Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, January 20, 2007

The Answer is: Money

A question from the comments:
Why do some specialists 'pad' their reports with superficial or even fictitious statements? Statements as you mentioned above, about performing certain physical tests, when the tests weren't done. Or embellishing what they say they explained to a patient. Are these specialists trying to impress the primary care doctor with their 'thoroughness', so as to keep the referrals coming? Are they trying to make themselves look better than their fellow collegues? Or are they simply filling out a quasi 'form letter' report, which is just slightly individualized for each patient?
The answer, as always, is: Money.

A quick primer on how doctors get paid:

You go to the doctor. The doctor asks you what's wrong. You tell him. He asks questions to find out more details about what you've told him, and perhaps more questions about other things you didn't even realize had anything to do with what's wrong with you. This is called "eliciting a history." Then he examines you. This is called a "physical examination." At this point, the doctor has begun to formulate a pretty good idea of what's wrong with you, or at least has some idea of what he needs to do in order to find out. This is when tests -- which may include blood testing, imaging studies like x-rays, ultrasounds or MRIs, stress tests for your heart, lung function testing, etc. -- may be ordered (and why it is inappropriate to order these studies before the "history and physical" parts have been done.) Putting it all together to make a diagnosis and deciding on a treatment plan is called "medical decision making." Explaining it all to the patient and/or family is called "counseling."

Each of those elements of an encounter -- history, examination, medical decision making, and counseling -- comes in varying degress of complexity, as follows:
  • History: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
  • Exam: Problem focused, Expanded Problem-focused, Detailed, Comprehensive
  • Medical decision making: Straightforward, Low complexity, Moderate complexity, High complexity
How to determine precisely what determines what level each component meets? Not to worry; those, too, have been elaborated:
  • History: History of present illness, Review of Systems, Past/Family/Social history
  • Exam: Each component of a physical exam has been listed as a "bullet point", and the number of bullet points determines the "level" of the exam.
  • Medical decision making: takes into account the number of diagnostic or treatment options, Risk of complications and/or morbidity or mortality, and the amount and/or complexity of data to be reviewed.
Once you've assigned the level of complexity for each element of the encounter, there are grids you use to determine which level (1-5) of service you have rendered. Or more specifically -- since frankly, all this really refers to is the documentation -- what level of service your documentation supports. You then assign your service the appropriate code for level of service, bill accordingly, and hopefully get paid.

There's more to it, of course. If it's a new patient (includes someone you haven't seen for three years or more) you use a different line on the grid, do a little more, but get paid more. If the encounter is at the written request of another doctor and you send that doctor a written report, it's called a "Consult", which pays considerably more (for each level of service.) If you don't actually do a history or physical, but have an encounter, say, entirely for the purpose of "counseling" (discussing the diagnosis and/or treatment with the patient) then you can code on the basis of time, as long as said counseling account for more than 50% of the face-to-face visit time. Here are the times in minutes for an outpatient encounter:

TimeLevel 1Level 2Level 3Level 4Level 5
New Patient1020304560

I swear I'm not making all this up (although those who know me wouldn't put it past me.) (cough*Kensington fan*cough) Check out this document to see what we're up against.

The whole point of this is that a Level 5 visit pays considerably more than a Level 2 visit, especially if it's a consult. So the advantage to the specialist who over-documents is that he can code a higher level of service and get paid more. If the flip side of that malpractice catch, "If it wasn't documented, it wasn't done" is the assumption that all documentation is accurate until proven otherwise, then I have no idea what can be done about it.

But that's the answer to "Why do they do it?" And it sure isn't because they care about primaries' or colleagues' opinions of them.


At Sat Jan 20, 05:14:00 PM, Blogger outre said...

I recently discovered a padded report after my latest round of obtaining my med. records... I apparently blocked out the 'long talk' my surgeon had with me.

Thankfully, all other reports were true to life but the false claim in that padded report irked me.

At Sat Jan 20, 07:50:00 PM, Anonymous Anonymous said...

Ah-Ha! Now I understand better why certain statements have shown up in certain specialist reports. Ones like "Her X-rays were reviewed" (I didn't have any X-rays with me), or "I answered all the patient's questions" (Uh, no), or best of all "I sat with this patient and discussed all her films with her" (There was no sitting or discussion of any sort; the visit lasted 5 minutes). And of course, all the supposed physical tests that appear on the report, usually one's that begin with a proper name, like Babinski or L'Hermitte or Tinel.

All the above take time, especially talking with a patient. So I can see where a specialist writing these statements down suddenly looks like he/she spent a lot of time with a patient, and so can get more money for the visit.

But it's really disheartening to read statements like those above that refer to discussions, since patients are now encouraged to 'partner' with their doctors, and when these ficticious discussions are documented as if they took place, it can make you the patient feel really bad.

My absolute favorite fictitious statement is the one where a doctor wrote that I suffer from intermittant bouts of headaches. I simply do not recall discussing this with him, it wasn't the reason why I was seeing him, and I rarely have headaches, maybe 3-4 a year. I think he wrote this to make me look like a more 'complex' patient, so he could bill the insurance company for more money.

At Sun Jan 21, 01:19:00 PM, Blogger Sid Schwab said...

Padding = dishonesty = fraud, which is a separate problem from the one of trying to get the most out of a reimbursement schedule constantly on the down-wane. There's no excuse for the former (in the case of the ENT group you have cited, I think they deserve the blowing of a whistle), and no alternative to the latter, if you want to stay in business. Feeling most of my income came from operations I did, I undervalued my office work to a probably crazy extreme. In fact, the business people in my clinic sat down with me to discourage my approach, pointing out impressively how much legitimate income I was forgoing.

On an unrelated note, since you didn't comment to me directly, but elsewhere: I don't think whether one has hosted GR or not is a precondition for rendering a valid opinion on the nature of them. Had I hosted one or ten, my opinion and approach would be the same: I don't like themed rounds and I'd not have done one. Which is not to say -- as I made clear -- that I feel like doing anything about it other than expressing an opinion and opting out. That's valid, whatever else is true, because it's a true statement. It's not -- nor could it in any way be -- a demand. If that's the way they are going, so be it. I'm not saying I'm right, in the sense that I believe people who do it are wrong. I don't like strawberry ice cream as much as chocolate. So I don't eat it; I don't advocate the withdrawal of strawberry ice cream from the market.

At Sun Jan 21, 02:27:00 PM, Blogger #1 Dinosaur said...

To be very clear, Sid (and Flea, from a comment on the previous post): I am NOT talking about legitmately coding for what you do. I am specifically addressing the suspect documentation of this particular group. My problem is that since I don't actually know what levels they're billing, I have no idea how/who/where/what whistle to blow.


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