Kevin, M.D. - Medical Weblog

Thanks for the nod.

My point was not, however, that the EHR is flawed, but that the E/M system is the problem. If EHR is simply used as a documentation tool, it merely adds to the mess. The benefit of EHR is that it enables us to get away from the E/M mess through use of care management and the "medical home" model put forth by the AAFP among others.

At the present time, however, EHR simply allows us to bill at the level of work we actually doing. It is, in a sense, putting a patch of new fabric on an old piece of clothing. The clothing is the problem, not the patch.
 

IMHO, physicians should throw the E&M codes in the trash and charge by time in 5 minute blocks:

It enables you to focus on the activity that you think will most help the pateint instead of getting paid more to get off track and check all the boxes. A careful history or couseling about med compliance would not then get unpaid while a pointless slapdash exam gets overpaid. It would enable focus on value.

The E&M system frankly rewards lying. Time based charges are also subject to fraud, but it would be easier to catch the big fraudsters as there are only so many hours in a day.

E & M does not pay for care, it pays for good writing--supposedly non-fiction but not always.

I reviewed a stack of charts recently in which every admission of every patient of this physician had a extensive physical exam documented--each one exactly the same in every tittle.

I can't believe that we did this to ourselves.
 

Another advantage of simple time-charging for E&M (like all other professionals): Aunt Bea, Andy having gotten married and left Mayberry, is lonely, and when she gets lonely, she hurts all over, etc etc and comes to see me. I check all the boxes, dictate a long differential, and order 7,000 worth of tests and meds. We do this 8 times a year for total annual healthcare costs of 56,000, of which I get about 1000 or so in fees.

Or I can sit back and talk to her about her grandchildren, leaving her feeling less lonely and physically fine. In the current system, I would legitimately only get a small fraction of the 1000 I made in the first scenario--a pittance, yet I have left the patient feeling better and avoided spending tens of thousands on unnecessary tests.

We would give better care and cheaper care charging equally for our time regardless of the service provided, with no financial incentive to play internist when what is needed is a psychiatrist.
 

Sounds good, but we can't just call the shots. We have given over control and can't just "change the way we bill." If it were that easy, we would not be in this mess.
 

One of the phenomena that I see as a neurologist are those out there whose letters to me about patients have a template or cut-and-paste look to them. Every note is 3 (or more) pages. Every note has a detailed history that is indistinguishable from their initial visit, every exam is incredibly complete, to the point of suggesting that they are spending 40-60 minutes on a follow-up visit. The idea of course is that the note shows the tremendous amount of work I have done to deserve this fee, and I anticipate that it will only worsen as we go to P4P.
Sooner or later, CMS and/or private payors will begin questioning patients, asking how much time the doctor spent on the visit, showing them the note the doctor "dictated" about the visit, and asking, "Does this look like the visit you experienced?"
And let the fraud charges begin...
 

I am a professional outpatient coder (CPC) for a large hospital in the state of California. I am considered an E/M expert, and I assign these codes 8 hours a day everyday. The E/M code assignment is based on the documentation only. There are ways to improve your documentation without committing fraud. I am not a big fan of EMR because it only 'unintentionally' allows the physician to commit fraud. You have to remember that reimbursement is based on documentation, not documentation based on reimbursement. You also have to remember that it is inappropriate/fraudulent to bill high level office visits for minimal problems. Your ICD9 codes have to show a presenting problem that warrants a comprehensive visit. A simple finger sprain billed as level 4 or 5 is just asking for fraud investigators to come knocking on your door. If as a physician you want to improve your reimbursement without committing fraud, spend the money to hire a certified coder to review all of your records and billing. Ask for references from the potential coders and use coding tests from AHIMA or AAPC to make sure you coder is competent.
 

The AMA made this mess. It can unmake it. It publishes and owns the codes.
 

"The AMA made this mess. It can unmake it. It publishes and owns the codes."

Boy, you've got that idiot hat screwed on pretty tight. Yes of course, that old boogeyman the AMA, up to no good once again. What will they get their hands on next?
 

The AMA does in fact hold the copywrite to the coding manual. They are currently soliciting nominations for new members to the editorial advisory panel. If anyone has any contrary information, please share. Sarcasm doesn't add value, but can have a free ride with the information.