Friday, August 24, 2012

What is Medical Coding? And Another Example

     So many people read my recent post on coding for a typical patient visit that I thought my readers might like to know more about this benumbing process.  I do not in any way advocate the continuation of this process, at least not until there is standardization across all insurance providers about how much liberty doctors should have to decide what patients need, and how they should get paid for their work.
     What is "coding"?
     Coding is the process of translating both the conversation that takes place between doctor and patient in an exam room and the behind-the-scenes thought-processes of the doctor as he/she listens very intently to what might seem like ordinary parlance, but in fact is a prodigious set of  clues pointing to the exact source of the problem--and sometimes the cure.
     It must be obvious, then, that coding cannot possibly denote what truly happens between the doctor and patient.  Human communication is multilayered, and the communication behind the closed door of the exam room is full of innuendoes and subtexts.  When patients talk to me about the weather, for instance, they are not talking about the weather.  When they tell me, conversationally, that an estranged family member is coming for a visit, they are not really talking about the physical appearance of a brother or sister.  (Stormy weather may mean that I'm likely to give them unpleasant news.  Calm weather may mean a loss of connection to a feeling function.  An estranged family member may suggest that a hidden aspect of the patient is about to emerge in the form of a symptom or illness--with features oddly analogous to the family member--because it can no longer tolerate being cut off from consciousness.)  Physicians listen with a sixth sense, taking in symbolic messages sent by the patient's inner guru--who acts as a guide to the underlying medical problem, which is sometimes a psychological problem, or a life problem.
     How can I describe all this in a SOAP note--which is the method for telling other doctors what I found and what I thought?   SOAP notes were designed for abbreviated conversation among healthcare providers, but insurance companies have decided to use them as the only basis for payment.  They have burdened doctors with the job of explaining to laypeople a process that has been abridged for the purpose of transmitting vital information to other doctors.  As a consequence, we have been forced to write virtual essays--two or more pages for each patient, in my office--rather than notes.  In spite of our efforts, insurance auditors are trained to find holes in the documentation so they can reduce or deny payment for medical services.  It's easy for auditors to find problems, because no one agrees about what constitutes adequate documentation for most physician services, especially office visits.
    Even if documentation requirements weren't impossible (because there is no consensus), how could I, in any case, explain to an insurance company, in the rudimentary numerical language of coding, why I spent the time I did, or what circuitous paths and cross-paths my thoughts took as I assembled information into a plan for treatment, and attempted to make inroads past the patient's resistance?
     "If it isn't documented, it didn't happen!" the malpractice lawyers--and now coding specialists--tell doctors.  Lawyers win cases because our complex decision-making isn't recorded in detail.  Doctors are not literature professors or journalists, so our documentation falls short, and insurance auditors refuse to pay for our services on the basis of short office notes.
     There are many subtleties about which we cannot write, because we barely intuit them as we make our way through the dark forest of the patient's interior world.  And writing in minute detail, even with computer templates, is a waste of time.  The current system can't be tweaked any more, it needs to be replaced.  I believe "coding" should disappear altogether.
     Here's another patient and the accompanying codes.
     Mr. J. is a 32-year-old office worker who says he has migraine headaches.  He tells me that he needs Demerol and Phenergan shots for the acute pain.  This is old-fashioned medicine, but many doctors still keep these products on hand for acute migraines with nausea.  Mr. J.  also wants a prescription for hydrocodone to use "when the headaches start."  I am not a fan of opioids for recurrent, chronic pain--there isn't support in the medical literature for such treatment, and opioids have been associated with immunosuppression, higher rates of infections, cancer, heart disease, constipation, mental cloudiness.  I don't know Mr. J.  I talk with him for more than half an hour, do a physical exam, obtain a urine drug screen because he's requesting opioids and seems agitated, perhaps by pain.  On exam I note that his right arm is weak compared with the left, and his sensation to light and sharp touch is diminished on the same side.  He denies having had a neck injury.  His mother died of an aneurysm at age 63.  Mr. J. is overweight, does not smoke, has "three or four  drinks" every evening after work, and doesn't exercise. He says he was told his cholesterol is high.  His last physical exam was five years ago.   He had a DUI last year, and he is vague about the reasons for his divorce two years ago.
     I recommend the pain machine--a combo of electrical nerve stimulation and muscle spasm reduction delivered via a device (Hako-Med) invented by a German doctor, approved for treatment by the FDA, and covered by most insurance plans.  Mr. J. agrees.  First, I perform a nerve conduction study to assess his pain and weakness--it reveals a pinched nerve in his neck.  He agrees to lab tests that might uncover underlying causes of neuropathy.  We discuss weight loss and cholesterol-lowering lifestyle interventions, and the possibility that he may have a problem with alcohol, or underlying depression.  He is somewhat amenable to my suggestions, and seems grateful that I have taken more than a cursory interest in him.  I do not recommend Demerol or hydrocodone.
     Here's what we "tell" the insurance company.

