Coding ethics

[Nanaimo]

I work in the ER doing charts (I have another real screen name here but don't want to use it considering the nature of this topic). I attended a mandatory "Coding" meeting today and it really got me thinking about priorities.

For example, the first 10 minutes of the presentation the head of the coding group told us about a new "code" that would be like a free $10 in the doctor's pocket. It involves writing in the chart "I spent greater than 3 minutes counseling the patient about smoking cessation." But the subtext or "hidden message" was that in fact, we could "capture the code" (even in some pre-arranged acronym format) after speaking just a few sentences to the patient. When you find out they smoke - "You should stop smoking" and then upon discharge - "Here's a number to help you quit smoking." $10. The implicit message was, "We can capture this code without REALLY doing much work."

Other more flagrant examples include the now defunct code "Under My Direct Supervision" - which was appended onto the documentation of fluids given in order to capture a few more dollars. "NS 1L IV given UMDS (under my direct supervision)" could be charged at a much higher rate than simply "NS 1L IV" - even though there was no difference in the care provided. I was instructed by doctors to "always" write UMDS when documenting fluids given, whether or not any additional supervision was occurring. Then when the code was no longer reimbursed at a higher rate, we were instructed to stop writing UMDS. Some people still write it reflexively!

There are also issues with level 3 and 4 visits being artificially "bumped" to level 5 just to make more money (I have been instructed to do this). Am I missing something?

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[docB]

I hear what you're saying but remember that getting paid for what you do is not unethical, it's work. The new smoking cessation code (coincidentally I just went to a meeting that discussed it today too) was created by CMS to incentivize docs to do the counseling and bill for it. It's not unethical, it's CMS's view of preventative care.

Now "bumping" level 3 and 4s up to level 5 is upcoding and it's absolutely illegal. Like prison illegal or "lose your CMS certification and never work again" illegal. If you do level 5 work and the patient's acuity and presentation merit level 5 then take it. If they don't then leave it alone.

 

[GeneralVeers]

I hear what you're saying but remember that getting paid for what you do is not unethical, it's work. The new smoking cessation code (coincidentally I just went to a meeting that discussed it today too) was created by CMS to incentivize docs to do the counseling and bill for it. It's not unethical, it's CMS's view of preventative care.

I agree with the above. We're going to face tighter and tighter reimbursement from the government and insurance agencies. By understanding the coding principles and maximizing the amount you bill for it's the only way we have of keeping our earnings level.

My personal favourite is billing for "CPR performed by doctor" even if you a few chest compressions.

If you perform Ultrasound-guided central line access, you can bill for both the ultrasound, and the central line. Close to $500.

Additionally documenting a pulse oximetry with interpretation (i.e: normal) can get you $2.50 on every chart. This adds up quickly.

 

[Squad51]

There are also issues with level 3 and 4 visits being artificially "bumped" to level 5 just to make more money (I have been instructed to do this). Am I missing something?

There is a difference between instructing residents to always perform and document an HPI, ROS, and PE that meets the requirement for a level 5 visit (completely legal) and merely changing the chart to reflect increased care without performing it (completely illegal). I know that question came up where I did a rotation. The reason given was that the coders should always be free to code for a level 5 visit, should the patient condition warrant it, and that lack of resident documentation shouldn't hinder the EM group's billing. But please be clear, the difference is that the work was being done - and the overwhelming majority of the cases were billed at level 3 or less. Is that what you are being asked to do or are you being told to change charts to reflect more work was performed than actually was?

 

[igcgnerd]

As a scribe, I always document and it is perfectly ethical to document the HPI, ROS, and physical to a level 5 whether or not the problem will be able to be billed to a level 5. IT sucks that they took away the infusion differential when I used to be able to document "UMDS". I still do document that for the sake of chart completeness however its only paid for as an intervention the same way analgesics or ABX would be compensated for.
The ultrasound on the central is a great idea so is billing for an ortho splinting procedure w/ any dislocation post reduction as long as you note who actually did it. If it was a tech we can document that the ED doc was present for the "key" portions of the procedure.

 

[Dr. Wexler]

My personal favourite is billing for "CPR performed by doctor" even if you a few chest compressions.

Are you changing the way you practice in order to get paid? Are you reaching in to do a few chest compressions because you 'might as well' since you can get paid for it? If a doctor does a few chest compressions just to be able to bill for it, is that ethical? Better documentation to get paid better is good in my book. But making changes to the way you practice in order to be able to check off a box on a chart to get paid more is morally hazy to me. I'm interested to hear what others think.

