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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
My IT team installed our first (of many) EHR(s) in a doctors’ office (the hospital-owned Family Practice clinic) in 1994. I don’t think, from that day forward, there was a single day when I wasn’t
privy toon the receiving end of some of the frustrations expressed in this post. The other ones, relative to upcoding, downcoding, rightcoding and the vicissitudes of what’s considered proper “documentation” in this day and age. also came my way over the years, both from the doctor and the hospital side.Thanks for a post which is the clearest explanation of this madness I’ve ever read.
So perhaps “upcoding” explains why my recent Medicare “annual wellness visit” to my PCP (which was perfectly normal in all respects, as shown in the chart notes for my AWV) got billed to my insurance company coded as a “physical exam with abnormal findings” with a coded reference to non-existent abnormalities. I thought perhaps they’d mixed my chart up with someone else’s!
I told the insurer I was not pleased with anyone recording “abnormal findings” when there were none; they told me to talk to the doctor’s office, which I did, and after my becoming rather insistent about not recording abnormal findings when there were none, they finally agreed to undertake a “coding review”.
In the weeks since that call? Crickets.
You’re absolutely correct. As you know, all that matters is what the coders think the regulation states. Because CMS makes it as clear as mud, different coding groups will downgrade notes for different reasons. I asked the coders for their guidelines once and was looked at like I was insane.
When I was in Utah I had a PCP and I got guided into one of those “annual wellness visits”. When I moved to Arizona, I don’t have a PCP so I got some calls from Utah, the conversation had a tone as if I was supposed to have a PCP and I was supposed to go for the “annual wellness visit”. I told them not to call me. What is this all about anyway, I go to the doctor if I need one?
This is how a “low trust society” is fostered. By this and many other ways (such as pretending men and women are the same or rewarding electoral fraud), our government provides incentives to lie. Do that often enough in an increasing variety of situations and people start doubting each other by habit even where no formal incentives exist.
Then rule of law gives way to raw power and trickery. Then tribal insularity becomes the surest defense against abuse.
The misery and financial distress caused by sudden repeal of regulations would not be greater than the ruin omnipresent government is pushing us toward.
Well, that explains what I see as a lawyer when I have to review medical documents. So much repetition!
It’s perverse, is what it is. Heinlein’s “bad luck.”
I wonder if that’s why doctors suddenly started asking me if I kept guns at my residence. This was usually met with a quite rude response. No one has asked me that in a long time so perhaps I wasn’t the only one.
What next, now that you know who rules the medical profession . . .
Had patient come in to the ER in acute respiratory failure, was getting ready to intubate the patient, got a stat portable CXR.
I’m waiting and waiting for the film.
Finally, called radiology to find out what the holdup was.
They told me they didn’t “flash” the film, because the order wasn’t entered. They were just sitting on it. While my patient was trying to die.
Rules you see.
That’s an Obamacare regulation.
The Obama administration wanted to know which homes had guns in them (Why? A very interesting question that I would prefer not to think about…). But it would have been politically difficult to just ask people.
So they added that to the “meaningful use” and “quality measures.” So now doctors have to ask if you have a gun in your house if they want to get paid to treat your bronchitis.
And remember the other key feature of Obamacare: Now the federal government has access to your medical information. Which now includes whether you have a gun in your house. And it also includes a whole lot of stuff which has nothing to do with medicine, and doctors don’t care about. But nosy leftists do care about.
So there you go.
Some people think Obamacare doesn’t work. They’re wrong. It does exactly what it’s supposed to do.
Dr. C, you have just described the elusive 10th circle of hell. I can’t imagine.
The answer is “Not enough”
Sorry, all you doctors, but there is one absolute benefit from your entering all orders into a computer. The nurses and pharmacists can now read your writing, instead of having to decipher scribbled notes. I spent ten years as a hospital pharmacy technician, and our pharmacists were always on the phone to doctors to decipher their handwriting. There were some close calls on which drug was specified.
During those ten years in the hospitals, I watched many medical students progress through the system. The students’ handwriting was always clear and easy to read. Once those students graduated and became residents, their handwriting deteriorated almost immediately.
Fair point. I never understood that.
The whole point of writing something down is so someone can read it. If they can’t read it, why bother?
I can see how this is frustrating to Doctors. Our GP retired not long after he sold his practice to a large multi-site system. During the time before he retired, he was more and more tied to the computer and less to the patient. My current Doctor is “hands on” only with the computer.
