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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
Regarding bad handwriting and shoddy record keeping, would y’all object to a general transition toward typing on various computers? The time when many accomplished doctors were unfamiliar with computer use seems to have passed.
There are various risks to computerized records and common mistakes in usage. But it’s the same with paper documentation.
That’s because they’re choosing to retire early.
Since Dr. Bastiat said he doesn’t know why medical students handwriting deteriorates once they become residents, may I offer a guess? Please, please, don’t hit me!
My guess is it’s a power thing. Medical students have no power at all, are the lowest of the low on the totem pole, and they want to please their superiors so they will get good grades, graduate, and become residents. Once they do graduate and become residents, they suddenly have the power. They are not the lowest, and there may be multiple people below them. So, their writing is not as easy to read, and those lower than themselves must come to them, bow down (so to speak), and ask them to confirm what they wrote.
Just my guess.
Ha, ha, ha.
See Hospital.
Don’t get your point. We were both in the military doing identical jobs for two different countries.
His acted reasonably and rationally, ours was hidebound and inefficient.
Absolutely. I would get ER patients all the time sent from the VA for evaluation.
They would show up with 100 pages of notes. Endless repetition of the same information, old note useless notes, old evaluations by audiometry, optometry, physiatrists, old clinic notes with nothing to do with current issues.
What I found impossible to find was
Invariably the VA clinic was closed or the doctor was unavailable.
Well, first, I’ve never seen a chart on an index card, so that’s different from civilian. As for the pallet full of charts, I don’t know how many men this was for, but it seems a bit like a normal medical records department on a plane, which is odd but not bad.
We were very limited in the number of pallets we were allowed for the Med unit of the fighter squadron. Using an entire pallet for charts and supporting forms meant one less pallet of drugs or dressings or other medical supplies. My point was the Brits were able to distill it down to the minimum needed and their ability to function did not get degraded one bit.
It’s interesting that the book The House of God follows interns before the age of EMR. They kept patient info on single index cards. It’s a shame that Shem’s follow up book, just released, showed his complete disconnect with modern healthcare as he campaigned for “Medicare for All” throughout.
I might be wrong here but I think that the government has a unique control over all military personnel. But I thought that the 1973 SCOTUS ruling on abortion hinged on the individual’s right to privacy. Now the government mandates what medical information is gathered, and wants all medical information to be stored in a particular way, which, I believe, makes it easier for the government to access this information. What is more it makes the medical information so much easier to steal, or now, hack.
Furthermore, Watergate was in part about a failed physical attempt to gain a dissident’s psychiatrist’s file on him. This would never have been botched if it were an electronic record, and this break-in would have gone undetected.
They absolutely still ask, along with how often you and other members of your household wear seatbelts and whether you or anyone in your household uses tobacco products. Because when your spouse drives to the corner store alone without a seatbelt it has a health-related effect on you, I guess.
We have a non-working Japanese Arisaka rifle from WWII (souvenir originally belonging to my husband’s grandfather) junked in the basement with a bunch of other stuff we don’t know what to do with. You have to climb over a tower of paint cans to get to it. Do we have firearms in the house or not? And really, whose damned business is it anyway?
@craniotomy, your post is clear, interesting, edifying, and utterly dismaying.
Mission accomplished. Thank you.
There’s a sequel to House of God?! I gave that book to a pre-med student. She returned it having not finished the first chapter. She said it was too depressing. I think she left pre-med as well.
Yeah, when I was a med student in the 80’s, when we started a new rotation, we had a “passing” of the cards. The outgoing crew turned over their file cards on the patients on the service to the new crew.
On one rotation we were at morning report and the nurses came to us and asked us to renew the IV orders on a patient. We all looked at each other, no one on the team had that patient.
The patients card had been lost, and he had been on autopilot for 3 days until his IV order came up for renewal.
Yeah, DOD bureaucracy rules. This was in the mid to late 80’s however, before HIPPA and a lot of the nonsense had been instituted. It was just the DOD being a hidebound Leviathan.
I told my non medical sister to read It.Told her we all thought it was hysterical.
She called me long distance to yell at me and tell me how sick we were if we thought that was funny.
By the way they made a movie out of the book that never saw theatrical release.
Yes, it came outa few years ago and it is truly cringe-worthy. He goes on and on about how all the problems in modern healthcare are because of insurance company profits. The descriptions of an old-man trying to click through the EMR and then blaming it on private insurance companies are mind-numbing. There are scenes where he his private practice group recruits doctors who are in tears about all the check boxes that those evil insurance companies make them click. Then he tries to make the argument that if only we had single payor, it would all get better and we could just care for patients. Clearly, that runs against all the evidence I’ve seen (and tried to present here). I then listened to an interview with the author where he admits he lived the stories of the first book but not with the second. He just made them up after hearing stories from colleagues.
My guess is that the TV show St. Elsewhere was at least loosely based on it.
The EMR at the university where I taught students for 15 years required a diagnosis be entered before findings and history. It could not be deleted or changed. This was NOT the “chief complaint.”
When I was a faculty member at UC, Irvine I became aware of the terrible chart situation. Residents kept their own personal charts and discarded them when they finished their residency. A friend of mine who was med-mal defense lawyer, told me he did a lot of work with UC. He said an EMR would pay for itself by cutting the costs of med-mal defense and settlements. Of course, none of that happened. I have not done any med-mal expert witness reviews since the EMR was imposed with Obamacare.
Nope. Medical students do some writeups but not at the pace of residents. In my days at LA County Hospital, medical residents would workup as many as 36 new patients in 24 hours. These were not known patients but new sick patients.
I showed that movie to my medical students every year. I assume you mean the George C Scott movie.
It is really a bit much for medical students. “The Hospital” has a lot of humor and my students were used to the County Hospital. It might also suggest a change in who is going into medicine now.
I spent 30 years telling medical students and my office staff to NEVER use a patient’s first name unless they ask you to. Then HIPPA came along.
I’ve noticed that the more sticky notes and index cards I see lying around a medical office, the worse their software is.
The summary of my visit to my doctor now includes a list of every ailment that was a false alarm or an issue in the past, as if that’s what was discussed. Cut and paste.
Last time I was in because of ailing with Lyme Disease, I was well overdue for my annual visit, so all of the old issues that are no longer issues and were not discussed are listed as having been discussed. are listed. During the visit the doctor asked me if it was OK to talk about Advanced Care Planning. I told her, “You can talk about it if you want,” and she went through a canned spiel. I said something about “ambiguous situations,” and didn’t care to say more. Mostly I wasn’t feeling all that great and just wanted her to deal with the Lyme disease. I saw later that Medicare got billed $100 for that little “discussion,” of which I paid $10. Pretty small potatoes, but I’ll bet there are a lot of those discussions, and meanwhile people can’t get the treatments and tests they really need.
My old doctor (who wasn’t that old) didn’t take well to his practice becoming part of a larger system, and especially didn’t take well to having a computer with him during all patient visits, despite the techies who were assigned to help him in the new ways. He closed his office, so I had to find a new doctor.
Advanced care planning discussion is billed with CPT code 99497 and is worth 2.17 RVU. That’s why they wanted to talk to you about it!
Yes.