I'm open to both sides and I'm not trying to be inflammatory although this is a touchy subject. I think there is a great argument that "if insurance is willing to pay me for compressions, they must think it is worth it. If they want to define the duration/number of compressions required to bill then they better do it because I don't have time to ponder how much effort is required before it is fair to submit a bill for CPR".

 

[southerndoc]

I was under the impression that CPR could be billed because of patient condition (instead of critical care time, unless the patient was resuscitated). I didn't think you needed to actually perform chest compressions in order to bill for the CPR code.

 

[igcgnerd]

I was under the impression that CPR could be billed because of patient condition (instead of critical care time, unless the patient was resuscitated). I didn't think you needed to actually perform chest compressions in order to bill for the CPR code.

You don't have to actually perform it to bill for it, just supervise it which you obviously are if your running the code. You can bill for the CPR, critical care time (if the code lasted longer than 30 minutes), and the pronouncement if the PT expires.

 

[Apollyon]

You don't have to actually perform it to bill for it, just supervise it which you obviously are if your running the code. You can bill for the CPR, critical care time (if the code lasted longer than 30 minutes), and the pronouncement if the PT expires.

I don't know about all of that - what is your source? I've been told specifically that, if I document a cardiac arrest chart, I canNOT bill critical care time, because it's a bundled thing, with critical care time flat-rated in. Likewise, the pronouncement as a separate procedure sounds sketchy. I mean, if it is kosher by CMS et al guidelines, I'm all for it, but I'd like to see the paper on it.

 

[GeneralVeers]

I don't know about all of that - what is your source? I've been told specifically that, if I document a cardiac arrest chart, I canNOT bill critical care time, because it's a bundled thing, with critical care time flat-rated in. Likewise, the pronouncement as a separate procedure sounds sketchy. I mean, if it is kosher by CMS et al guidelines, I'm all for it, but I'd like to see the paper on it.

Critical care time cannot be billed using time spent on CPR, intubation, central lines, suturing, fracture reduction or any other billable procedure. Critical care time is separate and applies if you have to perform clinical decision-making, talking to consultants, re-evaluating the patient, managing a drip/vent etc.

BTW there is a separate code for "CPR done by physician". I'm not saying anyone should change their practice but just be aware it's there. I've been in a few codes where the others involved were not doing adequate compressions and I had to jump in and do it myself.

 

[Apollyon]

Critical care time cannot be billed using time spent on CPR, intubation, central lines, suturing, fracture reduction or any other billable procedure. Critical care time is separate and applies if you have to perform clinical decision-making, talking to consultants, re-evaluating the patient, managing a drip/vent etc.

BTW there is a separate code for "CPR done by physician". I'm not saying anyone should change their practice but just be aware it's there. I've been in a few codes where the others involved were not doing adequate compressions and I had to jump in and do it myself.

Umm, yeah, I know, junior. It's time spent in critical care, not including procedure time.

 

[GeneralVeers]

Umm, yeah, I know, junior. It's time spent in critical care, not including procedure time.

I was clarifying igcgnerd's statement.

 

[Nanaimo]

Would you guys say it is fair to make all ED cases (non-ACU) level 5? For example tonight we had a young healthy female with urinary complaints, treated for presumed UTI with PO meds, got a UA which was negative. Prescriptions for meds given. She even left before the UA came back. The visit all-in-all took about 10 minutes. After I finished a quick level 4 chart for her, the doc took possession of the chart. Finding that it was level 4, the doctor went ahead and clicked off more ROS questions and exam items. These things were borderline, like you don't need to listen to lungs to see that the pt is not in respiratory distress, etc. So check it off right? "No respiratory distress." Do a few more, and the chart is a 5.

Is this right? Or does it even make a difference? If a coder looks at this visit the way they are trained to, they'll see a level 3, maybe level 4 visit. But it's over-documented to a 5. Does the coder bill it as such?

 

[igcgnerd]

Even if the you document a level 3 problem to a level 5 in regards to the HPI, ROS and PE, based on the problem only so much will be paid for. I would rather document too much in the ROS and PE and chart a 3 to a 5, then have a 5 and only chart to a 3 or 4. Of and by the way I looked i t up in our coding binder, the compensation for a code does not include an official pronouncement which is a completely separate procedure.
If you get a code w/ a long PTA down time, common procedure here is to do a cardiac US which is another billable procedure.

