Thursday, June 28, 2012

A Brief Introduction to Coding

     Starting in the 1980's Congress created and has been adding to a mountain of rules that dominate every aspect of a doctor's business.  Medical coding is one of the government's obsessions.
     Coding is a way of converting verbal descriptions of diseases and procedures into numeric or alphanumeric designations.  It amounts to an entirely new language that health care providers must learn.  It started in the 1950's as a way of tracking mortality on death certificates.  In the 1970's the HCFA (Health Care Financing Administration) began requiring that codes be used for billing.  Soon they were attached to reimbursement rates.  Since then, via dozens of updates, the initial array of codes has multipled like weeds into formidable fields of digits, and now there is a pandemic of numbers that has taken over communication with insurance companies.  No one knows what to do about it.  Every "fix" results in thousands of new numbers being added to the code books.
      Doctors like me who need to get paid have started thinking of patients in terms of their diagnosis codes instead of their human qualities and needs. This happens for at least part of the precious time relegated to the office visit.  Everything we say or do with patients must be converted to these numerical symbols. If it isn't done correctly, or if the numbers look suspicious, or if an insurance company wishes for its own reasons to postpone payment, the doctor isn't remunerated for services.
     It's as though the office visit, the illness, the patient, and the special nature of the encounter have become irrelevant.
     If a patient tells me he has a cough my first thought is, unfortunately, "786.05." Then I begin to wonder, "Is this 465.9, or 466.0, or possibly even 162.9  (a cold, bronchitis, lung cancer)?  And is his headache (784.0) a migraine (346.01), sinusitis (461.0), or neck strain (723.1)?  If I do a chest x-ray (71020) or spirometry (94010) will it be covered with the office visit (99213) if I attach a modifier (-25) with the cough code (786.05) or do I need a symptom of chest pain (786.59) and an additional modifier (-59)?   
     All day long my head is full of these numbers, thousands upon thousands of them, and I spend hours each week looking up more because the coding manuals are constantly being revamped, and I am never truly proficient.  There are diagnosis code books, office visit and procedure code books, medical supply code books...we buy updated collections every year, to supplement our electronic coding resources.
     Somewhere along the line I may recall with a start:  There's a patient here, it's a human being, and he is asking for help.  A little crack in the armor I've donned to deal with insurance companies opens up in that moment and I reach out to touch the patient.  I am thankful that I am still able to do this.  I think it means I'm still a doctor.  But it seems not to be a requirement for the job.
     Codes get in the way of patient care, especially when there are frightful numbers of them, as is the case with the 2013 version of the diagnosis code book,  ICD-10--a quantum change from older versions.  It does away with the previous twelve years of numbers and starts all over, quintupling the number of cryptograms doctors must master.  Once this new volume becomes mandatory all the codes I have in my memory bank will be rendered obsolete.  Insurance company computers won't recognize the ICD-9 codes.  And they certainly won't recognize English.
     Have any people who actually practice medicine day after day participated in the compilation of these codes?  If so, they must have sadistic motives.
     Why haven't we doctors rebelled against such an absurd system? 
     Consider the possibility that one of my employees, whose job it is to enter these codes into a computer, might get a number wrong?  The office visit may go unpaid;  the insurance company, if it pays, may recuperate the money months later;  or the claim may be rejected until the office note is sent to the insurance company by snail mail, after which the charge may be deemed "fraudulent." The physician is held liable for everything staff members do, and could ultimately be charged with a crime.
     It is so easy for errors like this to occur that in my office I have installed "macro codes" to prevent mishaps. My billing employees no longer work like Bartleby the Scrivener by entering thousands of numbers, but have single keystroke entries that expand into the diagnosis and procedure codes representing our most common services.  (Most small offices, including mine, have more billing personnel than providers.)  Whereas the current ICD-9 manual has 25,000 codes, the newly released ICD-10 manual  (optional now and mandatory by October 2013) has 148,000 different codes, necessitating that I revamp my macro system, a job that will take months.
     To speak any language, one needs about 3,000 words.  Why, then, do we need 148,000 codes to tell insurance companies what we did with patients in order (maybe) to get paid?
     Let me illustrate the situation with an example. The most common medical condition in Family Practice is high blood pressure. There are hundreds of different codes for high blood pressure:  hypertension with renal, cardiac, or ophthalmic complications; malignant, gestational, accelerated, antepartum, intraocular, pulmonary, or necrotizing hypertension; hypertension with liver disease or heart failure; postoperative, puerperal and psychogenic hypertension...the list goes on and on, with fourth and fifth digit's mind-splitting.  Worse still, doctors have to know which diagnosis codes will support the "procedures" we do.  Will a hypertension code cover a urine dipstick test?  Or a renal artery ultrasound? Will longstanding hypertension allow me to order an echocardiogram to look for cardiac enlargement?  Billing personnel need to look up these "compatibilities" for every procedure, and for every different insurance company, because they vary.  There is no consensus among insurance companies about which procedures doctors should be allowed to do based on a patient's symptoms.  It's guesswork, and doctors are forced to care more about whether a diagnosis code supports something we want to do than whether that service is best for the patient.
     You can see how much less time is available for thinking about the patient's medical condition, lifestyle, and future health during office hours.
     When ICD-10 is in place I will need to change all the problem lists in my patients' charts so that new codes for their afflictions replace the ones I painstakingly recorded over the past decade.  It will take months.  This wouldn't be so bad, except that coding is only one of many areas of government and insurance regulation, and when they're all put together the practice of medicine becomes untenable.
      Since passage of HIPAA in 1996 federal and state investigators have been given license and funding to investigate and prosecute "health care offenders" (physicians) for many "offenses" including those related to not having mastered the staggering number of codes required to represent medical services on charge sheets.  It can be a serious violation if a doctor doesn't link the codes correctly to procedures, or if written documentation for each patient visit isn't comprehensive enough to satisfy the insurance auditors' standards.
     I keep wondering if the government raided my office because something went awry with our coding.  Despite my compulsive efforts over the years to educate everyone in the office about accurate coding and documentation could we still have stumbled, and sent codes that weren't exactly right for a patient's condition? 
     "No, no," my lawyers reassured me. "That can't be it."
     "Why not?"
     "Your case is a federal case.  Coding problems wouldn't be federal charges, they'd be civil charges."
     I took a deep breath and let it out.  The two lawyers glanced warily at one another.
     "It's likely that you will have both federal and civil charges," they continued..
     "What?  What do you mean?"  Now they were telling me I could have several crimes on my hands.
     "Maybe they won't be able to find a federal crime.  Then they'll drop it down to a civil suit," the lawyers went on.  "But the civil charges are almost as bad, because the government's fines ($10,000 per error, plus three times the amount of the payment, extrapolated to every patient) can add up to hundreds of millions of dollars 'owed.'"
     "And this is all for coding errors?" I asked.
     Then I was told about a doctor whose fines added up to $1 billion.
     I looked at my lawyers with eyes that must have been the size of golf balls.  They looked right back at me, nodding their heads.

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