health care billing undercuts any assertion that providers are over-billing. In
its response letter to HHS, the American
Hospital Association decried the lack
of coding standards. “Since April 2000,
hospitals have been using the American
Medical Association’s Current Procedural Terminology evaluation and management codes to report facility resources
for clinic and ED visits,” the AHA wrote.
“Recognizing that the E/M descriptors,
which were designed to re;ect the activities of physicians, did not adequately
describe the range and mix of services
provided in hospitals, CMS instructed
hospitals to develop internal hospital
guidelines to determine the level of clinic or ED services provided. In 2003, the
AHA and the American Health Information Management Association recommended that CMS implement national
hospital E/M visit guidelines based on
the work of an independent expert panel
comprised of representatives with coding, health information management,
documentation, billing, nursing, ;nance,
auditing and medical experience.
“In the 2004 and 2005 OPPS rules, CMS
stated it would consider national coding
guidelines recommended by the panel.
However, to date, CMS has not established
national hospital E/M guidelines.”
;e AHA response is on target, says
Robb, the consultant. “We don’t have a
standard health care system,” she says.
“Every facility develops its own poli-
cies, compliance and implementation. I
would never just state that providers are
up-coding.”
Parallel worlds
For Robb, the root of physician confusion
lies in the di;erence between hospital
facility billing and physician professional
service billing. Hospital reimbursement
is largely driven by the DRG system,
which assigns a global payment for fa-
cility services based on the patient’s di-
agnosis and severity. In contrast, physi-
cian work is reimbursed in a separate
channel that measures work output and
complexity of decision-making in the
evaluation and management of patients.
;us the rules and implications of such
practices as copy and pasting may have
entirely di;erent rami;cations, she says.
“You have such diversity between what a
hospital can do and a clinic,” Robb says.
“Physicians are getting a lot of mixed sig-
nals. What is OK to do on the physician
side may not be on the hospital side.
;ere are a lot of dynamics in play.”
Some observers took the HHS warn-
ing letter in stride, saying it was as much
politics as policy in play. “With all the at-
tention on the de;cit, the letter let CMS
show it’s being tough on Medicare fraud,”
says Richard Temple, national practice
director, IT strategy, at Beacon Partners,
“Physicians are
getting a lot of
mixed signals.”
—Deborah Robb
a consulting ;rm. “It was a dramatic
;ourish and not indicative of rampant
fraud.” Nonetheless, Temple o;ers one
piece of advice to help sidestep any dubious billing.
“Use data analytics behind the scenes
to analyze how frequently successive visits are duplicative or virtually duplicative
of one another,” he says. “;at will allow
you to proactively zero in. And then demonstrate to providers you have that kind
of tool.”
THE IMPACT OF ACOs
What happens to provider billing under accountable care? In some models, pay-
ments would no longer be based on fee-for-service, but rather outcomes. Some
industry observers think that as the industry embraces the new payment model, is-
sues of overcoding and overbilling will begin to recede. “Coding is entirely way too
complex,” says Rita Numerof, a St. Louis-based industry analyst. “Physicians often
wind up under-coding. They can manage complex problems, but they’re nervous
about coding for an extended visit. They don’t want to be identified by an insurance
company as an outlier. Then all their invoices would be held. So they rationalize and
eat the charge, which is not fair for doctors doing the right thing.”
Numerof calls for wholesale changes in the way the industry reimburses. “We
need to get to a different payment system. We can focus on bundled payment and
get away from the minutia of a coding system that is becoming more complex and
less relevant.” The caveat? Numerof contends that for any reimbursement system
to succeed in holding down costs, consumers must have a bigger economic stake
in their own outcomes and in the quality of services rendered. As such, consumers
would be positioned to be a “watch dog” over health care outlays.
Other analysts are less enthusiastic about accountable care—at least as far as
its ability to simplify billing. Bundled payment models are an unknown, says Debo-
rah Robb, director, physician services, Trust HCS, which offers coding consulting
and training. “Would the same amount of documentation be required or will it be
different?” she asks. “If we see one note that has been copy and pasted, would you
take the money back even though the procedure was done correctly?”
However industry payment models unfold, documentation and coding will
remain a big industry bone of contention in the years ahead, says Ed Hock, senior
director, revenue cycle solutions, at Washington, D.C.-based The Advisory Board, a
research and services firm. “It won’t get any easier as we get into ICD- 10,” he says,
referencing the forthcoming coding and classification system set to come online in
2014. The new coding system includes far more granularity than its predecessor,
ICD- 9, and will thus require even more detailed documentation from physicians.
As far as upcoding goes, Hock stands by the integrity of the industry. “The vast
majority is doing the right thing by coding the care actually provided. You do need
to educate physicians to document accurately about what is actually happening.”