 

[Seaglass]

That's right, the thing that most frequently causes a chart to be down-coded is poor documentation of the history and physical. The actual complexity of the case is the other factor that determines coding level and the coders assess that. If you are interested I think I have a copy of the guidelines so you could see how that is worked out but the bottom line is that this is going to be coded at a level 3 no matter how much you document.

Regarding "no respiratory distress" as an exam item for the physical - I would say that's valid if he really noted it and it's true. For example I will often put "2+ radial pulses" in the cardio section since I routinely check them as I'm talking to the patient. Again, you can and should document anything that you do (even if it seems minor) but never things you didn't do. There are lots of things that I can assess just in the course of talking to the patient. One of my favorites that adds an organ system is "Psych: normal affect."

 

[deleted65604]

I feel frustrated by all this billing crap. Why do we document? To help future patient care, right? So future providers can see what happened and why. Most of what we chart, however is fluff. What we chart currently is so inclusive that it will stand up in court to prove that we didn't commit malpractice. We also chart so that we can bill for the appropriate level of work. This seems to be a bit of a slap in the face.

In a perfect world, with no dishonesty on the part of physicians and no malpractice being commited, we would spend a fraction of the time that we do charting. In a perfect world, I would write on the chart, "laceration on arm, simple 2 cm, repaired, follow-up in 9-10 days for suture removal, bill for a level 4 visit." But now, I have all these ridiculous PMH, and a detailed procedure, including consent, neurologic, musculoskeletal exam, and the documented search for foreign bodies. These things aren't important for medical reasons. They only are "necessary" for medicolegal reasons, and to justify the level of billing.

I personally am extremely annoyed by the whole process of charting. It is a huge waste of time, and it negatively impacts patient care (I spend up to 1/3 of my time charting, at least it feels that way). So, if a physician views it as a game to play, then they are right, and I for one, feel their pain. Nurses spend even more time documenting (up to 1/2?) If we (physicians, PAs, and nurses) could spend half the time charting and use that time to take care of other patients, then patient errors would plummet, waiting rooms would empty, and quality of care would sky-rocket.

 

[GeneralVeers]

In a perfect world, with no dishonesty on the part of physicians and no malpractice being commited, we would spend a fraction of the time that we do charting. In a perfect world, I would write on the chart, "laceration on arm, simple 2 cm, repaired, follow-up in 9-10 days for suture removal, bill for a level 4 visit." But now, I have all these ridiculous PMH, and a detailed procedure, including consent, neurologic, musculoskeletal exam, and the documented search for foreign bodies. These things aren't important for medical reasons. They only are "necessary" for medicolegal reasons, and to justify the level of billing.

I hope you like doing charity work, as that's all you'll be doing if you don't document. The government is going to pay an increasing portion of our salary in future years, and if it's not documented on the chart, you aren't going to get paid for it. They're looking to cut costs, which is why they made up this complicated scheme to avoid paying out.

 

[southerndoc]

I hope you like doing charity work, as that's all you'll be doing if you don't document. The government is going to pay an increasing portion of our salary in future years, and if it's not documented on the chart, you aren't going to get paid for it. They're looking to cut costs, which is why they made up this complicated scheme to avoid paying out.

The private insurers usually follow Medicare rules. So if you don't document properly on all patients, you could lose your ability to bill a particular insurance carrier/HMO. Of course if you don't properly document your Medicare patients and an audit shows you are documenting to the level billed or if you're upcoding, you could go to jail or pay hefty fines. Much worse than the problems with private insurers.

 

[deleted65604]

I didn't say I won't chart. I just said it is a big pain. I suppose you guys enjoy all time dotting i's and crossing t's for the coders and lawyers.

 

[docB]

Questions about EMS run reports moved to new thread.
http://forums.studentdoctor.net/showthread.php?t=533418

 

[Jeff698]

I just saw this thread title again after some time and had a strange thought.

Apparently, ethics has suffered a cardiac arrest and medicine is hard at work resuscitating it. Film at 11.

Take care,
Jeff

 

[Hard24Get]

I just saw this thread title again after some time and had a strange thought.

Apparently, ethics has suffered a cardiac arrest and medicine is hard at work resuscitating it. Film at 11.

