Another Surreal Moment in Modern Medicine

A few months ago my office manager, Debbie, informed me that it was time for my annual “coding audit”. This is where my employer sends in a hired gun to determine if my choices of office codes for billing purposes are correctly done. Did I document enough to support a 99214? Did I code too many 99212s when my documentation should have been higher, and thus my reimbursement better? The audit is based on Medicare-guidelines, although the ten charts pulled were of patients of all ages and insurance types. Doctors generally approach these sessions with the same dread we felt getting our report cards in grade school.

The tiny blond that came in to discuss my results refused to sit down next to me. It was distracting and intimidating. Since I’m 5’10” it was also infuriating to have this schoolmarm personality towering over me while she explained why she’d flunked me. Seven out of ten charts did not pass her muster. Two of the explanations made sense – one was “overcoded” – not enough documentation to support the 99213 I’d coded and the other the opposite. Six charts were “complete physical exams” (CPE) done on healthy non-Medicare patients. Since Medicare does not pay for preventive exams why were they pulled for a Medicare audit? It got stranger. She told me that I’d flunked because there was no “chief complaint” on the physical form. What? There shouldn’t BE a chief complaint for someone who is having a physical. In fact, by definition, there shouldn’t be one because it is a preventive service. No amount of discussion would dissuade the woman that she was wrong. I didn’t have immediate access to my own specialty society’s information on the subject:

The comprehensive history and examination performed during a preventive medicine encounter are not the same as the comprehensive history and exam that are required for certain problem-oriented E/M codes (99201-99350) and defined in Medicare’s Documentation Guidelines for Evaluation & Management Services. In fact, the documentation guidelines don’t apply to preventive medicine services. The history associated with preventive medicine services is not problem-oriented and does not involve a chief complaint or history of present illness.

I gave up arguing, signed the form under written protest and she left. 

Here is the kicker–a week ago one of the people whose chart was audited called to tell us she received all her money back on her physical! She thought it was a mistake and  was upset. She argued with Debbie and insisted that my office take back the money saying “But Dr. Nieder did all that work and spent the time with me.” 

I am furious. This suggests to those six patients that I did something wrong. Ironically, this means my employer is out hundreds of dollars for work they paid me for and that should rightfully have been reimbursed. Jawdropping in it’s lunacy. Can anyone wonder why the concierge movement is such an attractive, viable alternative to this?

1. http://www.aafp.org/fpm/2004/0400/p49.html

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Reducing Fragmentation and Patient Care NOW not Next Year

I do not recommend doing this, but today I attempted to listen to two Webinars at the same time. One was also tweeting the discussion and the other had very detailed slides which made it easier to follow but as studies show, we are not really capable of that kind of multi-tasking. The topic of the first suggested it would discuss Primary Care and its future. However, what the expert proposed was a “How to” plan for bringing more customers into a healthcare system. This was boiled down to a recommendation that these system open small clinics, run by NPs, in competition with drug store and grocery store clinics of similar ilk in order to funnel patients into the listeners’ systems. The other Webinar was a discussion by three mobile health leaders (mHealth) on the future use of their products in the global mobile health arena (wow, that rhymed).
It’s is a good idea to know what is going on in the minds of healthcare system development teams and as I listened to the expert’s remarks I could not help but ponder on what, in my humble opinion, would build the kind of “team loyalty” that hospitals and other healthcare systems are dreaming of. What is it that patients want? I agree that they need healthcare access in their busy lives at more convenient times of the day than traditional physician offices offer. What my patients tell me (and what people tell me at cocktail parties) is that they would prefer access to their very own providers, those individuals who know them best. No insult intended to NPs because they are essential to the healthcare team, but they are physician extenders, not physician substitutes. What about developing systems that give patients greater access to their own providers? This would really engender loyalty to a healthcare system, especially one in which physicians are employees, more and more the norm these days. I believe mHealth can do that. What if you could access your physician after hours via Skype? Or text your doctor just for a quick conversation about whether you should seek immediate care or be seen the next day? Gee, what if the physician had access to their schedule and could book them on the spot?!? What I’m advocating here is a “concierge” type practice without the concierge price. Of course there would have to be some sort of reimbursement procedure to give already overworked primary care doctors the incentive to take care of patients in this way but wouldn’t that be a cheaper investment than opening the equivalent of “Little Clinics” everywhere?
Along with the cost, the second complaint I routinely hear from patients about their medical care is its fragmentation. From a patient and a primary care perspective, no one on the health care team is talking to each other. In fact, frequently the word “team” is a misnomer. Using tools like Doximity physicians can employ a HIPPA compliant platform to discuss cases and improve care. Of course the phone always works, but with the ability to ask questions and respond in a timely but convenient fashion, doctors and other providers like NPs, PTs, etc. can reduce the fragmentation patients feel from their healthcare team.
Of course I realize that ACOs (Accountable Care Organizations) are supposed to be developing this kind of care. But does the bureaucracy that surrounds these systems bother anyone else but me? Do we really have to wait for the lumbering movement of government sponsored programs in order to improve communication, fragmentation and access to care when the technology is already here today? 
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