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Wednesday, May 25, 2011

How I Spent My Day, most of it good, some of it stupid (E and M codes)

Today started early because I was being the hospitalist as well as the stress test doctor as well as my usual identity as primary care physician. A hospitalist is a doctor who takes care of all of the patients in a hospital who have no other doctor or whose doctor doesn't take care of patients in a hospital. It is a fine job, as it is practiced in many larger communities, though it limits the doctor's ability to make long term connections with patients, who usually see someone else when they are not confined to a hospital. People who take hospitalist jobs work shifts, make a fixed salary and get lots of time off.  In our small town, the hospitalist is my long suffering partner, nearly all of the time, but I and my other internal medicine colleagues spell her evenings and weekends and occasional vacations. We all squeeze our hospital work into a day that also includes outpatient primary care medicine.

As the hospitalist I had 6 patients to see before clinic started at 10, only 2 of them really critically ill, and because this is my week for doing stress tests, I had two other people to supervise while we used various methods to stress their hearts to see if they had coronary artery disease. The stress tests are a great joy because I get to meet new people and hear their stories and give them health advice while they are open to it. While they are walking or being injected there is nothing else I need to be doing, no computers to interact with, at least not in a distracting way, and no distractions. There is plenty of time to find out who they are and maybe help them make a slight detour if their lifestyle and habits are heading them in a deadly direction.

After nearly 25 years of medical practice, most things I do are rewarding. There are exceptions, however.  Most exceptions fall into the category of things I can't do well.  If there is something I don't know about or physically am not skilled enough to do, I can find a colleague to help. The most difficult situation, though, is when it is necessary to be in two places at the same time, or do two (or three) things in an inadequate amount of time. When situations like this arise, I begin to be annoyed by inefficient processes.

The New England Journal of Medicine published an article this week about one of the stupid processes upon which we physicians, those of us involved in fee for service medicine, waste our time. 

here is the link:
http://healthpolicyandreform.nejm.org/?p=14489#more-14489

When I see my patients in the hospital, I just estimate the time and complexity of my services and bill accordingly. When I do stress tests, I am paid by the hour. When I see patients in the office I must calculate their bill based on Evaluation and Management Codes, introduced for the first time in 1991. These codes are an attempt to calculate the value of a medical service based on various pieces of information that can be documented in a patient's chart. If I document a very complete history and include a physical exam of several parts of the patient's body that is exhaustive, I can bill a 99214, which will pay me substantially more than a 99213 which still requires quite a bit of documentation. If I do everything imaginable in the appointment and document that, I can bill a 99215. This is the king of the outpatient bills and pays the most money.  If I document that I spent an hour talking to the patient, I can legally bill a 99215, but if I work really fast and ask a whole bunch of questions and poke and prod every part of my patient and that patient is pretty complicated, I could potentially get 2, 3 or even 4 99215's in an hour. But by law if I bill a 99215 and I don't document that I did all of the little things I was supposed to to qualify for a 99215, I can be heavily fined or even arrested. (Legal sanctions apply only to Medicare and Medicaid billing, but E and M coding is used pretty much universally by all insurers.)

So today, like every day, despite the fact that today was plenty crowded with people who needed my attention, I spent a significant amount of precious time making sure that I documented (typed up, clicked on) enough elements for my outpatients that my billing would stand up to scrutiny should I be audited.  My electronic medical record is built to help me with my E and M coding, but because it is so geared to coding, it is not nearly as good at concisely expressing what I did with my patient.  I can review the patient's family history and social situation, but if I don't include the verbiage, which may be identical to the verbiage I documented last week, my documentation will be inadequate to bill for the complex and time consuming interaction and I will need to charge less than the appointment was worth. The time I spend polishing my documentation is time that I can't see sick patients. It also, more insidiously, affects the way in which I care for my patients and what my brain is doing when I am with them. It is vital for the survival of my office that I make enough money to support my nurses and receptionists, pay my rent and eventually support my family. So I, like all other fee for service physicians, play the E and M game. I am mostly unable to get payment for any of the rest of the work that I do, such as telephone management or written communications, so E and M coding of my face to face patient interactions pays for everything else I do.

When the various codes were introduced in the early 90s, many of us objected to the changes, but now we are so accustomed to spending our time and brain cells to categorize our work in this way that very few people even realize what an impact this has on our quality of service.  Robert Berenson MD, Peter Basch MD and Amanda Sussex MPH who wrote the New England Journal article are the first to publicly complain about this system for years.  Improvements in billing including streamlining the coding has been suggested, but instead it will soon be getting even more complex. Truly the best solution to the foul and tangled web of medical billing will be significant payment reform. Calls for the end of fee for service medicine have been increasingly common, and as far as I'm concerned, it can't happen soon enough.

1 comment:

Caty Karther said...

There are many things which keep on changing such that in many hospitals there are limited numbers of doctors which have the responsibility of taking the care of the patients.