Wednesday, November 19, 2008

Medical Coding and Billing and String Theory


(Things that I dont understand and the more confused I get the more I learn about them.) Of the two, I think String Theory makes the most sense! Well here it goes. For those of you who are unaware, CMS has created alogrithms that physicans must use to determine their charge for each level of service. Further, these things must be documented and thus it has led to the classic concept that you get paid for what you document rather than what you do.

This is the start of the basic algrithm for a simple office follow up visit as deciphered by the American Academy of Family Practice. You dont really have to read it because it is only the tip of the iceberg and does not include all the tables and guides. It is kind of like the tax code, it goes on and on and no one is really sure what it means.

Calculating medical decision making
According to Medicare's Documentation Guidelines for Evaluation and Management Services, a level-3 established patient office visit requires medical decision making of low complexity. Moderate-complexity decision making is required for a level-4 encounter. Before you can distinguish between the two, you must understand that the level of medical decision making in a patient encounter is based on three parameters: the problems addressed, the data reviewed and the level of risk.
The problems and data are evaluated using a system of weighted points depicted in the tables below. These tables were developed by the Centers for Medicare & Medicaid Services and distributed to all Medicare carriers to be used on a voluntary basis; although widely used, they are not part of the official E/M guidelines.
An encounter earns points based on the number and type of problems addressed. For example, an encounter with a patient whose chronic illness is stable would be worth one "problem" point, while an encounter involving a patient with a new problem for which additional work-up is planned would be worth four points. The data table works similarly, with different numbers of points available depending on the type of data and the nature of the review. For example, reviewing or ordering a clinical lab test is worth one point, while reviewing and summarizing old patient records is worth two.


The risk table below is identical to the one in the E/M guidelines. It only takes one element from any of the three categories listed in the table (presenting problems, diagnostic procedures and selected management options) to qualify for a particular level of risk. The documentation guidelines explicitly state that the physician should use the highest level of risk present when determining the complexity of the medical decision making. For example, an encounter with a patient who presents with one stable chronic illness would amount to a low level of risk. However, if the physician actively manages prescription drug therapy during the encounter, the risk level for the visit qualifies as moderate, because prescription drug management is associated with moderate risk.
After you determine the problem points, the data points and the level of risk, you can determine the complexity of the medical decision making. The table
below (see "Medical decision making") shows how the categories work together. The highest two of three elements determine the overall level of medical decision making.

Long and short of it, you look at tables and count up points to see what level of visit you can charge for. But you can only charge for what you document. This is why many feel that they get paid to write notes and not see patients. The average note is now a 500 word essay!

I often think that we should be like other professionals and just charge by the hour. Especially since we do not get paid for phone calls, especially those that come in at 4:00am. Our attorney charges us by the hour and for each phone call, so does the architect that designed the building only to have it not meet code which meant we had to call our attorney who then charged us for more hours.

3 comments:

Andrew Garland said...

The solution to this is like the one for the tax code: programs to take the simple data and fill out the complicated forms.

You will reduce your practice to a set of your own keywords. The software will translate and integrate the keywords, looking for the best presentation to maximize payment to you.

Any notes will be generated in a way similar to home inspection software. Again, a few keywords will generate a 500, 1000, or 4000 word note, as you wish.

This standardization has some regrettable defects. You wont be able to read either your billing descriptions or your clinical notes, being that they are so long.

Maybe you can write down the keywords and a bit of explanation about the exam and keep it in a folder somewhere, for each patient.

SeaSpray said...

Throckmorton... I didn't think I could possibly respect doctors or empathize/sympathize any more than I already do... but after reading those tables... I do.

Does it all get memorized, although I am assuming tables change accordingly. As far as I am concerned y'all should be getting paid for the 99214 anyway because even the 99213 is involved.

And when MDCR sees docs consistently going for the higher severity...they'll find a way to knock it down. Unless this stuff is a carved in stone standard.

I have to tell you... I had no idea...this was so involved. But my experience with coding is after the diagnoses have been made and was more generalized for the ED and I imagine that even that has gotten more specified now that trained coders took it over. Although...we still did the OP codes.

And when do physicians learn all this? On the job?

Btw... the pt with bilateral knee pain on increased NSAIDS has to come in every two months for a cbc and renal screening? and NSAIDS can cause HTN? All a moot point because I "try" to take I-buprofen sparingly. But it is one of the best drugs ever created in my opinion.

What exactly does i-buprofen do to the kidneys? I know it's not good and my urologist prefers that I not take it and so he knows I take it minimally. I have to remember to ask him WHAT it does that could compromise the kidneys.

Anyway... 500 word essay notes? for routine visits? just don't forget...go for the 99214! :)

Lawyers definitely seem to have it made! I think it is wrong that physicians are becoming more and more micromanaged. I know there has to be checks and balances... but how did doctors treat patients and get paid prior to all this detail?

I think it is sad that you seemingly get paid for documentation vs patient care. It really is a Business. I prefer to think of it as skilled and caring doctors looking out for their patients and it bothers me to think how much you all have to look out for your own interests 24/7 because their is potential for loss on all fronts.

You work in such an honorable profession... it just doesn't seem right that you have to deal with all this extraneous minutia vs hands on with the patients.

I mean you go into medicine... presumably to help patients and yet that patient care time is challenged and so is your paycheck because so much time has to be spent with all the regulation, rules and cya against lawsuits.

You need a reliable middle person to handle all that so you are freed up to practice more medicine... but I guess it all still comes back to the physician.

The average person doesn't have a clue about these things. I didn't until I began wandering through the med blogasphere and have learned a lot... although... I feel frustrated for all of you and as a patient... feel concerned for the future of medicine, i.e., will students continue to seek out medical careers? Will even my favorite docs get burnt out? Will the quality of medicine be compromised?

I am a hands on person. I would hate not having full knowledge of something printed out in notes that was representative of what I diagnosed, nor would I be happy with not having easy access in a timely readable version. There's always a trade off.

Andrew said"Maybe you can write down the keywords and a bit of explanation about the exam and keep it in a folder somewhere, for each patient." I think that is a good idea, but if course...additional work.

* I see that the Independent Urologist has a short post up on how to convert an EMR from a cost to a profit center.

mercydoc said...

Amen, Throckmorton! I say let's all go back to fee for service and have everyone just carry catastrophic care insurance. It gets even worse! Insurance companies will take a physician's billing statements and put it in a spreadsheet to see how many 99212s,99213s and 99214s etc have been billed, and if the "spread" falls out of the norm, (like too many 99214s) they may be audited. This happened to a colleague of mine, and they actually made her pay back money the insurance company said she owed them because her chart notes didn't justify her charges. Sometimes it was just because she didn't put "face to face time" counseling/coordinating care for the patient - because if you are not coordinating the care IN FRONT OF THE PATIENT, you can't bill for it!!! (Imagine if lawyers had to be present in front of their client in order to bill them! Why the double standard?). But she got off easier than if the government was involved. I believe they can fine a doc $10,000 if their chart is audited and does not pass the mustard! So what I do, and a lot of docs do this, is we "undercode" just in case we are audited for fear that our documentation is missing one key element and we are accused of overcharging the Medicare!!!