What does that mean? Well. It means everything. And it means nothing. It is the enormous universe of numbered codes (CPT) that every physician must grasp in order to get paid for services provided. In order to remain a viable business, physicians must learn how to code. And they must learn how to code well so they aren’t accused of fraud.
The current coding system is ridiculously difficult and vague. So difficult and vague that audits by the Medicare National Bank (MNB) often result in multiple different opinions by the MNB auditors themselves.
Coding is a system of confusion. I am here to say the coding system is insane. Current coding rules are used by all third parties to determine the economic value of your care. To determine how much your encounter with the patient is worth. Ultimately, the coding system has become the most important aspect of a physician’s professional life because coding determines revenue. And revenue determines the viability of the business model. And that ultimately determines how much you take home to feed your family. Dr Kevin blogged about that here.
So let the games begin. The current coding rules are a futile attempt to bring rings of value to medical service. Services which are so vastly different and unique for every patient. I will attempt to walk you through an example of the payment system, and how it relates to relative value units (RVUs) and ultimately how that affects physician payment.
The number of codes is massive. For all imaginable procedures, encounters, surgeries. Any possible health care interaction. Hospitalist medicine is limited in the types of codes we use. So I only have to remember a few.
95% of my billing is based on about twenty CPT codes:
There are a few others, but these twenty-two codes determine my very financial existence. Medicare says so. Imagine a surgeon, a primary care doc, and a medical subspecialist. Every single interaction has a code. There are codes for codes, modifiers for codes, add on codes, disallowed codes, V codes, M codes. It seems as if the list is endless. And you have to get it right. Every time. Or you don’t get paid. Or you are accused of fraud. It is an impossible feat. The process of taking care of patients has turned into a game of documentation. And that has drastically affected the efficiency of the practice of medicine.
Let me walk you through a 99223, the code for the highest level admit for inpatient care. A level three. There is no actual law, as I understand it, on the Medicare books that definitely defines the requirement for these Evaluation and Management (E&M) codes. There are generally accepted guidelines which carriers are expected to follow. 1995 and 1997 guidelines. Even the guidelines from different years are different. And you are allowed to pick and chose from both. More silliness.
The following is my understanding of what Medicare requires in order to bill a level three admit, CPT code 99223. You must have every one of these components or it’s considered fraud, over-billing or waste. Pick your verbal poison.
1) History of Present Illness (HPI) : This requires four elements (character, onset, location, duration, what makes it better or worse, associated signs and symptoms) or the status of three chronic medical conditions.
2) Past Medical History (PMH): This requires a complete history of medical (medical problems, allergies, medications), family (what does your family suffer from), social (do you smoke or shoot up cocaine?) histories.
3) Review of Systems (ROS): A 12 point review of systems which asks you every possible question in the book. Separated by organ system.
4) Complete Physical Exam (PE): With components of all organ systems, the rules of which are highly complex in and of itself.
5) High Complexity Medical Decision-Making: This one is great. It is broken down into three areas and you must have 2 of 3 components as follows; Pull out your calculator.
5a) Diagnosis. Four points are required to get to high complexity. Each type of problem is defined by a point value (self limiting, established stable, established worsening, new problems with no work up planned and new problems with work up planned). You must know how many points each problem is worth. Count the number of problems. Add up the point value for each problem and you get your point value for Diagnosis (5a). You must have four points to be considered high complexity.
5b) Data. Four points are required for high complexity. Different data components are worth a different number of points. Data includes such things as reviewing or ordering lab, reviewing xrays or EKGs yourself, discussing things with other health care providers (which I have never been able to define), reviewing radiology or nuclear med studies, and obtaining old records etc. Each different data point documented (remember you have to write all this down too) is given a different point value. You must add up the points to determine your level of complexity. Get four points and you get high complexity for Data (5b).