Account Service:  3499
Date:        Name:      Provider   Class      Procedure    Diagnosis      Units  Amount
6-14-12    John Jay    OC           EM          99395-25     V70.0              1          $$
6-14-12    John Jay    OC           EM          99203-25     723.1, 346.01  1          $$
6-14-12    John Jay    OC           PT           97032-GP    355.9               3          $$
6-14-12    John Jay    OC           PT           97112-GP    728.85             3          $$
6-14-12    John Jay    OC           LAB       80101           780.09             7          $$
6-14-12    John Jay    OC           LAB       80102           780.09             1          $$
6-14-12    John Jay    OC           EM         G0396          303.91             1          $$
6-14-12    John Jay    OC           LAB       36415-59      723.1               1          $$
6-14-12    John Jay    OC           EM         97535-GO    272.2, 278.00  1          $$
6-14-12    John Jay    OC           DIAG     64992-59      355.9               3          $$
6-14-12    John Jay    OC           DIAG     64995-59      355.9, 723.1    3          $$

     Maybe this system seems reasonable to some people.  After all, when you go to the grocery store you get a receipt listing everything you bought along with the price.  The problem arises when the price of bread varies from one person to the next, or when one patient has to pay the first $133 of his bill, and 20% of everything after that, except for peanut butter and chewing gum;  and the second customer has to pay the first $250, except for ice cream, peanuts, and steak;  the third has to pay the first $5,000, except for fifteen different items for which he has to pay 50%, 23% or 17% of the manufacturer's arbitrarily assigned pricing, and 43%, 16% and 8% of the price after the first $5,000 has been paid out-of-pocket...and so on, until next year, when--at a time ordained by each of hundreds of different plans, the same customers will be subjected to a completely different set of percentages owed for each item or service received.
     Patients never seem to know about pricing or "patient responsibility" in advance, nor to understand the meaning of the word "deductible" in most instances.  In fact, patients live in a world protected from coding, non-covered services, deductibles, costs, and percentage co-pays, because the manuals they receive once they are lucky enough to acquire health insurance are so colossal and incomprehensible they get tossed in a closet or filed away without ever being opened.
     It's up to the doctor's office to explain what a patient can and can't have, or how much might be owed once insurance carriers pay their part.  But the rules about what a patient must pay are complicated and differ in important ways even within the exact same insurance plan.  Phone calls by medical staff or patients to these insurance plans, for the purpose of clarification of coverage guidelines, are met with the same bafflement on the part of representatives.  Patients--who feel that "having insurance" is enough--are often baffled and angry when they owe anything, and sometimes storm out with angry words.  They vow not to have anything done in the future, so as not to be surprised when they find out their insurance doesn't cover certain services, or because it requires a deductible, or additional payments for select procedures, for inscrutable reasons.
     Such is life in the world of medical billing and coding, where patients buy--or are awarded--a product (insurance) which is supposed to pay their bills from a distance far-removed from the place where they get treated.  Maybe it used to make sense, but not any more.  Maybe it should work, but it doesn't--except for insurance companies, who seem to have the final say about whether they will pay for anything, or not.


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