[Accidental1]

Originally Posted by golfing eagles

I'm not sure what is meant by "local office", but I think the people who missed the boat most are those that created this ridiculous system of diagnostic codes and procedural codes that no one really understands and are either intentionally or accidentally vague at best.

This "coding crisis" began back around 1987 with the advent of "DRG's" (Diagnostically Related Groups) to determine hospital reimbursement, as well as LOS (Length of Stay) parameters and outliers. A new category of employees was created, "the coders". Reimbursement became dependent upon how many diagnoses were listed, but get this, also the order in which they were submitted. Billing departments all over the country told physicians to just list every diagnosis a patient had, whether relevant or not to their stay, and "the coders" would put them in the most beneficial for reimbursement order, which was created by the brain children at CMS in the first place.

Over the years, this grew and grew, and created more regulators (nitpickers) as the coding became more complex and more vague. This created another layer of complexity (and employment), the "outside auditors". Every medical practice had a way of auditing their coding. Small practices would generally conduct internal audits by having a colleague review their encounter note and coding. Large practices and hospitals would hire these "outside auditors" to do the same. This was necessary because it was better to find your own problems/mistakes and self-report than to have CMS find it first, penalties were less severe. TVH is a very large practice and has outside auditors.

CPT coding is almost as complex as ICDM-10 coding in some ways. For traditional fee for service billing, the difference between a 99213 and 99214 is about $40, which can be make or break in a small practice with large overhead. But your documentation better fit the code submitted (Note: I said "documentation. Not how much time you devoted to the encounter, not how much judgement and skill was required, just what you wrote in your note. I'm sure many of you have gone to a physician that spent more time typing into his laptop than engaging you, the patient---this government/insurance industry/lawyer concept of "if you didn't write it down it didn't happen" has pervaded the medico-legal industry and to a certain degree paralyzed meaningful patient encounters in favor of "documenting. What you write is now more important than what you did. Sad.)

The difference between 99213 and 99214 requires an "expanded problem focused history" as opposed to a "problem focused history", 2 items from past history, family history or social history as opposed to none, and at least 2 items in 6 categories of the review of systems. There must be at least 6 systems physically examined, as opposed to one, with 2 items from each of those documented. And then you need a "moderate" level of complexity, which is vaguely defined but has a point system for reviewing lab/x rays/procedures/etc. and best of all an ill-defined "complexity of medical decision making". So from the 3 main categories---history, physical, and complexity---2/3 are necessary for a 99214 (established patient) and all three for 99204 (new patient). I hope this gives the layperson and small idea of just what goes into coding just a simple visit for say HTN and elevated cholesterol, and the pitfalls/potential for errors that ensue. Rest assured, CMS is constantly watching for so called "over coding". They periodically require you to submit 25 notes for review and will gleefully penalize even one mistake. And that's just the CPT billing coding; the diagnostic coding is even more complex. So that's traditional Medicare that I am most familiar with, TVH is reimbursed based upon the more complex billing coding structure, which is also vague and subject to interpretation.

Diagnostic coding is defined in the ICDM-10 handbook of a zillion codes---7 digits with 2 digit modifiers for a total of 9. I defy anyone, even a professional coder, to state they understand the whole system. Here's an example of a real code that I saw a while back:
"Struck by bird, goose, flying, in right flank, renal capsule perforated, minimal blood loss, not requiring dialysis". That must come up about once every 100 million years. But I'll give a more realistic example---"acquired platelet dysfunction". Everybody on aspirin technically has that diagnosis---subject to interpretation. This may have been submitted to an outside auditor who said it's fine. Then, maybe, in negotiation for a sale it came up again and wasn't considered fine. So they is no choice but to self report and now the chips are going to fall where they may. But anyone who jumps on the intentional fraud bandwagon has no idea of what they are talking about. None whatsoever.

Is this complex coding system the same for Advantage and Traditional Medicare patients?