5c) Concepts. I call this the basket. Predefined and sometimes vague medical processes that are defined as high risk. This includes such things as the need to closely monitor drug therapy for signs of toxicity ( I would include sliding scale insulin in this category), de-escalating care, progression or side effect of treatment, severe exacerbation with threat to life or limb, changes in neurological status, acute renal failure and cardiovascular imaging with identified risk factors. There are too many categories that are defined as a high risk concept. I cannot remember all of them. If you have a concept considered high risk, you get credit for high risk in the concepts category (5c)
Now remember, out of 5a, 5b, and 5c, you must meet high high complexity criteria on two out of three to be considered high risk. Did you remember to bring your calculator to work? And once you’ve calculated your high complexity category, don’t forget to write down all the components required from HPI, PMH, ROS, PE to not be accused of fraud.
Folks, this is what I have to document every time I admit a patient to the hospital in order to get paid and not be accused of fraud. This is what the government (and all other subsequent third party systems) have decided is necessary for me to treat you as a patient. This is what I must consider every time I take care of you.
I always find myself wondering if I wrote down that I personally reviewed that EKG. I wonder if I wrote down that your great great grand mother died of “heart problems”. I wonder if I remembered to write down all your pertinent positives on your review of systems and whether I documented the lack of positives in all other systems that were reviewed.
And remember each CPT code is given an RVU value, the value of which is determined by its own three components.
The work RVU
The practice expense RVU
The malpractice expense RVU
Then the MNB multiplies your total RVU (add the three components above) and attached a geographical multiplier (you get more RVUs in NYC than in Montana).
Then, they take that number of RVUs and they multiply it by the Congressional mandated value of the RVU (currently about $35/RVU). That value is currently determined by the political whims of politicians and is controlled by the irrational sustainable growth formula (SGR). That is the formula that is overturned every year because of the irrational economics it employs.
And that’s how a physician is paid. This is what determines whether physicians survive in the business of medicine. And whether they have enough money to pay the electric bill, the accountant’s fees and the matching contribution to their nurse’s 401K.
Oh yeah. I almost forgot, I have to do all this while actually taking care of your medical problems based on sound scientific principles.
This is coding in a nutshell. A 99223. This is what I think about when I’m admitting you through the emergency room. This is E&M medicine. This is Medicare medicine. This is how your government has decided the practice of medicine should be. To get paid, I must document what Medicare says I must in order to care for you, the patient. It doesn’t matter what I think is important to write in the chart. What matters is what is required to get paid and not be accused of fraud.
Like I have said before, the medical chart has become nothing more than a giant invoice for third parties to assert a sense of control on their balance sheet. It doesn’t matter who that third party is. They are all the same.. I’m telling you, it’s nothing more than a really inefficient game of cat and mouse. It is a terribly inefficient and expensive way to practice medicine.
And I might remind you, the exercise above was an example of just one patient on one day. I do this upwards of fifteen times a day. Every day. Day after day. Year after year. Oh yeah, and the rules are different for inpatient followup codes, discharge codes, critical care codes, and observation/admit same day codes. They all have their different requirements. And I have to get it right for every single patient I see. Every day. Over 2500 times a year. With the expectation of 100% accuracy.
Why? You see, in the eyes of Medicare, you are a nothing more than a 99223.
“Potential sources for this (health care reform) are new taxes on people or businesses, substantial short-term savings from the existing Medicare and Medicaid programs, or increasing the deficit”
After Last week’s passage of Health Care reform plans by committees in the House and Senate, attention has turned to the Senate Finance and House Commerce Committees to see how congress will pay for reform in a deficit neutral way, as mandated by President Obama. The price tag over ten years–$1.2 Trillion–is paired with the observation that a shortage of $240 billion currently exists. This assumes that $948 billion already has been found.
The only way to ‘find’ $948 billion without increasing the deficit is to increase taxes on businesses and the wealthy or by reimbursing less for services provided through Medicare and Medicaid. I will leave the never-ending tax-rate argument for political pundits, and instead focus this post on short and long-term savings from Medicare and Medicaid because I believe paying less for services than it costs to provide them will negatively impact the quality of medical care in this country.
