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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
So when they say, “Learn to code!” this is what they are talking about.
Not realizing, or not caring, that much of that has been – and continues to be – outsourced to places like India.
“Scrubs” can be surprisingly insightful too.
Adding to a conversation that is beyond its expiration date.
“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 think MichaelKennedy and I are from a similar background and disagree on some small details at the edges, but that quote above says it all.
I just feel like I should comment. I didn’t read through so I might be duplicating, but as a nurse, I definitely have opinions on having to read through these notes. Providers will c/p from other providers, include every lab in the entire hospitalization, and repeat everything from their previous note.
Somewhere around day 20, when the pt is post-op day 9 and the note talks about them having a crani to decompress after their scans from the ED and emergency stabilization… we get a bit sick of it. It’s old and it contributes nothing. More importantly, it confuses things.
In reality, I think it is even worse. When called into court, these documents will be examined at length and determined to be erroneous, inaccurate, at at worse, malpractice. They do not indicate that the patient was ever seen individually, that the plan was ever changed, that the unique concerns of the patients were addressed. This is a bigger problem for physicians, considering the litigiousness of our society. As we move toward Universal Healthcare (blech!), there will be more lawsuits. As care is homogenized, there will first be lawsuits regarding individualization of care. Until that is determined to be a risk to patient care (pathways are awesome, EBP rules, no one should do anything intuitively, etc, etc), physicians will feel the pain.
We are frequently told this in nursing. Make sure that your notes hold up.
Doctors often think that their notes will hold up if they have ALL the information. Maybe so. But if information is included indiscriminately, it can easily be determined to be auto-included by a computer program. It’s a huge legal risk and worse, it’s bad for the patient.
As providers, we deserve more flexibility to document care accurately, correctly, and completely as well as appropriately. If other records can easily be referenced (as is required by law now with electronic records), it should not be on the provider to make the EHR navigable. It is on the reader to read it/navigate it correctly. The information is there. We should be able to include it, reference it, and use it to document and support the patient’s care. If we can use it for billing, great. But we need to start accepting and trusting our medical professionals (to some extent), or we need to find a new way of determining medical competency. If we cannot trust them to perform care and document correctly, we probably should not trust them with the patients either.
Bravo. I completely agree. A physician daily note on a floor patient need not be more than a few sentences of text. I have been in med-mal cases where a physician’s auto-populated note was used against me, clearly copied & pasted text but was treated as if it were infallible. I would much prefer if my notes could just contain the information I think is notable, in my professional judgement. The problem is, that means my notes won’t reimburse as much. As I’m a hospital employee, that means less money for our department and meetings regarding my “productivity.”
Wouldn’t “universal healthcare”/”single-payer” actually reduce or even eliminate lawsuits, since you would be suing the government, and you can’t sue the government without its permission?
Not at all. You don’t sue the payor, you sue the provider of care. Unless the doctor is actually employed by the government, you’d still be suing the physician.
But isn’t that actually the point of single-payer etc? Such as the National Health Service in UK. All the doctors ARE employed by the government.
Great comment.
This is a key point. Much of the documentation fetish we’ve developed is based on a distrust of physicians. It’s a lot easier to cheat clerical stuff than ethical stuff, but that’s not how lawyers think. Plus, even if the government really wanted to improve quality of care, how could it possibly do so?
For various reasons (Obamacare, increased regulation & government control, decreased autonomy in decision making while being held to increasingly impossible standards, etc etc etc), we are getting fewer and fewer of the best and brightest in medical schools recently. And we have a lot more physician assistants, nurse practitioners, and various other ‘mid-levels’ making really important decisions. So concern about quality of care is reasonable.
But this is how a lawyer would fix it. And it’s not helping.
That’s not meant to be a typical doctor slam of lawyers, by the way. I can understand the perspective of someone who seeks to tighten centralized control through the only tools they have available – documentation and reimbursement.
But this is not helping.
Perhaps. I have only heard a few on the very far left call for a NHS type takeover of US healthcare. The M4A push is more like the canadian model. The government just writes the checks while the hospitals are still all independent.
Maybe they need to move to a sensor system that can track how long your sensor was in the room. This clearly indicates the amount of time physically spent in the patient’s presence, which should enhance billing and additionally indicates when and where a physician is. We do this with staff other than med staff, so why not? Why not make it more transparent and easily tracked that you were where you said you were; with the patient. I believe part of the billing is due to patient care time, if I’m not wrong.
Stethoscope time makes sense; I see providers do that, though they have no interest in lung or cardiac function (although, I’ve seen specialists find things that way). It’s strange that is how we’re assessing value, rather than visualization of patient, interaction with pt/family, and research on plan of care.
Again, something needs to change. There needs to be more care in healthcare.
This is a great point. When I give this story about the onerous documentation requirements, a common reply is “well shouldn’t you just be doing all those things in your assessment anyway?” It’s as if, by requiring certain points in the documentation, the government can ensure all physicians do a good job. Or, on the contrary, if they DIDN’T require all this documentation, physicians would just stop doing thorough physical exams and history taking. The good doctors will be good doctors and the bad doctors will be bad doctors. Documentation requirements don’t change any of that.
