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Why Is Your Doctor Typing So Much?
“We had to downgrade half of your notes this month.” The coders sat opposite the table from me. The department chair sat to their left.
“You billed a level 5 clinic visit for Mr. Arancibia here,” they brought my clinic note up on the screen.
“Yes,” I replied, “I spent an hour discussing his brain tumor surgery with him and his family. It’s a very complex tumor and required at least that much face-to-face time. I figured it would be worth the highest level of billing.”
“But you didn’t document that you listened to the heart and lungs.”
“I didn’t document because I didn’t do it. I didn’t do it because whatever I heard wouldn’t make a lick of difference in my clinical plan. I’m a neurosurgeon. I haven’t used a stethoscope since medical school.”
“We can’t bill a level 5 unless you document that you listened to the heart and lungs. You have to perform a comprehensive physical exam for a level 5. We had to bill this visit as a level 2.” The coders looked disappointed.
The department chair shook his head, “A level 2 is only worth 0.93 RVU. A level 5 would have gotten us 3.17. And that’s just the professional fee. Look at this,” he gestured to a spreadsheet that the coders brought up on screen, “we could be nearly tripling your clinic billing if you just documented appropriately.”
Mentally, I weighed my options.
Would you like me to cut my discussion with the patient short so I can perform a comprehensive physical exam, even though that won’t change anything about the patient’s workup or treatment?
Would you like me to simply lie about my physical examination in the note?
Would you like me to see fewer patients so I can fit in more comprehensive exams and the appropriate documentation?
I knew the answer, though. No need to be snarky. It’s not the chairman’s fault that these rules exist.
It’s not even the coders’ fault. Their job is to take my clinical note and turn it into a billing code.
That’s the problem.
Traditionally, medical care is reimbursed as “fee for service.” Provide a service (clinic visit, inpatient consultation, surgery, etc) and receive a fee. What it has become, however, is “fee for documentation.”
The most common services physicians provide are within the broad category of “Evaluation and Management (E&M)” codes. E&M codes include all clinic visits, ER visits, and care for admitted patients. Essentially anything that isn’t a surgery or procedure. The codes are typically stratified into levels 1-5, based on the complexity of care. The differences in reimbursement are huge. However, the rules governing what can be billed in each tier are complex and murky at best.
They are complex and murky because they are determined by the government. This isn’t because of private insurance or the result of a fragmented system. This is top-down governmental regulation.
The Centers for Medicare and Medicaid Services (CMS) issues guidelines on what must be documented to bill for each level of E&M code, certain checkboxes that must be met. This all must be included in the clinical note. Thus, physician notes have gone from a means by which physicians could outline their clinical reasoning and communicate with one another to a means by which coders can assign billing codes.
Physicians and coders have decided that more information in the note means a higher likelihood of it passing a CMS audit. With electronic medical records’ ability to automatically import data, notes have ceased to have any clinical utility. Brief notes which should only occupy a few lines are now pages long, with every lab and radiology finding from the last year auto imported. Notes are copied and pasted from one visit to the next. The physicians who generate the most revenue off their clinic visits are those who ensure each note has the required CMS guidelines for a level 5 evaluation. Time writing notes is rewarded, not patient care.
Entire industries exist around these guidelines. There are classes physicians take to maximize billing. There are companies that contract out the coding and consulting firms that train unyielding doctors on how to become stenographers. There are lobbyists at CMS and within the American Medical Association who come up with the guidelines for each code, along with the codes themselves.
Ever wonder why doctors don’t reply to emails? There’s no code associated with that.
Instead of using clinical judgment, physician behavior revolves around the documentation “guidelines” assigned to each code. Patients experience this with those forms at the doctor’s office, asking about a lengthy list of obscure and unrelated symptoms. That’s because CMS decided that the top-level billing codes require a physician cover a 15-point “review of systems.” Since covering a review of 15 comprehensive bodily systems alone would eat up twice the allotted appointment time, physicians have patients fill out the form themselves. Of course, that review of systems was derived for a primary care practitioner, yet it is still mandated that every dermatologist, gastroenterologist, or orthopedist include it in documentation if they are to receive adequate compensation. The same goes for the physical examination requirements. Heart and lungs are a must, even if your specialty is bones or brains.
That’s why, as a neurosurgeon, I’m expected to use a stethoscope on every patient. I simply can’t bill for a top-level clinic visit otherwise. It doesn’t matter that I’m not trained to interpret heart sounds and am the last person who should be basing clinical decisions around the results of a stethoscope examination. CMS would rather I do that rather than spend time covering what, in my professional judgment, matters.
So here I am, documenting at all hours of the night, taking my work home. Here we are, as a profession, writing lengthy and useless notes to satisfy our coders. Those who claim the administrative burden will improve with Medicare-for-All have never read CMS billing guidelines.
Published in Healthcare
Please do continue with those.