I was surprised to learn of a battle being waged between the executive and legislative branches on the issue of “long-term savings” from Medicare, as it relates to “Medicare Payment Authority”. White House Chief of Staff, Rahm Emanuel, has called Medicare payment Authority, “the least talked about, most important issue on the table” and clarified its’ importance by stating, “Structures that fundamentally alter the long-term costs are a must for real health-care reform.” This issue does not follow party lines with a mix of Republicans and Democrats being in opposition or support of the President, irrespective of party affiliation.
Our Congressional Representatives have the power to set Medicare Payments, outside of any pre-set rules or regulations by simply passing legislation. The Washington Post describes this power as “one of their most valued perks….a powerful tool on the campaign trail”. President Obama’s administration wants to either transfer payment authority to MedPac (the Medicare payment advisory commission) or create an independent Medicare Advisory Council, reporting to the executive branch so lawmakers can no longer tailor Medicare spending to address local concerns.
Before leaving office, Senator Ted Stevens secured a permanent 35 percent increase in Medicare payments for Alaskan physicians only. The political benefits to an incumbent running for reelection need not be explained while it is easy to see the inefficiency in such a system. At a time when politicians are admonishing those working in the Health Care Field to be more efficient, I would urge congress to take a dose of their own efficiency medicine and support the current administration in their efforts to curtail long-term spending by surrendering this power.
According to the White House, $622 of the $948 billion will come from short-term savings squeezed out of existing Medicare and Medicaid programs through one of two ways: by improving efficiency (309 billion) or enacting policy changes (313 billion). The Medicare Fact Sheet posted on the White House website, states that one policy change will have the added benefit of encouraging efficiency: “incorporate productivity adjustments into Medicare payment updates”. This policy change measures the productivity of the entire U.S. economy, as measured by subtracting the hours worked from the amount of product created and extrapolates it to Health Care (a profession which does not produce “products”). This idea justifies the withholding of 110 billion dollars from “providers” with an unexplained benefit stated in the closing sentence describing this policy, “This adjustment will encourage greater efficiency in health care provisions”.
I found it difficult to believe that anyone could suggest paying less would encourage greater efficiency in caring for the infirm and old until Boston Medical Center, a hospital serving thousands of indigent residents, sued the state of Massachusetts one week ago, charging that the state is now reimbursing only 64 cents for every dollar spent treating those covered under Medicaid or Commonwealth Care (the state subsidized insurance program for low-income residents). This should be of great concern to us all since the House’s plan adds 11 million people to Medicaid and cuts funding while reformists tout Massachusetts as an example worth following, being the only state with universal coverage today. Before state wide reform was enacted this hospital had operated for 5 years without a loss. However, when the hospital showed losses over two years of 138 million dollars, state officials observed the hospital had a 190 million dollar reserve (not for long it appears) and suggested that Boston Medical could reduce costs by operating more efficiently.
The above example demonstrates the willingness of government bureaucrats, inexperienced in providing actual medical care, to give flippant advice while failing to appreciate how fiscal efficiency, doing more with less, impacts medical efficiency, caring for the ill effectively. To be sure, something must be done to curtail run-away costs in health care and I agree with the president when he says, “The status quo is unsustainable. Reform is not a luxury, but a necessity”. However, reform needs to focus on sustainable Short-term and Long-term savings in such a way that prevents hospitals and doctors from having to make a choice between providing sub-standard care or going out of business. Furthermore, I would hope that Congress take an honest look in the mirror regarding long-term savings before only enacting short-term savings which could negatively impact the care available to us all.
Dr. Alan Dappen, Dr. Steve Simmons, and nurse practitioner Valerie Tinley are regular contributors to the Better Health blog. I’m a big fan of their innovative medical practice, and decided to follow them during one of their work days as they deliver affordable, quality healthcare to patients in Virginia.
This is how primary care used to be… and a model that deserves more attention.
We often are asked in our practice, “Why don’t you accept Medicare?” The immediate answer is simple: we cannot afford to. We opted out of Medicare because the service won’t pay for phone consultations, won’t pay for email consultations, barely pays for an office visit, and does not pay nearly enough to cover a house call.