We have had multiple dogs over the years with various levels of health problems and Veterinary specialists – Doggie Cardiologist, Acupuncturist, several surgeons. In every single case, the interaction was more satisfying than my interactions with my various human doctors. The Vets would spend all the time we needed to answer our questions and were definitely “hands on” with our dogs.
I always felt like the difference was when we were finished with the Vet, we paid them directly – there was no third party looking over the transaction.
My wife and I are now both on Medicare which is both good and bad, but I would like to go back to the GP I had 45 years ago (Dr Livingood – seemed like a good sign). He was old style.
I remember 30 or 40 years ago, every chart was identical, except perhaps for a rare proprietary form. I was totally free to chart in the standard way everywhere. Since EMRs came about, every system is different, and even Epic EMRs are tailored to run differently from place to place. And even within one facility, the Epic systems are changed from month to month. I miss the old paper charts.
And perfectly fine and easy to use documentation system built up over a century of hands-on experience wiped out in a couple of decades.
Two things: the AWV has a zero co-pay under Medicare, and I never went to a doc either unless I needed to before becoming enrolled in Medicare.
Secondly, my ongoing prescriptions are only refillable for a maximum of one year, so I have to have an office visit annually, get labs done, anyway. Glad it is no charge, but I do think at the least they could code it properly.
My observation is that EMRs were supposed to help medical professionals work more efficiently but were transformed into primarily being vehicles for satisfying bureaucratic needs.
The U of Arizona medical center in Tucson bought an EHR system. They wound up spending so much money on it that the U got into financial trouble. A retina guy told me the story. They ended up selling the whole medical system to an outfit called “Banner.” I understand a number of docs have left as the new boss requires all sorts of intrusive rules. UMC used to be an outstanding medical center. I had a minor surgery about 15 months ago as an outpatient. Hospital bill $36,000.
I was, long ago, an enthusiast for electronic medical records. I was a member for years of the AMIA. I was naive.
https://www.amia.org/
For a few years, I reviewed and testified in med-mal cases. The Kaiser charts were always a foot thick with risk management nonsense. I’m sure all charts are the same now.
The pediatricians are asking your kids, if you have any. The Stasi cometh.
No, it’s all about billing and control.
When I was a flight surgeon in the AF and we deployed we had to transport almost an entire pallet that had the squadrons medical records in it. This is for a bunch of healthy fighter jocks and young aircraft mechanics and ground crew. For every patient interaction I had to generate a complete SOAP note, no matter how minor.
I was working with an RAF flight surgeon one time and he asked me why I wrote so much on every patient. I explained to him.
He laughed. When his squadron deployed he carried all their records on 4X6 file cards in a single file case he could put in his backpack.
His charting consisted of making a 1 or 2 line note on each patient, complaint, Dx, treatment.
EMRs are billing platforms pure and simple. They were never intended to help make medical professionals work easier or more efficient. That was just the lies they told to get us to submit.
The only continuing medical situation I have is cardiology so I go to my cardiologist once a year to check that and renew my prescriptions, paid by medicare and my supplement coverage pays my co-payments and any deductibles so I’m not really looking for the free visit. I may do it someday if I feel sick.
The military might have been different.
As a physician who has worked in a variety of private and academic settings, I can attest that the jokes about doctors’ handwriting are true but you miss the point in Dr. Craniotomy’s post. The danger comes from creating complicated medical records that are created by cutting and pasting narratives that develop a life of their own through the process. There is little evidence that at every appropriate step in that process each person in the diagnostic chain reevaluates the clinical situation and considers even basic clinical data such as a directed physical exam.
And there are so many tabs to click labelled “reviewed”. (Unless it’s germane to the patient’s presenting complaint.)
I agree with both of you. There are many benefits to EMR over paper charts. I started residency as paper charts were being phased out. The notes were terrible because I could never read what the consultants were writing. Finding charts, which was the task of the lower level residents and students was insanely frustrating. The synthesis and display of patient data (labs vitals etc) was frustrating. My job on one rotation was to spend the hours of 2am-6am gathering all the vitals and labs to present to the attending in an easy to digest manner. That is all much easier with EMR.
My issue is that instead of allowing the markets to deliver us a truly innovative product, we have had government regulations shove this unworkable monstrosity down our throats. It simply shifted and amplified the administrative burden. We need to open the regulations to allow an innovative EMR without all these documentation and “meaningful use” criteria.