White Coat Underground

When I see a patient at the office, I spend time developing trust, forming a therapeutic alliance, thinking through their physical complaints, examining them, and applying the best evidence to formulating a plan for maintaining their health. It’s a lot of fun.

Less fun is the part where I try to get paid. To bill an insurance company, I must use numeric diagnostic codes that best fit what I’m seeing, and I must pick a code representing a level of service, that is, how hard I worked.

The diagnostic codes are referred to as ICD-9 codes, and the service codes are called E/M codes. Not all ICD-9 codes are easily billable. For example, if a patient comes to see me for anxiety or depression, I can’t bill for it. I can bill for “malaise and fatigue” (780.7), but not for generalized anxiety disorder (300.02) (supposedly it’s possible, but, like the Loch Ness monster, it’s always a friend of a friend of a friend who saw it).

Once I’ve pigeon-holed a patient into a set of diagnoses for billing purposes, I’d better make sure that there is a diagnosis code to “match” with any tests I order, or the patient will get a big bill. If I think a blood count is necessary, but I forget to write “anemia” (285.9), the insurance company won’t pay for it.

In determining how I’m allowed to bill for a visit, I have, for a returning patient, five choices: 99211-99215. The level is determined by the number of “elements” I document, or something like that. These five E/M codes are determined by my documentation. I must document a “chief complaint” as any physician should, and then…well then it gets tough. I make notes in a chart based on a standard format used by physicians for decades, but parsing out what code is born from it is difficult. In determining the code, I must consider three parts of my note: history, physical exam, and medical decision making (remember, it’s flu season, and I’ve got a lot of patients waiting…).

Included in “history” are several items, including past medical problems, medications, and a “review of systems” in which a doctor must document having tried to obtain information on 14 separate organ system. It’s not clear to most physicians how much needs to be present for a particular billing level.

Physical exam is easy though. Sort of. I mean, we all do them every day, but the coders divide exams into categories based on how many organ systems were examined. These levels range from problem-focused (one area examined) to comprehensive (9 organ systems examined).

Medical decision making takes into account how much thinking you had to do, how much data you had to review, and how much risk there was. How is this determined, and how do you combine these three elements to get a code?

This helpful tool should clear things up.

If I want to get paid for my work, then while seeing patients and making complex medical decisions, I have to look over what I’ve written and attempt to apply some sort of complicated and nonsensical flow sheet. If I choose wrongly, payment can be denied, or worse, I can be charged with fraud.

So why would anyone want to practice medicine in the States?

Any real health care reform has to address this insanity.

Comments

  1. #1 Benton Jackson
    October 26, 2009

    I’d like to see someone code an episode of “House”.

  2. #2 Colin
    October 27, 2009

    “So why would anyone want to practice medicine in the States?”

    Sounds like a hoot: where do I sign up?

    I describe to people how many hoops I have to go through and how much I’m paying *just* to apply, and they scoff and call it a “racket” and “that should be illegal”. Then they ask about tuition and the answer is where the jaw drops. I will, however, spare them the horrors of billing insurance companies that this post spells out.

    I have a long-time friend who’s sole agenda (he’s campaigned for years and helped get Obama elected) with health care reform is getting insurance for everyone. He doesn’t care about anything else. As far as he’s concerned: it’s all pink lemonade and lemon pie after the public option is passed. In other words: you just made this post up out of thin air. :)

  3. #3 CanadianChick
    October 27, 2009

    good lord – what a hot mess that is.

    years ago, I temped as a medical secretary/billing clerk for a specialist (who is now MY specialist!). Billing for an entire days patients took about 15 min. Done manually.

    Name? check
    British Columbia Personal Health Number? check

    doctor’s stamp, into an envelope, postage, mail. Few weeks later, cheque arrives in mail.

    Only time something would be rejected was if the PHN was wrong or if the patient hadn’t been covered under the provincial health care plan for some reason (usually because they let coverage lapse. Once we called them, they’d reinstate it, we’d resubmit, all was good).

