A new study from the Center for Public Integrity has identified a trend towards higher coding of Medicare visits over the last decade — and suggests this increased utilization of higher codes could signal increasing, habitual abuse. 

The study also notes that medical groups representing doctors assert that treating seniors has gotten more complex over the last ten years — both because Medicare patients tend to have multiple, complex conditions and because EMR and coordination of care make treating them more time-consuming and make documentation and coding more accurate.

A few tidbits from the report that stood out:

  • The report cites the seemingly alarming statistic that “more than 7,500 physicians billed the two top paying codes for three out of four office visits in 2008, a sharp rise from the numbers of doctors who did so at the start of the decade.”  But, 7,500 is less than 1% of the total number of practicing physicians in the US (829,673, per the Kaiser Family Foundation).  Even if every one of these physicians is coding fraudulently, this is a pretty small proportion of physicians who are ‘cheating’ — compare that with, for example, the 15% of Americans who’ve admitted to cheating on their taxes.
  • The report reveals that the lowest code, 99211, typically pays only about $20.  Will the reality of how paltry this is — considering this figure not only compensates the doctor, but pays for the office, technology, clinical and business staff — be lost in the outrage over more evidence of  ‘greedy doctors’?  (If every single minute of an hour were dedicated to 99211 visits — ignoring the need for administration, transition and documentation time between patients, late and no-show patients — that still only amounts to $240/hour.  Not much to pay a doctor, cover her overhead, and compensate staff.)
  • The report also notes that, “the number of doctors who billed at least half of their office visits at one of the two most expensive codes more than doubled to at least 17,000 practitioners…[and] those who quit using the two least expensive codes rose 63 percent, climbing to more than 13,000 in 2008.”  Once again, 30,000 physicians is a pretty small fraction of the base upon which to draw the conclusion of a general trend of abuse. With respect to the elimination of lower codes, it does not appear that the investigators considered the difficulty many physicians have with 99211 (the “nurse visit” code) in particular.  Many physicians fail to use it in cases where it can apply, due to concerns about proper documentation and complying with the somewhat fuzzy definition of the code. 

Regarding this last point, we certainly see undercoding as a much more common coding problem in the practices we work with.  Doctors are so leery of an audit (or of downcoding by a payer, Medicare or private), that they err on the “safe” side.  We also see enough practices adapting to new EMRs to validate that using them lengthens patient visits — especially when providers aim to use them to their fullest value for patients, the physicians and the health system as a whole.

Certainly deliberate padding of Medicare bills is a deplorable practice, but, based on our experiences, it’s hard to believe it’s rampant or even common.  (Despite this study’s alarmist tone, the data cited actually suggest that abusive coding practices have been pursued by a small fraction of practices.)  It’s much more common for physicians and NPPs to cheat their practices by defensively under-coding in our experience; if EMRs are helping practices like these bill properly for their services, that seems only fair, especially since those practices have endured the pain of implementing technology that is intended to help serve patients better.

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