Blending codes, aka HMO extortion

As you may know, Anthem Blue Cross and Blue Shield in Ohio is blending 99213 and 99214 codes into a single rate. This is a chilling trend that must be stopped.

As physicians adopt EHRs, documentation and patient care is going to improve – necessitating a proper reimbursement rate. Use of EHRs should be rewarded, not penalized:

“Before my EHR, I wrote on a piece of paper,” he says. “When somebody came in who was diabetic, hyperlipidemic, and hypertensive, it was extremely difficult to document everything I said and did.

“The EHR allows me to do that. But now, Anthem says, ‘Oh gosh, now that you’re coding appropriately, we’re going to pay you less.’ So they’ve arbitrarily changed the rules. They make no differentiation between someone who comes in with a sore throat and someone who comes in with multiple medical problems that require fairly intense management, because they’re paying the same for both.”

Of course, the blended rate is much closer to the lower code:

It’s the difference between a $74.20 payment [for 99214] and a $51.58 payment [for 99213], and they’re paying us $55 for the in-between code. If you have someone with high blood pressure, diabetes, and high cholesterol, and you address all those issues, it’s worth more than $55.

Although confined only to Ohio, this can easily spread nationwide if there is no protest:

“However, if there’s no big uprising and no voice against it, that could change in a year or so,” he observes. “That’s why we think it’s vital that we make our voice heard in opposition to this kind of payment policy. It goes against CPT, and that’s what we base our billing on. If the plans make this change, we’re going to have a lot of problems.”

I encourage every physician to protest this code extortion by writing to the medical director at Anthem:

Barry C. Malinowski, M.D.
Medical Director
Anthem Blue Cross Blue Shield
Southern Ohio Health Service Area
4361 Irwin Simpson Road
Mason, OH 45040

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