    Yup, this Canadian health care system sucks and totally doesn’t allow doctors to spend ANY time with their patients…

  4. #4 Bob O'H
    October 27, 2009

    And reforming the healthcare system is going to improve matters … how? :-)

  5. #5 mxh
    October 27, 2009

    Yeah, this is something you don’t learn about in med school. Apparently, (from some of the physicians that I work with), the addition of electronic records have made the process even more tedious. They have to go through several pages of checking boxes after seeing every patient.

  6. #6 Joe
    October 27, 2009

    I recently heard an interview of a doctor who retired from the Navy after developing a chronic condition that prevented him from practicing. The interviewer asked why he didn’t leave earlier to take up a more lucrative private practice and he replied that in the Navy he could practice medicine with bureaucrats second-guessing him.

  7. #7 Dianne
    October 27, 2009

    I once complained to the hapless person sent to teach us about how to code (talk about an awful job!) that this whole scheme sounded like it was designed to make it easy for insurance companies to deny coverage. She said I sounded a little 297.0.

  8. #8 catgirl
    October 27, 2009

    So insurance companies won’t pay for a patient to see a doctor about anxiety or depression? That’s ridiculous, but not surprising.

  9. #9 David
    October 27, 2009

    E&M codes – brought to you by CMS – the same people who run medicare & medicaid. The government created this monstrosity and the insurers followed along. Just one of the reasons I oppose a government-run single payer plan.

  10. #10 BB
    October 27, 2009

    ICD code true story: when I broke my ankle last year, for some reason my orthopod had to code my X-rays as “X-rays, upper extremity.”

  11. #11 titmouse
    October 27, 2009

    The only reliable, objective measure of physician “effort” is time.

    We could eliminate the entire CPT headache by simply billing for provider time inclusive of face-to-face, collaboration, data review, thinking, charting, etc.

    Using time as a measure would also simplify fraud detection, as there are only so many hours in a day.

    Of course a time-based system might adversely impact our more procedurally oriented colleagues, who argue that the time spend developing a technical skill must be factored in, as well as the increased malpractice risk associated with invasive procedures.

    I’d answer that a modifier code for each post-graduate training year necessary to become competent in the procedure might address the former, and tort reform might address the latter concerns.

    As a bonus: eliminating the crazy E&M documentation requirements would cut a lot of useless copypasta and canned verbiage from patient charts.

    I am so totally right about this. I don’t know why no one listens to me.

    Oh, another thing we must get rid of: the DSM.

    I suppose the DSM is a money-maker for the APA. But the multi-axis system is problematic. The distinctions represented by Axis I, II, and III are scientifically meaningless. Further, by separating out part of the ICD-9 system and calling it “DSM-IV”, psychiatry is kept in a kind of medical ghetto. This is not only uncool but also foolish.

    Your ability to bill for fatigue but not depression arises from olde timey dualism, politics, turf wars, and managed care strategies that need to die yesterday.

  12. #12 titmouse
    October 27, 2009

    The Medicaid and Medicare fraud squad are total fuckers. The system is so filled with gotchas. Doctors who underbill all the time in hopes of never having to deal with an audit still get hit. And when they hit, it hurts. The government demands it’s money back for the preceding six years. And doctors are threatened treble damages and five years in prison if they take the matter to court and lose their case. So most doctors settle for some portion of the disputed amount.

    A colleague of mine seeing old folks in a nursing home got in trouble for not billing the co-pay. Never mind that he wouldn’t collect it from his destitute patients. His defense cost well over $50,000.

    Fuckers. I wish I could arrange my life so I’d never have to deal with them, ever. Extortion and organized crime in a government suit.

    I think the fraud squad luvs the complexity of the E&M code documentation requirements. When most doctors are vulnerable to accusations of fraud, they’re not likely to make trouble.

  13. #13 Dave the Hospitalist
    October 27, 2009

    I work for a large university health system somewhere to the west of PALMD. We have an office tower with two floors of billers who read every note written every day in an 800 bed hospital and bill accordingly off of our documentation. Essentially, billing is too complex and too improtant to leave to doctors.

  14. #14 gaiainc
    October 27, 2009

    October is also the month when the new ICD-9 codes come out. Have you read up on them? she asks with a really weary tone of voice.

