Ms. Mary Jones requests a visit with the doctor for a gynecologic exam and physical. She is a 65-year-old who has started a new relationship, and therefore requests STD testing. Her mother has Alzheimer's, and Ms. Jones is concerned that her memory may be waning. "Could I be getting dementia?" she asks. She has just retired from work as an auto mechanic in a noisy garage, smokes cigarettes, and likes to party with work friends. She fills out a checklist of symptoms and I note that she has marked off numerous red flags: chest pain, trouble breathing, racing thoughts, a desire to lose weight, thoughts about quitting smoking, a tender lump in her breast, an inability to catch her breath when exerting herself beyond an easy walk, and a number of life stressors. She hasn't been to the doctor for several years. "My last doctor never did anything," she complains.
I spend 45 minutes during her exam, discussing her risks for cardiovascular disease, the likelihood that she has developed emphysema, the occupational risks associated with working in a noisy, fume-filled garage, her new relationship, and the fact that she's never had a mammogram or colonoscopy. I examine her thoroughly, perform Pap, breast and pelvic exams, check for trichomonas and gonorrhea under the microscope, run a urinalysis, measure her hearing and vision, have her breathe into a spirometer to determine whether her shortness of breath is attributable to emphysema, do an EKG and chest x-ray, and refer her for mammogram and colonoscopy screenings. I suggest an optometrist for glaucoma testing (recommended at her age) and a dentist, because she has cavities and plaque.
We spend additional time talking about how she might lose weight, and I recommend a stress test at her next visit. I prescribe treatment for emphysema, a diagnosis that is confirmed by her x-ray and spirometry results. She wants to start Zumba at the local gym--I ask her to wait a week or two, until her cardiac testing is complete. She describes multiple attempts to quit smoking in the past, says most of her friends and family smoke (but not her new partner), has not picked a quit date, and says she can't afford smoking cessation products like Zyban, nicotine patches, or Chantix. She asks to have "blood work," which is appropriate, given her symptom list. I send off a cholesterol panel, blood count, thyroid test, syphilis, and chemistry labs--most of these are sent to the lab and will be billed separately to her insurance by Quest. I run a five-minute HIV test in the office and give Ms. Jones results, along with STD counseling and condoms. Given her memory issues and family history of Alzheimer's, I do a neurobehavioral assessment and urine drug screen. Most of the tests are run by ancillary staff, but I interpret them.
Ms. Jones' insurance claim form looks like the following. The section for charges is arbitrary and essentially irrelevant--insurance companies establish all fees for doctors, so we usually set our fees at twice the insurance rates for the ease of calculating amounts pending--half the amount not yet paid, or A/R.
Here's how this patient's services look when they are translated into insurance jargon--in this case, Medicare. One number change--a slip of a clerk's finger--could constitute "fraud." Pre-loading charges into the computer is fraught with problems, not least of which is that a diagnosis code specific to the patient's complaints must be entered for each service. In addition, codes are not the same across insurance companies. This claim would have to be somewhat different if the patient had Blue Cross, for instance, and therein lies an enormous problem. Sending the claim below for the exact same patient with Blue Cross could constitute "fraud" Physicians must speak a different language, with different vocabulary and grammar--thousands of combinations of numbers and letters as illustrated in the example below, and different "allowed" combinations for different insurance carriers.
The systems invented to order these numbers are called ICD-9, CPT, and HCPCS. But the insurance companies which make the rules for which letters, numbers, modifiers, and combinations of codes are permissible to bill--are all over the map. If the doctor's office doesn't know the rules--and no one knows them well enough--it will be underpaid. Family physicians provide such a wide variety of services, across a range of specialties, that keeping up with the many codes is a monstrous task.
Date of Service 1-1-11
Patient ID # 3203
Patient Name Mary Jones
Patient DOB 12-12-45
Provider Type NH2
Provider Class: Procedure Code: Diagnosis Code: Units: Amount:
E/M 99204-25 611.71, 786.05, 1 xxxx
IMAG 71020-59 786.05, 496, 305.1 1 xxxx
DIAG G0101 V72.31 1 xxxx
E/M G0402 V70.0 1 xxxx
LAB G0328 V76.41 1 xxxx
DIAG 94375 493.90 1 xxxx
DIAG 99173 368.10 1 xxxx
DIAG 99552 389.12 1 xxxx
DIAG 92567 389.00 1 xxxx
DIAG 93000-59 786.50 1 xxxx
DIAG 96116-59 290.0 1 xxxx
LAB 81003 V15.85, 788.1 1 xxxx
LAB G0434-QW 780.09 1 xxxx
IMAG 76645 216.5 1 xxxx
DIAG 96150 311 1 xxxx
LAB Q0091 V72.31 1 xxxx
HM 99406 305.1 1 xxxx
LAB 86703-QW V15.85, 786.00 1 xxxx
LAB 83986-QW 616.10 1 xxxx
HM 97535-GO 278.00 1 xxxx
LAB 87205-QW V15.85 1 xxxx
The patient spent one and a half hours with providers and specialized employees--including ultrasound, x-ray, lab and nursing staff. The office note for her visit takes up eight pages, including two hand-written reports specific to her concerns and our thought processes (called "assessment and plan" in doctor-lingo), a gynecology form with notations about her exam, and multiple pages with results from her diagnostic studies. It takes about thirty minutes to review, interpret, and record results, as well as write a unique office note about the visit--we do much of this documentation after the patient checks out.
This patient is making a plan to quit smoking and was relieved that her chest x-ray and EKG didn't show major problems. She will schedule a date next week to go over her lab results, talk about the impact of life-stressors (the foreclosure, her new relationship) and sort out whether this is a good time to make a plan to quit smoking--I advise her to reduce her use of cigarettes as much as possible, for now. She will undergo an exercise treadmill test and echocardiogram before we make recommendations for a fitness program. If these are negative she may be motivated to quit smoking and follow a healthier lifestyle.
We accomplish a lot with patients like this--a typical patient visit--but the documentation, coding and billing requirements are overwhelming. There are dozens of different insurance companies, and their coding requirements can vary significantly. For example, there are six different ways to code and bill a flu shot, depending on the age of the patient and the insurance company covering the immunization. This year, the codes for flu shots have changed again. If we don't keep up with coding changes, we will miscode services, we will not get paid, and we may be accused of fraudulent billing. In family practice, which utilizes tests and procedures across many different specialties, the number of codes, modifiers, insurance variations, and rules for billing far exceed anyone's ability to keep up with changes.
The chances that a solo doctor will make clerical errors in the world of billing and coding, therefore, is 100%. The chances that a solo doctor could be a target for allegations of fraud, therefore, are very high--maybe also 100%, unless the doctor chooses to offer very few services, as a way of avoiding scrutiny, or as a way of keeping the billing as simple as possible.
Since taking care of patients properly is more important than coding and billing, providers in my clinic give relegate their best hours to patient care Documentation, coding and billing--which are superfluous to patient care--fill the late-evening hours. It doesn't help that insurance companies change codes at random, do not share codes (Medicare requires use of many codes that Blue Cross doesn't recognize, for instance), and are currently in the process of overhauling the entire coding system. All the codes doctors like me have memorized over the years will be useless. I know physicians who are planning to retire from medicine because the prospect of adapting to 130,000 new codes for describing patient symptoms and diseases is too onerous.
The coding above is not the same for every insurance company. Many codes vary for the exact same services, making it difficult to program a computer program to assist with transmitting charges to insurance companies. Providers must write in diagnosis codes for every test and procedure, and these codes must be specific for each patient.
An hour and a half later