codes)

All evaluation codes would be charged the same fee.

One code. Period.

Thinking codes cannot differentiate complexity. A patient coming in with a "simple cough" may have congestive heart failure. A patient coming in "short of breath" may have leukemia. A patient coming in with abdominal pain may have adrenal insufficiency.

A patient's complaint, even a single complaint will trigger a history and physical which, if appropriately performed, is an intensive, time consuming process in search of the differential diagnosis.

All patient complaints should be treated equally. Simple complaints present as advanced illness, just as often as complex complaints present with no organic illness.

The job of the physician, and primary care doc in particular, requires time to figure it out. And it should be paid at a much higher premium. Whether that means payment from the cash paying patient or payment from insurance, a thinking encounter should carry a vastly superior payment scale.

There should be no differentiation of thinking codes because when you are searching for the unknown, you don't yet know what you are dealing with.

Management codes (tinkering codes) on the other hand are another game completely.

In the absence of patient complaint (thinking code trigger), these codes should be universally pushed to the out-of-office, email and phone triage system.

In the absence of a patient complaint, the management of stable chronic medical conditions are a matter of titrating to an objective data point.

Lab values.

Vital signs.

The management of chronic medical conditions should be paid at a lower rate without the need for a face to face contact with a physician. The management of a chronic medical condition does not frequently require face to face contact, nor a physical exam, nor a history.

If a diabetic can track home blood sugars, and the physician can follow renal function and HgbA1C, a diabetic should be able to be safely managed by phone or email, at a much lower cost.

Management of stable chronic medical conditions, while still requiring advanced training, are less intensive than acute care evaluations and should be paid both at a lower rate and without the need for face to face contact.

I have not worked in an outpatient clinic since I was a resident physician, but I can assure you, there where many a patients I would see, and especially in my VA clinics, that needed only a medication adjustment for their chronic medical conditions.

Imagine for a moment how much clinic space would free up if management of stable chronic conditions were moved into the Internet/email/phone encounters. Physician interpretation and nursing follow through could take out the squeeze on offices everywhere.

The payment rate for intense face to face contacts should rise appropriately, while allowing management of stable medical problems to be paid for with less resources and improved compliance, at a cheaper cost.

This is how I would trash/replace E&M codes.

Keep It Simple Stupid

Patients win.

Doctors win.

WIN-WIN

Any questions?