    A lot of the reason that PCP’s can’t bill for psychiatric codes is that insurances have specific contracts with other clinicians to provide said mental health care. PCP’s theoretically aren’t supposed to be managing and yet we do, largely because patients can get in to see their PCP’s, but have a devil of the time figuring out whom they can see. There is also the matter of mental health benefits being used up a lot quicker than their medical benefits. My experience has been that if I code a non-mental health ICD-9 code as the primary diagnosis, I can still use the mental health codes and get paid.

    Medical schools and residencies suck at teaching new physicians how to bill and code. When I read over my residents’ notes, that is what I spend the most time reviewing with them. We have a billing specialist that goes through all the hospital charts from my department to make sure they are up to snuff. It’s fricking ridiculous.

    titmouse, I like your idea of time. However, I much prefer the Canadian system.

  15. #15 Ryan
    October 27, 2009

    While I may not support universal or government healthcare, I certainly agree that reform is needed, especially with this sort of nonsense paperwork and bureaucratic hoops.

  16. #16 Valsue
    October 27, 2009

    Why are you all doing your own coding/billing? Your time is best served seeing patients and documenting what you’re doing. Let your AHIMA or AAPC credentialed staff do the digging and office work for you. These professionals are bound by a Code of Ethics from their professional organizations that preclude fraud or abuse. Office staff trained on the job to punch in the numbers you give them aren’t.

    Undercoding(leveling) is as bad as overcoding because payment rates are based on past claims data showing charges. If a doc has been undercoding to fly under the radar, so to speak, then payment rates have gone down across the country – thanks a lot!

    Doing it the right way, the first time is always best. For the $50000 in attny fees, the previous poster could have hired at least 1.5 FTE credentialed coders/billers.

    AHIMA RHITs also know about EHRs, implemtentation of new systems, forms design, HIPAA, and legal requirements for health information and are worth the wages paid.

    I always wonder who is managing the offices of physicians burdened by the hoops – what sort of practice manager is too cheap to hire the ncessary staff to keep the practices alive and in compliance?

  17. #17 StThomas
    October 27, 2009

    I work as a GP in Scotland, and just got a visit to my practice from the people who pay me. I only have to enter 2 or three codes per consultation, to get paid for the things I’ve done. I’ll never bitch about it again (well I probably will)

  18. #18 titmouse
    October 27, 2009

    Valsue, back in the day (1980s), most psychiatrists were private practitioners. Coding and billing complexity has driven most into groups where several doctors can share resources, such as a full-time coder.

    But why do we need so much complexity and administrative overhead? I basically do the same thing with everyone I see: I listen, ask questions, and consider options that might help.

    I have no widgit inventory to sell. Widgitizing my day makes me cranky.

  19. #19 gaiainc
    October 28, 2009

    There’s also a problem of my administration being very penny wise and extremely pound foolish. They won’t do the necessary hiring. This is the same administration that is obsessed with patient call drop rates. It has to be less than 5%. Why? No fricking ass clue except that is what they have mandated, any pushback is soundly squelched, and all is sacrificed to keep that number less than 5%.

    And to echo titmouse, practices could hire a professional coder/biller. The question becomes why. Why should the system be that complex that we have to hire someone to do it?

  20. #20 Donna B.
    October 28, 2009

    From the patient’s perspective, these coding/payment issues result in less than adequate care, especially for those patients with “complex” issues.

    Even with my PCP (in the military health care system) I “present” with only one problem at a time. For any other problems, whether they are related or not (and what doctor can bill for enough time to ascertain this) I must make another appointment and drive another 30 miles. If I can get the second appointment at all… I hate “same day appointing” with a passion when it’s applied to all appointments every day.

    While I would definitely go to a PCP “off base” and be responsible for 50% of the charge, I cannot get an answer as to whether any referrals he might make would be covered as “regular” charges rather than “off plan” charges.

    Furthermore, comparing health care in the U.S. to Canada or the UK just doesn’t work. I have a sister who is a UK citizen and her healthcare is so entirely different from mine (both include the same “bad” things) that they are not comparable.

    Where she is treated for high blood pressure only after it reaches 140/90, I was treated at 130/80 and with medication mine is 110-120/65-70, hers is still above 130/80.