I am so glad I retired. When I was still teaching, other faculty members said 25% of their time was spent entering data on an EMR. That didn’t even include coding. Back in 1986, when the RBRVS came out (as a collaboration between the AMA and Harvard) the California Medical Association did not provide a billing explanation. My office manager and I sat down one weekend with the Congressional Record and a spreadsheet. We created a billing code spread sheet and spent the next month or two making copies for all the surgeons in the area.
Absolutely. No sense screaming at the sky about an election defeat. Healthcare rants may be sky-screaming, as well, but who knows? It is just barely possible that a few rays of good sense could pierce the bureaucratic darkness and cause small improvements in the system. At least there’s rational content to such rants.
To what extent are insurance company reimbursements piggybacked on CMS codes or do they have their own variants?
Exactly. I’ll get a consult note from an orthopedic surgeon and it says, “Ear canals are free of erythema & exudates, TM’s are clear.” and I just roll my eyes. Sure, buddy. Do you even own an otoscope? And if so, why?
But it’s not his fault. The rules are nuts.
This is what I teach medical students. You don’t get paid to take care of sick people. You get paid to write notes about taking care of sick people. And if you do that well, you are rewarded by being permitted to take care of sick people.
There are reasons that so many doctors are so cynical. You spend you life learning to cure disease, and then they pay you to check boxes. So we check boxes.
This is tragic. It really is.
I wrote a post about this last year, in which I tried to extrapolate the phenomenon you describe to the society at large. I’d be interested in your perspective.
Most of my face-to-face with my cardiologist he is typing so if I want to ask something and think that I have his undivided attention I must interrupt his typing. If I don’t do that because I don’t want him to forget what he is typing I usually remember what I wanted to ask during my drive home.
Some have their own variants but they typically use CMS as a guide.
I hate the old run-around:
Me calling physician’s office – “I’m sick and hurting”
Physicians’ office staffer – “There are no openings for another three weeks. Go to the ER”
ER – “You are not dying. We are discharging you (After 6 hours)” Go see your PCP for a follow-up. If you have any of these (Written list of the symptoms I still have), come back to see us.
Co-pay.
Dr. B: Excellent post! It captures the essence of “burnout.” Thankfully, as someone who doesn’t take private insurance (I work at a county hospital, only Medicare & Medicaid here), I don’t have to deal with the prior authorizations & denials. I do have to deal with the other CMS bureaucracy and documentation requirements. CMS does have some built in prior-auth mechanisms, though. It is usually just a pop up window in Epic which tells me the ICD-10 code I selected won’t authorize the lab or imaging I ordered. Then it gives me a list of approved ICD-10 codes, so I just go through the list and find one that applies to my patient. It adds about 5 minutes to my workflow but has never once stopped me from ordering a test. It’s just one of the thousand papercuts leading to death, just as you so eloquently describe.
Except that medical students re now being trained coding and protocol following instead of medicine. And admissions to medical schools will increasingly be determined by racial algorithms not potential and existing capability. Don’t get sick. One cannot be too cynical nor too skeptical of what one is told in almost any professional field.
I can remember when there was a concern that medical credentials would be diminished when affirmative action was adopted. This really gets much worse as we socialize medical care.
Exactly correct.
If you consider how little students are actually being taught in any school at any level, you’ll get a good idea of how little your younger doctors actually know and understand about their field. Worse – intellectual curiosity and willingness to fail or work through a wrong answer is being bludgeoned.
As long as someone besides the end customer is paying for healthcare, this is how it is going to be.
Meanwhile, I have a $1000 bill for my cat for several procedures. I have no doubt, out of pocket, I would be paying 20X that for a human, after insurance was involved.
Government always makes things cost more.
Also, I have just lived through having insurance refuse to pay for people based on crap. Literally told that a client did not need medical detox for benzos
Very true.
Before getting into public policy and writing, I worked for an Electronic Health Records (EHR) company focusing on behavioral health. When my 60-year-old PCP (who was also my wife’s family doctor when she was a kid) found out where I worked, he would ask me detailed questions about the codes and why it all was so damn complicated. He was so frustrated that he ultimately retired a couple years early.
I worked at this EHR company when Obama was elected and quickly passed the stimulus bill. That included something called the HITECH Act, which would allow medical centers to get “free” EHR systems. All the execs at my company were thrilled about all the government money they were going to get. I warned them that it would be ugly but since they were all progressives, they mocked my concerns.
The legislation (going from memory) said that the government would pay for any EHR employed for “meaningful use.” Our CEO, and the CEOs from our competitors, said, “Great! Just define ‘meaningful use’ and we’ll get to selling!”
The feds replied… yeah, we’ll get back to you.
Fifteen months later, they finally had a definition for “meaningful use.” It was 650 pages long. Ask your patients about smoking, get a pap smear, track pregnancies, cover elder care, include youth growth charts, etc., etc. My CEO was stunned. “You bureaucrats have obviously made a mistake! Our software is focused only on behavioral health. We don’t treat two-thirds of the stuff you want us to enter codes for. Here are the changes we request before you finalize this definition of ‘meaningful use.'”
After waiting another three months, the government submitted their new definition. It was 800 pages long. Also, Obamacare had now been passed, so we might need to change it all in the near future.