Take care,
Jeff

I think the moral of the story (pun intended) is doing more work for more pay is okay, pretending to do more work for more pay is not, and it is important to document everything you do.

BTW, Jarabacoa, every profession has to carefully document what they do. It's not just good for defense from lawyers, it's good for the patients as well. I can't tell you how many times going back in the chart has saved lives, and how many times better documentation could have. We like to whine about it, but very little of the documentation we do is truly useless/pointless.

 

[deleted65604]

Thanks for educating me. Have you started residency yet? I wonder how you will feel after documenting on 5000 patients during residency. I believe it if you say that you have seen more lives saved than you can count with documentation, but I would prefer specific examples of real life scenarios where you have seen documentation save lives. Previous documentation is always helpful, but only in my experience to be able to minimize histories. (Patient has severe back pain and had a normal MRI last month, very helpful. Patient has chest pain, with normal heart cath last month, very helpful.)

ER visits are going up every year, and ERs are shutting down. The population is aging, and we are just going to get more and more busy. I think you could argue that we are certain to get insanely busy in the next few decades (not that we aren't already.) I can see 3 patients per hour and get them dispositioned, but I can't see 3 patients per hour and document every nuance of history, EKG finding, chest x-ray read, social history, and medical decision making. Sometimes, you are faced with either charting or trying to see as many patients as you can and trying to put a dent in the waiting room. The worst is to work your butt off all 12 hours of a night shift, and get to the end of your shift and still have 13 charts that are incomplete. I remember being so tired that I couldn't type without falling asleep. I would start typing gibberish into the computer, random phrases of incomprehensible words. The longer I stayed there typing, the more tired I got, and the longer it took me to chart.

One of the residents that graduated last year got a job working 7 24 hour shifts a month. Sounds sweet, huh? He saw 60 patients his first shift and had to go home and sleep, and then come back to the ED and finish charting for 4 more hours. Charting is miserable. It is onerous. I would argue that it is compromising patient care, rather than helping it. That is just my opinion after charting on around 5000 patients.

I think the moral of the story (pun intended) is doing more work for more pay is okay, pretending to do more work for more pay is not, and it is important to document everything you do.

BTW, Jarabacoa, every profession has to carefully document what they do. It's not just good for defense from lawyers, it's good for the patients as well. I can't tell you how many times going back in the chart has saved lives, and how many times better documentation could have. We like to whine about it, but very little of the documentation we do is truly useless/pointless.

 

[The White Coat Investor]

Charting bites, I agree, but I look at it as a game, and I intend to win it. I suspect I lose more $ from a busy shift when I don't have time to ask all those ridiculous ROS questions than I get from little $10 stop smoking chats so I don't feel particularly bad using things like that. And to be honest, I actually have spent 3 minutes counseling patients about smoking when the ED isn't very busy.

If I have to do a chest pain or abdominal pain history/physical, check labs and x-rays, call and talk to someone, and give therapy, I sure as heck am going to make sure I ask a couple extra ROS questions to make sure I get that full level 5 payment. Those are the rules of the game, they'll change next year, but for now, that's what I'll do to get my money.

Better to see 2 less patients in a shift and have 5 patients coded at a higher level due to thorough documentation. Having level 5 patients downgraded is costly.

Documentation is for billing, medicolegal, and continuity of care. All that matters for continuity of care is the HPI (maybe), the relevant exam (maybe) the test results, the reasoning (maybe), and mostly, the plan. All that matters for medicolegal is the MDM, the vitals, and the plan. Once you take care of those two things, all that you have to add for billing is the social hx, the ROS, and the irrelevant exam points. That's not too onerous is it?

 

[southerndoc]

Those are the rules of the game, they'll change next year, but for now, that's what I'll do to get my money.

How are they changing?

 

[Jeff698]

How are they changing?

What, in medicine, doesn't change? Especially from insurance companies whose job is to NOT pay us.

The thing I object most to about documentation is it no longer has anything to do with relaying information to other doctors. It's all about billing.

Have y'all seen the output of the computer charts? They suck.

I'm now using MedHost. I went back and tried to decipher what happened at a prior ED visit and was lost. iBex is the same way.

These systems are built in recognition of the business reality of medicine. Unfortunately, in the process of allowing us to stay afloat financially, they kill any ability to relay information.

Sniff. I'm going to go feel sorry for myself now.

Take care,
Jeff