A Taste of Our System’s Coding Complexity (Provider Version)

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Last Tuesday, I wrote about the complexities in hospital billing. This week, I’ll look at provider billing.

The same preface is required, so let me copy that from last week:

Any provider’s goal with billing is to bill honestly to the highest amount they can for the necessary work they’ve done. Not billing for something that we are legally allowed to bill for is leaving money on the table and unnecessarily lowers our income. So keep in mind that, when I talk about billing the maximum possible, this is an honest and appropriate goal that is very different than taking advantage of the system or committing some kind of fraud.

When I was in residency and would work in our outpatient clinic, we had coders reviewing every single note we wrote, checking to make sure our documentation supported the bill we’d submitted for each patient. Us residents would get messages from them fairly frequently (some of us multiple messages per week), asking to go back and clarify things like the name of a problem or to change the billing code we’d used. The worst was after doing a half-day of dermatology clinic, where there were also tons of little procedures that required procedure codes and different specific details in our notes to justify. One time, I remember taking more time to fix all the notes to the coder’s specifications than it originally took me to write all of those notes.

We hated these messages from coders because it was just one more administrative annoyance required of us. (The coders themselves were lovely and patient with us, but that can only make it so much better.) We’d have fairly frequent coding training sessions, which helped us do the right thing the first time a little more often, but short of dedicating a full week or more to coding training, there was no way to teach us all the things we needed to know to do everything right the first time. And every minute spent training us on billing meant one less minute training us how to be good doctors.

When I started working as a hospitalist, I had a coding training session as well. And then I, like every new hire, was on a probation period, during which time a coder reviewed every single patient note I wrote to ensure I was doing everything properly.

My first day off after starting my new job, feeling overwhelmed at all the medicine I was supposed to know, do you know what I did? I went to a public library and spent a whole day studying the pages and pages of coding requirements the coder had given me. Over the next week or so, I took copious notes, and eventually I was able to clarify things in my mind enough to feel confident. This required multiple email and phone discussions with another very patient coder. Sometimes communication was a challenge because we had to try to translate her coder’s brain and terminology to a lowly physician’s clinical brain and terminology.

I wanted to be studying medicine, but without getting the bills right, the hospital doesn’t get paid!

Do you want to hear a little of what I learned? Let me tell you. I’ll insert the five-digit billing codes next to each one, just for fun.

When a patient is seen the first time by a member of my hospitalist group (not to be confused by the first day a patient is in the hospital), we need to code for an initial encounter. There are only three levels of complexity we can use, so let me lay out the requirements to bill at the highest level (99221).

First, their level of “risk” has to be high. There’s a long list of things that qualify, such as a change in neuro status, giving them a drug that requires intensive monitoring, or a “severe” exacerbation or progression of a medical problem.

Second, they also need to have at least four problems we are treating (a max of two of them can be self-limited), or at least one new problem that requires a workup, or a new problem without workup plus at least one other problems, or just a worsening established problem plus at least two other problems.

If they don’t meet the high-complexity level based on their problems, you can instead use a points system to meet the second criterion. If you get at least four points, it counts. There is, again, a nice list of things that get you points, such as ordering or reviewing labs, ordering or reviewing imaging, ordering or reviewing an EKG, personally viewing an image/EKG, discussing results with a provider, deciding to obtain collateral information about the patient from another person, deciding to get a consultation from another provider, deciding to request records from another location, and actually getting collateral information/consultation/records. Each one counts as a point. But if you order two imaging studies or EKGs or labs, you can’t double-count. This points system is part of what explains why there are so many seemingly unusual comments in a patient’s chart, such as, “I personally reviewed the EKG.”

So, let’s say the patient qualifies for high complexity based on those first two criteria, now I need to make sure I put all the other information in the patient’s note that will allow me to bill to that level. This includes at least four details of history from the patient (there is a specific list of what qualifies, but it includes the location of a symptom, its quality, severity, duration, timing, context, . . .), at least one symptom question about at least 10 different organ systems, and at least one thing about the patient’s medical history, family history, and social history.