Reimbursing based on time alone also creates problems. For one, much of my time is spent doing chart review, looking at images and planning surgery. This isn’t done in the patient’s room. For another, it’s just another way to cheat the system and reduces access to care. You’re incentivizing physicians to work slowly, which means fewer patients seen, which means longer wait times to get into clinic, which means decreased access to care.
“Independent” to do anything except anything the government doesn’t want them to do.
Exactly. You’re independent enough to not afford an independent practice, so you must allow yourself to become an employee. You’re independent enough to get sued but not independent enough to practice using your professional judgement if it differs from our cookie cutter EBP approach.
Naw, you include prep time, time reviewing case/labs/imaging, time to do notation. You roll it all in there. If it’s a complex case, all of those things should take longer. If it is a simple case, it should be shorter, including the face to face time.
But the algorithm clearly states that it’s science. Or are you a Science Denier?!?
That would be nice, and very possible given the EMR tracks our time logged in, our clicks, etc. I still worry about incentivizing physicians to work slowly. I worked with one spine surgeon who saw 45 patients a day in his clinic. The patients loved it because they had access to a top-level spine surgeon with no more than a two-week wait for an appointment. There are benefits to the fee-for-service system as it undoubtedly increases access to care.
What Dr. Craniotomy fails to mention is that those codes that CMS requires everyone to use are created by—-DOCTORS!!
Those codes and guidelines are created by the AMA under contract to CMS. The AMA has teams of doctors creating the ICD, CPT, and HCPCS codes. But this is not just standard work product under contract for the Federal government. Unlike every other federal contractor, after the AMA has produced the codes for the government, the AMA is allowed to COPYRIGHT the codes. They then get a fee whenever a code is used. I have heard bandied about a total of about $300 million a year that the AMA gets on these copyrights. The AMA denies any such income, but will not provide any transparent accounting or auditing of its income from their copyrights. Apparently, the AMA distributes those funds to it’s member specialty organizations.
The AMA sold this arrangement to its members on the grounds that if physicians were to be regulated by the Federal Government, it would be better for physicians to have a role and a say in that regulation. That has certainly worked out to the financial benefit of the AMA. Not so much to medical providers. As reflected by what Dr. Craniotomy’s experience.
The AMA is beholden to it’s paymaster, rather than to practicing physician who are led to believe that the AMA is a professional organization, when it is a defacto branch of CMS. And a highly compensated branch indeed.
This is one of the dirtiest secrets of organized medicine.
And those codes are used by all private insurers as well. So the AMA gets copyright income from all sectors of medicine.
And the fees that private insurers pay for medical services codes with these codes are directly linked to the Medicare fee schedule. In short, we already have Medicare for All. And the most venerable of physician organizations is on the take from the system. Corruption is written all over this.
Physicians, heal thyselves.
I’ll reply in more detail after Ohio State beats Indiana.
But I’ll just begin by pointing out the obvious – there is a reason that less that 4% of doctors belong to the AMA. And it’s the most liberal 4%.
It’s a dirty organization. The idea that the AMA represents doctors is absurd. It represents big government.
Yup, I declined to mention that in this specific point. I was going to go further down the rabbit hole in future posts but now you’ve spoiled my big reveal! The man behind the curtain was an elderly gastroenterologist this whole time. Just kidding. You are absolutely correct, though. Although, one minor correction, the ICD-10 codes are created by the WHO not the AMA. Let that sink in.
You’re too kind.
They’re idiots.
They want to know where to run to when the sh*t hits the fan. Barter safety for prostate exams.
It’s the only way to survive.
I had no idea what these codes were until I worked in the budget office at a hospital in Vermont.
And then my eyes opened. The entire spaghetti sandwich of enormously bad policy, politicians, monied interests (insurance and software companies), unions, voters, hell, the dog catcher – all mashed up into a hideously flawed billing system that’s completely manipulatable to maximize billing, but has literally zero to do with patient health.
It’s not that reimbursement for services is bad, on its own. That’s the whole point of a transaction – I get the taco, you get the cash. But with Medicare/Medicaid shifting costs elsewhere on each payment, meaning they underpay the actual costs of the procedure, you create Byzantium in administrative and technical overheads that become a permanent feature of “health care”.
Barry wanted more of this, because of his vast experience in this field. Obamacare was just a vehicle to enable more of the same, at a higher intensity. A bald-faced lie successfully sold to 100 million people, or so.
“Ever wonder why doctors don’t reply to emails? There’s no code associated with that.”
Hilarious and sad
Doctors should move to cash or concierge?
45 patients per day?
That is 7 per hour?
225 per week
11250 charts per year???
I have a dumb question: lasik, plastic surgery and IVF doctors type less because they don’t accept insurance?
I think lasik is covered now at least by some insurance.
And I doubt that lasik doctors have to check heart and lungs before they can get paid.