A Foreign Language: The Medical Billing System


I can sum up the biggest problem with the health care system in one word: bureaucracy.  The regulations that doctors have to memorize, in addition to plain old medicine (which in my experience is complex enough!) looks like the indecipherable ingredients on the back of a processed food bag: CPT/ICD codes, HIPPA compliance, Red Flag rules, CMS oversight, meaningful use of EMRS, prescription drug plan overrides, pre-authorization, high fructose corn syrup, red dye #3 and MSG.  Both MSG and physician regulations give me a major headache, and leave me with less energy to give to my patients (That’s why I blog!! To relieve stress!!)

I have spent years trying to learn the French language and suddenly figured out that I did not need to learn French when I was already fluent in another foreign language:  medical billing. 

Over a quarter of my overhead as a primary care physician goes toward paying for staff, software, transmission companies and other costs related solely to medical billing.  I frequently get resumes from billing clerks in other fields who think that because they did billing for an auto parts store or a plumber, they can get paid even better doing medical billing.  These billers believing erroneously that all physicians do is send a bill to the patient and get paid large sums of money by expending minimal effort.

The fundamental belief held by Medicare, Medicaid and other other insurance companies is that physicians will not be honest in their billing practices.  That is the reason the physician must code for an office visit, procedure or surgery using the right modifiers, codes and service locations in the right boxes of the form (called the HCFA form) to prove that he or she did not commit fraud and abuse.  Next the doctor has to pay for an electronic system to submit the form containing all the diagnoses and level of service.  Finally the doctor then has to pay for another service to transmit all the claims to the right insurance company.  The insurance companies are counting on our ignorance and hope that doctors will do what they typically do:  give up and just not bill.  I know that I, and most physicians, underbill the level of care of an office visit so that they don’t get audited by Medicare or other insurance companies.

An office visit can be rejected (not considered a “clean claim”) if the physician’s NPI number, Medicare numbers and the ICD and CPT codes are not just right.  Certain numbers (which is always a mystery to the doctor and billers) have to go in certain boxes, or else the the claim is rejected. 

Trying to call Medicare or an insurance company to ask a question about a claim takes several hours.  If you call Medicare back (and assuming you actually get through–make sure you have a couple of free hours on your hands to wait on hold), you will get a different answer from a different claims specialist. 

The key to all this complexity is very simple: doctors don’t understand the system and will often give up and just write off the office visit.  That saves the the insurance company or Medicare a bundle.  

I am not sure why coding the diagnosis hypertension to the most specific decimal point makes a bit of difference in the time and complexity of the care I provided to a patient.  Does my level of care make a difference if the patient has hypertension with kidney disease versus hypertension with heart disease?  Since they are equally complex patients, why does Medicare want me to distinguish their diagnoses? And why penalize me if I just bill using plain old hypertension, not otherwised specified (NOS)?   And why does Medicare have to know if the blood pressure is controlled or not controlled?  Do I or the patient get bonus points if the patient eliminates salt from his diet and gets his blood pressure controlled? 

Actually, some day doctors will be penalized for their patients have uncontrolled diabetes or cholesterol. I am not sure why I should be responsible for a patient who does not eat healthy or exercise, but the government is set on “outcomes” and “pay for performance,” which means that those patients who are non-compliant will not have doctors who are willing to take care of them.

Conversely, a patient may have underlying complex hypertension, but, if the blood pressure is controlled, I will spend less time on that medical problem and bill a lower level office visit.  So why does the detailedness of the diagnosis code (“to the highest specificity”) make a difference?  

Why make the doctor and billing specialist (and believe me, this person has to be a specialist) spend the extra time to put two decimal points on a diagnosis code that is of no relevance to the patient’s care?  Would it not make sense to spend the doctor and the staff”s time teaching patients about a no added salt diet to control hypertension rather than figuring out the right hypertension code to the highest specificity?  Like there isn’t any waste in the medical system there? 

Even more confusing is the fact that every year certain CPT and ICD codes and diagnoses are eliminated or converted to different codes.  That means every year the doctor has to buy new books and learn about new codes to the highest decimal point specificity, or risk having claims rejected.  Why do codes have to be changed from year to year?  The patient with hypertension and kidney disease still has the same ailment, but little did he know that his diagnosis code has changed! 

For example, if the diagnosis code for uncontrolled (“Malignant”) hypertension is changed, and I don’t want to spend $600 to buy coding books that particular year (I won’t be able to afford to buy them next year–that is the absolute truth) that tells me you have changed the diagnosis code and I use the old diagnosis code, why is my claim denied?  Have I not provided the same service to the patient, whether the high blood pressure is controlled, uncontrolled, two decimal points, one decimal point, with kidney disease (further broken down into kidney disease stages one through five),  has salad dressing on the side and a partridge in a pear tree?

I have looked in coding books frequently, trying to find a code for what my patient has.  The books themselves are mazes and not set up the step by step way doctors think.  If you look under “Disease” multiple completely unrelated diseases of many different organ systems are listed.  How would one know to even look in that section? Furthermore, there are diagnoses for illnesses that I know do not actually exist. Many codes are “V” codes or represent preventive medicine issues, which are not paid for by most insurance companies, including Medicare.  So why list them?   Somebody was actually paid to make up those diagnoses and assign codes to them.  Such a waste of manpower.

The rules of the coding system involving medical decision making, physical exam bullet points and past medical/social/family history are so complex that coders and doctors can’t possibly agree with the level of service that can be billed. For example, I can bill a higher level office visit if I ask the  patient about her family history.  Maybe that is a poor use of time if I am already aware of the family history or if the family history is irrelevant to the patient’s medical condition.  Either way, it doesn’t matter, because I can bill a higher level visit if I ask and document the family history in my note.  Some doctors learn to play the billing game well, which does not mean they provide better medical services.   Their billers just know how to bill more effectively.

President Obama claims there is so much fraud and abuse in the medical system that eliminating it will pay for a new health care system.  I believe the fraud and abuse are in the unnecessary bureaucracy utilized to ensure all the complex rules of billing are followed.  If changes in the health care system require more bureaucrats to carry out the system, then the point of changing the system to save money has been lost.

So many health care dollars would be saved if a straightforward  billing system were in place.  Patients should be furious that this money, which could be put to use to expand services to more patients, instead is being spent on bureaucrats who exist simply to make sure that the doctor is learning and using the foreign (billing) language correctly. 

Literally millions of dollars could be saved if so many people did not exist simply to monitor the doctor, with the underlying assumption that doctors by nature must be corrupt and require this type of oversight.  That money is better spent towards actual health care, not health care billing.

Last Updated by Dr. Vee on May 2, 2010

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