All of these services are critical to our medical practice. Medicare would require us to hire too many staff, as well as require us to do too much paper work and administration. I cannot afford to invest in either and still manage to operate in the black. Medicare has too many regulations and rules; we can’t understand a lot of them, and frankly, Medicare doesn’t seem to understand them most of the time either. If I would accepte Medicare, then they have the right to audit our notes and then fine us for non-compliance for infractions that are not readily clear. Their external auditors get paid for every infraction they find which means the temptations for fining doctors are irresistible.
Yet the truest answer as to why we do not accept Medicare is that the service does not focus on what we feel is paramount: practicing effective and efficient medicine in order to ultimately achieve and maintain the good health of our patients. The service’s paltry reimbursement structure coupled with its impossible to-adhere-to regulations doesn’t allow us to offer a complete service to our patients. This complete service includes wellness care as well as the ability to take the time to understand each patient’s unique medical needs and circumstances.
The crux of the issue is that Medicare worries about the forest, in other words, the internal process, money management, reimbursement and policing agreements, data mining, and organizing dozens of internal bureaucracies. These agendas and policing policies help the Medicare service to manage the forest, however these are often in direct conflict with what we feel is key to effective healthcare: taking care of the individual, or each tree.
I do want to make clear that being afraid of audits, punitive actions and the vagaries of no one understanding all the rules is never a reason to leave Medicare — after all, patient care is filled with risk. However, it became clear to me that I, a single doctor voice, dealing with the collective frustration almost all doctors feel when dealing with Medicare (and most insurance companies) had three divergent paths to choose from:
Do nothing. Ignore the conflicts of interest and the lack of patient-centered care and swallow frustration for a paycheck. Just do your best or what Medicare tells you to do.
Work towards reforming Medicare from within through involvement in the process and by working with your professional associations.
Ignore the payers altogether. Work outside the system, returning to the roots of primary care, reforming the business of primary care one person at a time.
Personally, I had to reject Option 1. I was witnessing too many wrongs among my colleagues and for patients. Primary care, a profession I am passionate about and believe in fully, would never have a future under this model. Hoping that things would work out if we just worked harder and harder while blindly submitting to Medicare’s interests and demands meant surrendering my patients’ trust, primary health care’s future, and my soul for a salary. There had to be a better way of making a living.
Working towards Option 2, trying to create reform from within the Medicare system, was nothing but futility on immediate analysis. The ability for me personally to influence the debate for what needs to be done in Medicare for primary care would be a David v. Goliath story without the biblical ending.
In the end I am just one family doctor, that’s what I know, that’s what I’ve spent my life doing and studying. Option 3 chose me. Opting out is financially the riskiest since it requires patients to do something that they have been socialized against for three generations, which is to pay directly for medical services (as they do with nearly everything else in our capitalistic economy). Doctors are well aware that 95% of patients will fire any doctor who refuses to accept Medicare.
This decision meant I might lose my shirt and put my home and small life savings at risk, something thousands of Americans in other professions do everyday. If they could take the risk, then my risk is nothing less than a trivial American story.
The United States was built on this: a country of immigrants fleeing an “old establishment” to build something new. It’s a group of people declaring: “You can’t tax us without representation!” It’s a government that permits us to challenge established norms, challenge power without being jailed or shot. The question today in health care for all of us as patients is will we stampede towards the utopian ideal of “free care” while ignoring the predictable consequences that nothing is free.
The question put to primary care doctors by Medicare is clear at the moment: Will you let us at Medicare regulate care, dictate “best” treatments and control individual health and choices since we know what’s best. Can you, doctor, be our “yes man?”
Eight years ago I cast my vote and opted out of Medicare. Predictably my journey has not been easy but I have never regretted the decision.
When my six-year-old daughter heard that I was going to write about President Obama’s speech to the American Medical Association in Chicago, she offered me this insight: “He’s not a doctor! He isn’t supposed to tell people what to do when they’re sick; he’s supposed to rule the world.” Yet, regrettably, doctors do need his help and it was with great interest that on June 15, the medical community listened.