Then, I need to document an exam with at least one thing in eight different systems. Or, if I’m a specialist focusing on one specific organ, I need to document at least eight things about that one organ. And some things don’t count. I thought I could use “Head/eyes/ears/nose/throat: atraumatic” as one of my systems, but it turns out I can’t. But I can instead say “Head/eyes/ears/nose/throat: Vision grossly intact.” Physicians, even internists like me, are rarely concerned about eight different body systems at the same time, so we have learned to say things to check off the eight systems without having to do too much extra work. For example, my standard physical exam includes the very useful “Dermatologic: No rash noted” because, when I’m looking at the patient’s face and belly and legs, I didn’t note a rash. My standard exam also includes the very useful “Psychiatric: Normal affect” and “Genitourinary: No Foley.”

Now you know the requirements to bill for a high level of complexity for an initial care episode. If I don’t meet every single one of those requirements, I can’t bill at that level, and I need to see what lower level my documentation would qualify for.

There’s another set of requirements for moderate level (99222) and low level of complexity (99221), each with their own list of what constitutes the right level of risk, the right number of problems or points, and the right number of history and exam details. And there’s yet another set of requirements for all three levels for subsequent encounters (99231, 99232, 99233). And another set of codes if the patient doesn’t qualify as sick enough to be considered an “inpatient” but is only here “under observation” (99218, 99219, 99220).

But you could bill for time instead of complexity! In this case, the documentation requirement is much simpler. You just have to have a statement in your note that tells how much time you spent on the patient (but time spent doing procedures counts separately), and at least 50% of it has to be related to direct patient care and also coordination of care. You also have to give some details about the content of what took longer than would have been otherwise justified based on the patient’s level of complexity. And you need to remember that, to bill for a high level of complexity, you need to have spent at least 70 minutes on an initial encounter or 35 minutes on a subsequent encounter. And for a moderate level of complexity, you need to have spent at least 50 minutes on an initial encounter or 25 minutes on a subsequent encounter. And for a low level of complexity, you need to have spent at least 30 minutes on an initial encounter or 15 minutes on a subsequent encounter.

But what if the patient was admitted after midnight? That means they have already been billed for that calendar day. But if you spend at least 30 minutes on the patient (or, if you are doing an initial admit and spend the expected amount of time plus at least 30 minutes more than would be expected), then you can bill for a “prolonged service” (99356). But you have to make sure that the total time the initial provider took plus your time is at least equal to 30 minutes plus the expected amount of time the initial provider should have taken based on the level of complexity and encounter type they billed for. This is why we have to put our time in every note, even if we aren’t going to bill for time.

And if the total extra time on the patient was at least 60 minutes, then you can add two prolonged service codes (99356, 99357), one for each 30-minute chunk. But make sure you specify how much actual face-to-face time if the patient is on Medicare, because that’s the only kind of time that counts for prolonged service codes for Medicare.

Maybe I should stop. I know everyone also wants to know the details of how to bill and properly document if a patient is admitted and discharged the same day (99234, 99235, 99236), which code to use on discharge day (99238, 99239, or 99217), when you can bill for critical care time (and what you have to document) (99291, 99292), but I’ll stop.

When I think about the cost to code this way, it’s significant. There are costs for the armies of coders reviewing providers’ notes and sending messages, costs in doctors’ time (learning this stuff, responding to coding queries, getting refresher trainings, documenting so many things that are irrelevant to medical communication), costs in software to make sure we are all billing to the maximum allowable, costs in consultants and administrative personnel analyzing our coding data and figuring out how to optimize it, and (most important of all) costs in quality of care because doctors have to spend so much time on this rather than learning more medicine.

I talk sometimes about despising the complexity of our healthcare system and that it is a major component of its crazy high cost, and billing complexity is one of the things I am referring to. I hope now you can see why.

And since I like thinking and writing about solutions, so I’ll give some thoughts on that next week.

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