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.

Tuesday, April 15, 2008

A Manner of Speaking

Scalpel said this:
Is billing for questionably-indicated procedures really any different than adding an unnecessary family or social history to increase one's charges? I say no.
The Happy Hospitalist disagrees with him, and he is right (HH, that is.) Here is why:

Scalpel is correct in only the most technical manner of speaking. In the sense that anything you do (or document) that is not strictly necessary for diagnosing or managing the patient is "fraud" then yes, documenting a family history in a geriatric pneumonia patient is the same as a colonoscopy for bright red rectal bleeding in a teenager with visible hemorrhoids.

The case begins to fall apart when you explore the concept of risk/benefit analysis. The risk of taking a history is zero. No one's colon was ever perforated by asking what their parents died of. No one ever suffered a pneumothorax from being asked if bleeding runs in the family. No matter how small the potential benefit of "history" vs. any procedure, you can't beat zero. Therefore unnecessary (sorry -- marginally useful) procedures can never be truly comparable to elements of a history.

HH and Scalpel agree that the central issue is that counting the elements of documentation to determine levels of payment is nonsense. It would be much more logical to simply pay for evaluation and management services on a straight time scale (like lawyers) rather than the ridiculous system in place today. Given the system that we are stuck with have, though, it goes without saying (sadly) than all players will take whatever steps they need to maximize income.

But for those padding their pockets with procedures to claim that we're doing the same thing by recording "unnecessary" elements of a history is like the school bully pointing at the Chess Club president and saying, "You beat people every day too, you know!"

Only in a manner of speaking, Dude; only in a manner of speaking.


At Tue Apr 15, 09:05:00 PM, Blogger scalpel said...

Well said.

I would argue though (for the sake of argument) that some procedures carry zero risk. To name some examples, when a Radiologist recommends an MRI to further characterize a little spot he sees on the CT, when I perform an ultrasound knowing that I could get a more complete study done by someone more technically expert than I (and frequently must do so to follow my own study anyway), or when a Cardiologist performs an ECHO to further define the cardiac anatomy, the only real harm comes to the patient's pocketbook.

We can argue the necessity of these evaluations to make ourselves feel better, but it seems that there is a broad spectrum between clearly indicated and unnecessary. I suggest that the necessity of some provides at least tacit justification for nearly all the rest.

At Tue Apr 15, 09:24:00 PM, Anonymous Anonymous said...

I'm a GP in Canada.
We generally work on a fee per service basis to a single payer-the government (provincial) insurer.
Are there fee schemes in the US that pay you according to how much history you take?

Wow- I get paid the same whether I spend 2 seconds or 2 hours eliciting history- I guess I might get a little more info if someone was going to pay me extra for it.

At Wed Apr 16, 05:25:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I happen to agree with Scalpel on this one (and posted so on his comments section).

Padding the chart to get to a higher level without medical necessity will get you in trouble, as much as doing unnecessary procedures. Ethically, I agree with you and the Happy Hiospitalist but the truth is that both are considered fraud by the governement. And the OIG amd their hired guns could care less about ethics. After all, there's money to be made in catching docs overbilling.


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