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.