I suspect that my colleagues in Chicago are the only crowd to boo the President during a speech since his election, and I think that much can be learned by examining why this occurred. Just moments before being booed, Obama received raucous applause when he acknowledged, “that some doctors may feel the need to order more tests and treatments to avoid being legally vulnerable. That’s a real issue.” Physicians in the audience then booed the next line, “I’m not advocating caps on malpractice awards which I believe can be unfair to people who’ve been wrongfully harmed.” The President went on to offer a plan to help physicians avoid practicing expensive defensive medicine. “We need to explore a range of ideas about how to put patient safety first, let doctor’s focus on practicing medicine, and encourage broader use of evidence based guidelines.”
I do not object to President Obama’s sincere and well delivered remarks to the AMA, but found some of them to contain trite platitudes. Encouraging physicians to “put patient safety first, focus on practicing medicine and follow evidence-based guidelines” is like asking airline pilots to pay attention to safety gauges, fly their planes, and respect passengers. I found the admonition to follow evidence-based guidelines as a means to avoid medical malpractice claims a particularly naïve statement. I’m not arguing against using guidelines, I just don’t see how guidelines will protect me from a lawsuit any more than the currently used standard-of-care.
I share the President’s opinion that any individual should have the option of remediation through the court system when wronged but large, punitive settlements change the way hospitals and physicians practice medicine and have resulted in an untold number of unnecessary surgeries as well as causing the actual death of many who never had their day in court. Unreasonably large medical malpractice settlements often have consequences that reach far beyond the parties involved in the original suit. Follow the relationship between cerebral palsy and C-sections and you will understand my assertion. In 1985, then trial lawyer John Edwards won a settlement of 6.5 million dollars against a hospital and 1.5 million dollars from an OB/GYN doctor arguing that if a C-section had only been done for an unfortunate child she would have been born without cerebral palsy. This case set off a chain reaction of suits throughout the country, leading obstetricians to practice defensive c-sections. The United States currently has the highest rate of C-sections in the world, the most expensive obstetrical costs per birth, and when measuring infant mortality ranks 42nd out of 43 industrialized nations.
In 1970, six percent of births in the U.S. were done by C-section; today that number has risen to over 30% while the WHO recommended, in 2006, that the actual rate should be no higher than 15%. Yet, the last four decades have seen the cerebral palsy birth rates remain close to 2 per 1000 live births in the U.S. without change. Considering that women are 4 times more likely to die during a C section than during a vaginal birth it becomes a simple and tragic mathematical exercise. Consider that in Scandinavia the maternal death rate is 3 per 100,000 births while 13 mothers die per 100,000 births in the United States; unless you’re African American–then you count an appalling 34 dead for every 100,000 births. Furthermore, once you have had a C-section there is a very good chance that all future births will be done the same way with an increased rate of hysterectomies, post-operative infections, blood clots, drug reactions, etc.
On the other hand, tort reform has resulted in major shifts in the physician workforce. In 2003 Texas put a cap of a quarter million dollars on malpractice settlements for pain and suffering but did not place a limit on the actual economic loss suffered by a plaintiff. The limit for a wrongful death case was set at 1.6 million dollars. Since 2003 Texas has seen 18% more doctors filing for new medical licenses per year (30% in 2007) and by the end of 2007 there was a 6 month backlog for the medical board to begin processing new license requests. The increased number of physicians has helped to improve access to care. Medical malpractice reform is necessary to avoid the kind of collective defensive behaviors that, ironically, may not be in the best interests of patients.
In my next few posts, I plan to discuss various aspects of our broken healthcare system. It is imperative that we understand all of these problems to avoid making things worse. This will require a probing and honest evaluation of what is wrong today. I also intend to discuss the President’s plans for reform and while I don’t agree with all of his plans, he has put forth many ideas that I do agree with. The time for reform is here, action appears inevitable, and the moment to speak out is now.
Until next week, I remain yours in primary care,
Steve Simmons, MD
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