Sunday, May 18, 2014

Openness and Transparency

Medicare recently released figures for physician billing It included all physicians who bill CMS for services.  CMS requires a ‘current procedural code’ (CPT) for each visit, outpatient, inpatient, laboratory, imaging and/or medication and durable medical equpment. There are numerous modifiers, such as those for bilateral proceduress and the like. The data was released without explanation or definition.  The codes are uniform and identical across all specialties.  This is the first time such complete information was released to the general public.

CMS uses the data to track and analyze billing practices. It is used to analyze for fraud and abuse. CMS studies the numbers for outliers...who bill the most….using a specific code. Some CPT codes are used to determine the amount of complexity or time involved in a patient visit.  CMS has specific items which are required to code for the level of complexity of the visit.  The CPT codes are complicated and providers will often consult with or have a ‘reimbursement expert’ to code. Except for general internal medicine most specialists use a relatively narrow range of CPT codes according to the procedures they do. (gastroenterology, ophthalmology,urology, radiology etc.

(NPR) National Public Radio broadcast information given by CMS and also commentary by a  physician who  heads the kidney transplant program at the University of Colorado.  The program is the only facility in Colorado providing these services and referrals come from a wide area, even beyond Colorado.

The data revealed the following. Some physicians  coded every visit at the maximum level of reimbursement (rare), some appeared to up-code or bill more than the standard level for some or all visits. Some even down-coded to avoid being selected for an audit.  They chose to decrease income to avoid such an audit which is time consuming and expensive. The outcome of many of the audits is a demand for repayment of the amount CMS determined was billed in excess of the supporting documentation.  Providers must document in the medical record exactly what systems (kidney, lung, heart, skeletal) were examined, and the amount of time for the visit.  The CPT code must be justified by the medical record.  CMS provides guidelines for each level of care. In surgical cases the code also includes all post-operative care for a defined period of time depending on the complexity of problems.

Physicians are the ultimate responsible person who attests to the level of billing and it’ accuracy.

In some cases the data reflects billings for multiple providers who  work for another provider. The data has nothing to do with quality of care. Frequently new procedures develop and it may take months for CMS to announce a code for the new procedure.  The rapid advances in medicine and surgery often result in procedures and/or tests for which there is no code.

Missing from the information is the necessary linkage between a diagnosis and a procedure, without which the claim is denied. If the ICD code and CPT do not fit CMS’s definition the claim will be denied.  CMS has a vast data base on what CPT codes match which ICD code.

The ICD-9 codes have been in existence since       . To further complicate matters a new expanded series of codes, ICD-10 will go into effect in the next 12 months.  The original date for compliance (October 2014) was extended because of providers and hospitals informing CMS and HHS they would not be able to comply with that mandate.  The number of ICD codes expands from 14,000 to over 60,000.  The data in the released information is based upon ICD-9.   The expansion of the ICD codes will require expensive EHR software upgrades and in some cases a new EHR.  Some  providers already replaced their systems several years ago due to early mandates for interoperability and other features.  This amounts to billions of dollars for providers.  The cost may well be more than the ‘fraud and abuse’ claimed by CMS.   CMS  has no provision for the expense of providers to continually be required to upgrade in order to bill.  This is a recurring problem.  CMS quarterly modifies its list of CPT codes and instruction for modifiers as well.  These are hidden costs to medical care, and their is little to no information available to the public regarding these CMS requirements.  The expense from these requirements is never ending and repetitive.

Private Insurers also becoming more open and transparent
Three major insurers are partnering with a not-for-profit group to provide consumers with greater access to healthcare cost information, the group announced Wednesday morning. (MODERN HEALTHCARE)

Openness and transparency not only apply to financial information, but more important to the physician-hospital-patient interaction.  Unfortunately patient centered medicine is still far from reality.  The transition from a physician led system has been a subtle erosion of ‘captain of the ship’ to a member of the team mind-set.

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