A patient of mine recently came to see me in a follow-up appointment after an emergency department visit. He had been working out at the gym, on a hot day, after he had skipped breakfast, and after his usual routine he felt extremely lightheaded. Everyone told him he looked “white as a sheet”, and a physician who was at the gym told him he must go to the emergency department.
In the emergency room, he had an EKG, was placed on a monitor, had extensive lab testing including troponin and d-dimer, and was ultimately told he was dehydrated and sent home.
Interestingly, his discharge diagnosis was “dizziness and giddiness”. He told me he felt like he was going to pass out and he even admitted to lightheadedness. But he told me he never said the word “dizzy,” and he certainly never said that he felt giddy, nor did he recall using that word.
When I think of the word “giddiness”, nothing medical really springs to mind — instead, it’s silly, frivolous, lighthearted, joyful. The dictionary has secondary definitions of giddiness that relate to the sensation of feeling dizzy, but if that’s not how we use the word, why are we using this to communicate something about a medical diagnosis and about our patients?
The coding specificity we have gained with ICD-10 makes us get extremely granular and specific, but it should always be done in the name of taking care of our patients and accurately reflecting what is going on clinically.
But being too specific can lead to problems, and a failure to communicate. Take, for example, the recent push to expand our use of Risk Adjustment and Hierarchical Condition Category (HCC) Coding (a mouthful in more ways than one). This somewhat contorted initiative was created to ensure that we adequately represent the severity of the medical conditions we are providing care for, by trying to get providers to always include the codes that increase the risk factor coefficient at which a patient is billed.
Just recently, I got back the results of yet another audit of my medical charts, one that looked specifically at my HCC coding for the previous quarter. Despite having been to a lecture, with lots of slides, and getting e-mail reminders, and being shown how this can positively affect the bottom line of the institution, I came out of the audit pretty dismally.
None of my diabetic coding made mention of the patients’ ophthalmologic complications. My chronic kidney disease coding did not mention staging, nor did my heart failure coding specify class. And one patient’s prior amputation was missed as a coding opportunity through several office visits in that period.
The auditors’ idea is that somehow by including all of the medical conditions that a patient has and classifying them at the highest level of risk, they can accurately reflect and reimburse for the complexity of the care each of our patients requires. While this makes sense from a certain standpoint, this is never been the way we’ve been taught to think about billing.
Billing in the electronic health record, even going back to paper charts and the paper bills we used to send out, was always related to the symptoms a patient presented to see us with that day, the diagnoses we made that day, the medical conditions we managed that day, and the medical conditions that interacted with the diagnoses made that day that were somehow complicating them or affecting how we managed them (such as diabetes with foot cellulitis, or COPD with upper respiratory infections).
That day. To include medical conditions we didn’t manage that day that had absolutely nothing to do with the visit, was anathema to our thinking, and was even considered billing fraud.
Just because the patient had heart failure, if you didn’t manage it that day, if it was in the purview of some other provider, in no way impacted your medical care that day, and you included it in the billing, well, you were up to something no good. Padding the bill.
In fact, when this sometimes inadvertently happened, such as when a medication that was refilled was linked to a problem, patients would see this reflected on their bill and often complained, saying, “I wasn’t there to see you that day about my heart failure; why am I getting a bill about this?”
And why the heck does Medicare need to be reminded every year the patient has an above-the-knee amputation? Doesn’t their institutional memory go back this far? Clearly, there are some conditions that worsen, and some that improve, but if we are accurately keeping up our electronic medical record, the problem list, their past medical history and past surgical history, then this information should be retrievable from someplace other than billing claims data.
Making this stuff yet one more thing we have to remember to do in our brief visits, when it’s time to drop the bill, is destined to fail.
When I got my report back, two auditors from our department came to my office and went over my charts with me, and showed me where I had opportunity to use higher codes to bill, to increase the risk factor score for these patients, to improve the reimbursement rate the institution receives for the care of these patients.
It makes sense to do what we can to get reimbursed accurately and adequately for the care we provide — nothing more, nothing less. But I kept telling them that this is not how I was trained; this is not how we think; this is not doctoring.
There has got to be some way that we can make the systems pass this information onto the people who need it, in a way that’s unobtrusive, and not some other new task that we as providers need to remember to do.
Because I just don’t think it’s going to happen.
Not today. Not ever.
Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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