Thursday, December 06, 2007

BLOGSCAN - Running Afoul of E&M Coding Rules

On the Covert Rationing Blog, DrRich continued his discussion of the irrationality of Medicare's E&M coding, that is, the bizarre and complex rules the US Medicare system uses to control its reimbursement for "evaluation and management services" that physicians provide patients. In turn, "evalation and management" means everything physicians do for patients: interviewing, examining, orderding tests for, diagnosing, counseling, prescribing treatments, etc for them. The regulations are so complex that it is virtually impossible to fulfill them. This, per DrRich, is a perfect example of a "regulatory speed trap." Again, while Medicare makes it so difficult, if not impossible, to bill correctly for office visits, it pays lavishly for procedures. Is it any wonder primary care is going out of business, and all physicians who mainly provide cognitive services (e.g., services as listed above, but not procedures or surgery) are seriously threatened?

1 comment:

Sam Eye Am said...

Rationing by not rationing.

I keep reading these OIG, HHS, CMMS “investigations” and have figured out why they perform them only after a long ill defined period of time.

CMMS wants and needs you to provide the care.

Physicians and medical organizations are not generally stupid, illegal, or ignorant. We became physicians by FOLLOWING THE RULES. If the regulations are in place, clear, posted, unequivocal, they will be followed by the overwhelming majority of providers and facillities. Who would perform tests, exams, procedures and code/submit them so incorrectly to incur huge insolvent incurring paybacks and possible jail time?


Allow the organization and physician to sustain/grow on the medicare or medicaid “diet” then start the process of extracting money back after a long period of time and after care/treatment has been provided. You dont harvest a tree until it has reached a mature size.

Very clever and highly premeditated.

If we knew or understood the planned subterfuge our business plan would not depend on reimbursement from medicare. [Excluding medicare from your practice would be the ultimate form of medical passive resistance.] Unfortunately, now the care has been given so the time for harvesting the money back is ripe. You cant take the service back. You cant reverse the patients diagnosis but on a technicality OIG, HHS, CMMS, and/or ACHA can take the money back plus penalty and send you to prison IF they determine and prove you committed FRAUD. A “bumper crop” indeed.

Utilizing PRG-Schultz,, the Federales have even enlisted the aid of “bounty hunters” who get to keep a percentage of harvest. These activities appear to be bringing hospitals to their collective knees. “The increasing hospital anxiety has elevated the auditing program to a top agenda item of the American Hospital Association.”

My mother a retired neurologist would intercede at this point and say “oh but the Feds only focus on people who are so egregiously fraudulent that you just need to be honest and document the diagnosis, justification and work that you did” I hope she is right.

In the words of Kurt Vonnegut, “so it goes”.

Someone will have to legally demonstrate that the Medicare provider agreement is an adhesion contract which is procedurally and substantively unconscionable.