    Her doctor will not treat her swollen feet, ankles, and legs even though they cause her considerable pain, whereas my doctor prescribes a diuretic for use as needed.

    She is, however, able to buy a low dose of narcotic pain reliever over the counter. I’m afraid to ask for a pain reliever for fear of being considered a drug-seeker. There’s only so much tylenol can do… and NSAIDs are often a no-no for one who has had bariatric surgery.

    So… yeah, I am sympathetic to doctors who try to provide good medical care and have trouble getting paid for it. I do think the problem is much more than ICD-9 codes (which, for a patient, I’m more than normally familiar with).

    While I recognize that the woo-mongers push “whole patient” care.. holistic, or whatever you want to call it… that IS what many patients want — we would, however want it to be effective rather than a placebo.

  21. #21 Donna B.
    October 28, 2009

    I think what I really wanted to say in my post above is that I am not a number. I’m human, therefore unique, as is every doctor I see. That’s why I can relate to some doctors and some doctors can relate to me.

    That’s why I want a choice.

    While patients in countries with “socialized” medicine may be subject to fewer number categories than we in the U.S., they are still subject to classification. And, frankly some classifications get sucky care in both systems.

  22. #22 Hemoglobin Goblin
    October 28, 2009

    You think you have trouble getting paid now? Wait until the government run single payer socilaism plan gets here. Whatever you make now, subtract 40 percent of it and then subtract another 12 percent of it for higher taxes. What do you have left? Looks like you might want to be looking for a second job my boy unless you like geting paid the regular medicaid rate wchicj will be even less when this fiascoof a healthcare plan goes through. When it’s all said and done your patient load will increase by 50 percent, your wages will decrease by 60 percent of more, and getting paid back from the government will literally take months if not years. And you actually want this to happen? Wow. Amazing.

    I suggest going to Mexico for healthcare. It’s cheap, no long lines, and no government vaccines filled with mercury to cause autism. Besides after Obama is finished, Mexico will be the last free nation on earth. All others are either socilaist or communist. Freedom is dying. Sad, that Christ will soon come back and kill socialism and communism and replace them with sane government policies. Sad that those dicators will burn forever in a lake of fire. Oh well, at least we’ll have healthcare … except if you are over 65, then they’ll just send you home to die becuase you are not cost effective. At least that’s how the UK’s government run population control system works.

    Of course, it’s simple self-preservation on my part, as I wouldn’t have been allowed to live in the New World Order due to my cognitive dysfunction.

  23. #23 Fried Chicken and a vacuum cleaner
    October 28, 2009

    Hey Doctor Boy. I didn;t write the last line of # 22.You did. Would you like to see my turkey now or later? You like cramberry sauce with eggs boy? Have you been vaccinated for droopy butthole disorder yet?
    I just had a thought. Only leftists encourage mercury filly shots, maybe liberalism is explained my mercury poisoning of the brain? Wow. I figured it out. it really is a mental disorder.

    BOC BOC BOC BICONK.

  24. #24 titmouse
    October 29, 2009

    Somewhere there is a bridge that is lonely.

  25. #25 James Sweet
    November 2, 2009

    I have a long-time friend who’s sole agenda (he’s campaigned for years and helped get Obama elected) with health care reform is getting insurance for everyone. He doesn’t care about anything else. As far as he’s concerned: it’s all pink lemonade and lemon pie after the public option is passed. In other words: you just made this post up out of thin air. :)

    So, in fairness, one could argue that taking the profit incentive out of health insurance removes at least one roadblock to fixing this mess. I mean, what incentive is there for an insurance company to streamline a system for decreasing their bottom line? Seriously.

    I say this as a person who is a firm believer in the free market model for most industries. I also say this without malice (well, without much malice) towards the insurance companies — we expect corporations to do what they can to maximize profits, and if the regulations are set up so they can increase profits by employing a complicated billing system, we have only ourselves to blame when that’s what happens.

    I’m not saying that a public option would solve this problem overnight, obviously. But I do believe the lack of a public option is one roadblock on the way towards fixing this problem.

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