Exceptional Coders | Innovative Technology

This is part 4 of a 4 part series on the business of medical coding.

This is the final installment of this four-part series.

Between lawsuits and new regulations about “quality”, there is a growing social assault on the practice of good medicine, which includes a certain amount of risk-taking, innovation, and professional autonomy. The problem lies in the unrealistic desire to have it both ways—meaning no possibility of a bad outcome, along with low cost.  That these two needs are largely at odds has been ignored for decades.   There is no financial incentive for a physician to provide elective services to a high-risk patient—even if that physician is the best in the world at performing it.  

A recent New England Journal of Medicine study[1] found most physicians will be sued for malpractice during their career. By age 65, more than 75% of physicians in low-risk specialties such as family medicine and 99% of physicians in high-risk specialties such as surgery will have been sued.

One study reveals that the cost of medical malpractice in the United States is running at about $55.6 billion a year – $45.6 billion of it is spent on defensive medicine practiced by physicians seeking to stay clear of lawsuits.[2]

The problems associated with malpractice are known to include physician health issues.   Medical Malpractice Stress Syndrome (MMSS)[3] is closely related to traumatic stress disorders, and includes feelings of intense shame, depression, anger, panic, and fatigue. 

This is part 3 of a 4 part series on the business of medical coding.

In the pursuit of their careers, physicians are taught to assume responsibility for peoples’ lives and to make decisions with the goal of best patient outcomes. The mind of a physician is constantly prioritizing and classifying patient information in an effort to make the best decision — often under extreme intellectual pressure. Physicians invest the majority of their young adult life in learning their craft.

The tenacity needed to stay the course is sometimes associated with a true “calling” to practice medicine, a profound love and respect for humanity and healing. Think shaman, medicine men, or even the patient-focused doctors depicted by Norman Rockwell. However, many physicians are startled by an unexpected problem: To comply with the law, they must move their attention away from the patient.

Medicare and other payers hold a physician responsible for correct billing and medical documentation. On the surface, this seems reasonable but the complexity of rules are not simple, or easy to remember.[1] For example, physicians are not allowed to simply document what is wrong with a patient and what they want to do for them. They are required to document their patient visits according to a minimum of 50 possible service variances; all are generic hypotheticals with no bearing on necessity or quality of patient care[2]. Physicians fail audits without this arbitrary documentation –regardless of the services they actually provided or the patient’s outcome. In some cases, due to one or two missing words.

This is part 2 of a 4 part series on the business of medical coding.

The United States leads the world in medical innovation. We have the best access to the latest medical advances–largely because they were discovered, developed and produced here in the United States. We have access to diagnostics that allow us to detect health issues early. We have medical devices that unblock arteries, replace joints and even body parts. We have medicines that have significantly lowered death and disability rates from heart disease, cancers, stroke, and other diseases. We have made HIV a treatable, chronic condition.

This might be news to rejoice if the high cost was producing a sustainable supply and demand, wage increases, or lower unemployment…or even just a longer average life expectancy for U.S. citizens. Despite being one of the best—and the costliest system in the world, it has done none of these.

The unfashionable truth regarding healthcare business in the United States is that, like all businesses, the goal is to make money. Lots of it. Our healthcare spending grew 3.6 percent in 2013, reaching $2.9 trillion or $9,255 per person. As a share of the nation’s Gross Domestic Product, health spending accounted for 17.4 percent. In terms of the average working person—this is about $3,500 per year….or 5% of an individual’s before tax income, more if you calculate Medicare and Social Security tax.As one of our top economic industries, there is political interest in the costs. There is no final agreement on how to cut costs. The debate has swung from the right-wing ideal of a free-market driven private care system, to the far left of a single payer system.

Stephanie Cecchini, CPC, CEMC, CHISP, ICD 10 Trainer, VP Coding at Aviacode

If you believe CMS…we get coding SERIOUSLY wrong. How wrong? In Evaluation and Management alone, $1,260,699,470 in improperly paid 2013 claims. Adding to the HEAT (pun intended), in recent years, the government and private payers have taken a firm position on fraud and abuse. The Patient Protection and Affordable Care Act allows the Centers for Medicare & Medicaid Services to suspend payments when there are “credible allegations of fraud.” It’s increasingly important to avoid even the appearance of wrongdoing.

Why does CMS believe their audits are right and physicians are wrong? Evaluation and Management codes, the codes that bill for office visits, are subjective in nature. From the aspect of medical necessity, the correct level of service is determined simply by how sick a patient is. Conditions that pose an immediate threat to life or limb qualify for the highest code level, whereas patients with minor or well controlled problems are at the lowest; however, peers may see the same patient and assuming the same diagnosis may still argue how sick the patient really is. Beyond medical necessity aspects, the rules that govern documentation requirements are also in many ways subjective. Reproducible audit results between unrelated documentation requirement auditors are not unfailingly prevailing. Properly trained and certified auditors may agree on the actual code selection better than 90 percent of the time; however, the means and measurements of their conclusion can be different upwards of 50 percent.

This is part 1 of a 4 part series.

Like elite military forces, physicians are trained to do what most of us cannot. People drawn to careers in medicine have unique personality traits and aptitudes that include high intelligence, compassion, inquisitiveness, and sensitivity to others. But, they are also extremely competitive, driven, and sometimes even obsessive-compulsive.[1] It is this relentless drive for perfection that hones a physician’s craft. They may not always be likable, but they know how to make life and death decisions independently, often instantaneously, and under immense pressure.

But, many physicians are extraordinarily unhappy.

Nine out of ten doctors discourage others from joining the profession. More than 300 commit suicide each year –making them twice as likely as the general population. A nationwide survey of physicians who practice medicine full time, found 5 in 10 have considered quitting medicine[2]. This is cumulating to a 90,000-doctor shortage in the United States by 2025[3].

Stephanie Cecchini, CPC, CEMC, CHISP, ICD 10 Trainer, VP Coding at Aviacode

While recently conducting an onsite audit of professional services (office visits and behavioral health claims), I was asked: “What is the most valuable resource to a healthcare practice.” My answer was, as it always is, “The Physician, of course.” The conversation sat with me for several days. Why is it that the physician, who is the number one producer of revenue, is also the first person to be required to jump through documentation hoops and reimbursement nuances that can be as clear as mud? Why are more medical coders not grabbing their ear? We all know, physicians like a resource that can simplify, demystify, and ease administrative burdens. There are new positions starting to really takeoff around the idea, such as the exploding use of scribes. Scribes, however, don’t usually understand medical coding. It’s the knowledge and action taken at the medical coder level that resonates in cash flow and compliance. Medical Coders are Health Information Managers (HIM). They are so often the bearers of “bad” news that some are shy to speak up for fear of upsetting the physician. Bridging that gap is necessary. Medical Coders need to know how to communicate effectively. So how can you be HIM…and heard?

There are many “best practices” Medical coders can take to communicate effectively. Typically, a physician will be more likely to listen and respond when you are able to communicate by both your actions and words of understanding of their needs, wants, and mindset. Our doctors are life-long learners, highly intelligent, and possess a deep appreciation for logic and reason. Physicians are naturally intuitive, some even feeling spiritually drawn to practice the art of medicine and healing. Generally hungry for and appreciative of tips and techniques in learning new skills, physicians crave correctness. Accurately documenting for coding and billing purposes can prove a frustrating dichotomy; it is both a challenge to achieve correctness, while also an intrusion that takes away from patient time. The right medical coder will communicate in a way that stimulates these traits and emotions.