During this 18-month lull time, few were buying new EHR software since no government refunds were yet available. And then we needed to recode our software to include all this irrelevant nonsense the feds mandated.
About two years later, my former CEO and all his competitors had sold their companies to one gigantic EHR company since they were the only one with enough lawyers and lobbyists to survive.
Hate to say I told you so, but…
Typical, Jon.
Thank you! This is exactly the problem and why we only have two EMR companies (Epic & Cerner) with any market power. Why are there hundreds of apps which can consolidate my banking data yet only two major EMR companies? Why can I order paper towels by speaking into thin air at home while ordering an MRI takes 57 clicks & keystrokes? The oppressive regulations have stifled innovation and market entry.
“Meaningful use” is one of the banes of my existence. Hospitals can’t tell us what it means, so they interpret it as “a doctor must input all the orders and data themselves.” When I take call at night, I can’t give a nurse a verbal order for a medication, even something like a tylenol. Because of “meaningful use” I have to get out of bed, turn on my computer, log in to the EHR, click click click and sign the order myself. It takes about 15 minutes instead of a 10 second verbal communication. Add that up throughout the night and now your neurosurgeon is sleep deprived the next day instead of moderately well-rested.
I think this might be why I missed out on my cardio-rehab. The facility rejected an order signed by the PA instead of the MD. By the time there was an opportunity to fix it I had traveled to Utah to avoid the Phoenix heat.
People who think that adding more rules and regulations won’t have a negative impact on quality of care aren’t paying attention.
My wife loathes going to her Rheumatologist because she says he spends the entire visit typing on his laptop, never even looks up at her and never even examines her. Her question is “why do I even have to go see him” Why can’t we do this by phone or Zoom?” I don’t have a good answer. As a former ER doc the thought of not laying hands on the patient at least to listen to their heart and lungs is something I can’t fathom.
For years they have been trying to get us to use a laptop or a tablet when we see a patient, but I refuse. I talk to them, examine them and then record in the EMR.
I hate the idiot billing reminders that try and get me to upcode the visit. I didn’t go to med school to be a billing clerk.
So glad I have about 1 more year to go before I can turn my back on the whole thing.
Cerner’s the one that bought my old company.
People, I took a job in Saudi Arabia in 2013 so that I could get away from Obamacare and US healthcare for a couple of years.
Thats how bad it is. ( FYI when I got there I was terrified and disgusted that JCAHCO had extended their grasp all the way there). No escape.
For anything short of a gunshot wound we would go to one of the DocInABox facilities around here – all within a couple of miles of the closest ER. They do almost anything – including physicals – and based on my 1 emergency (I tripped on a root running in the woods and fell on a sharp piece of granite. 13 staples on my knee later……) I’d take it over an ER any day. They were efficient, very capable, attentive and caring (one of the techs went out to the parking lot and checked on my dog in my car.) I got clear aftercare instructions and 2 follow-up calls checking on recovery. They are walk-ins only – no appointments – and checking later all the Docs shown as working at that site were well credentialed. And it was clean – there are really sick people in the average local ER. There are no sole practitioners anywhere in NH after ObamaCare and the hospital practices are not reassuring.
Excellent post, and we need more like them. People don’t appreciate the adverse effects of layering administrative burdens on providers. We were sold a bill of goods about the improved efficiency and, by implication, improved care and reduced cost that would come from comprehensive electronic records. It didn’t make sense when they pitched it, and it doesn’t happen in real life.
I have friends who own a small thoracic and vascular practice. They struggle every year to jump through the hoops so that they’ll get their Medicare/Medicaid reimbursements. For the past few years I’ve crunched their billing data for them, writing little programs to sort and summarize so they can figure out which path through the Byzantine “meaningful use” (or whatever it’s called now) maze will avoid penalties. (I scratch their back, and they stitch up the occasional skiing injury, call in the occasional prescription, etc. When you’ve got six kids, having something useful you can trade to a health care provider has real benefits.)
The old ways weren’t really the best ways. Except when they were.
Thank you for the complement. I’m trying to communicate how badly the regulations have reduced efficiency in healthcare. Hopefully it’s working.
The EMR example fascinates me to no end. I don’t think the old ways were necessarily better. I wish I could still give verbal orders or just scribble “MRI brain without contrast” to place an order instead of having to go through 57 clicks/keystrokes. Not having to scrounge for a physical chart or xrays, being able to pull up labs & imaging on the computer, these are vast improvements over the old ways. The problems come from excessive regulations. Look at the usability of the Amazon webpage & app compared to Epic. The only explanation is the regulatory burden keeping new entrants out of the EMR field. We have taken regulations and completely handcuffed promising new technology. It’s maddening.
My rheumatologist spends a lot of time typing while she talks to me (and nearly just as much time trying to navigate the system). But she never fails to examine all the joints in which I have issues. I hope that doesn’t change.
I looked this up on google and got: “You could have put your stethoscope and listened to the heart and lungs all at once. And then billed for your time. If you had just done the briefest “full neuro exam”, you could have billed a 99215.”
But I agree with you.