I’m not going to talk about me today.  Instead, I’m going to review what is going on in your doctors’ offices and why it pisses me off.  You’ve heard of March Madness. Well, welcome to December Madness.  Whereas March Madness ends by rewarding one college team with the national title, December Madness ends up with increased overhead, increased workload and the threat of a government audit and charge of “fraud and abuse.”

In 2021, the practice of medicine boils down to cataloguing you, the patient, using ICD10 (diagnosis code) and CPT (procedure code).  Everything revolves around codes.  The coding system changes yearly and there are hundreds of new and modified codes to be aware of and use to describe your patient’s visit.  Every year my staff and I had to learn all the new codes that pertain to family practice.

If you ask me, codes are worthless.  Actually, they detract from patient care and create a further barrier between patient and doctor. So, why do we have such a coding system?  The number one reason is that the AMA sells very expensive coding books every year.  The sale of their books is a major part of their revenue.  Number two is that the insurers of America use the codes as a way of controlling physicians’ behavior and cutting the insurance company’s expenses. 

The insurer, including Medicare, arbitrarily sets the payout on a given code and decides whether they will pay the code outright, deny the code,  or require prior authorization to validate its use.  When I started in medicine, I authorized a procedure prior to it being done and that was it.  Now the doctor’s staff has to call an 800 number, wait on hold forever and start over again.  Getting a procedure authorized for you may cost hours of staff time and that’s not cheap.  You also may be denied the right to do what your patient needs.

By the way, the insurer and Medicare never really deny care, they simply refuse to pay for it.  It’s your choice if you want to pay $5,000 for a non-approved procedure that, if it had been authorized, would have cost the insurer $50.  Doesn’t seem fair, does it?  Denials end up being a major cost savings for insurers and a major expense for physicians.

The number three reason is the coding system sets the physician up for “fraud and abuse’’ charges.  “Fraud and abuse” threats hang over every physician’s head.  What would you think if your doc was charged with fraud and abuse? In the US, we believe people are innocent until proven guilty, right?  Wrong!  Once its on social media, your goose is cooked. Patients who feel their physician charges too much will jump on the band wagon. 

Let’s look at how a code works.  Assume that to code an office visit at 99214 you need A,B,D,M,N,Q,R and Z.  The provider/coder is supposed to know exactly what is necessary to justify the code and document it in detail.  If the physician documents A,B,D,M,Q,R and Z, he/she has not met the criteria for a 99214.  If he does N but does not adequately document it, he is open to a charge of “fraud and abuse” for over charging.  However, there is a catch 22.  If the provider charges a 99213 (a lesser charge) and the auditor feels N was adequately documented and the charge should have been a 99214, the physician can be charged with “fraud and abuse” for undercharging.  It’s a no-win situation and I venture to say that, if a physician’s office is audited, it will be found guilty!  There is no way you can see your patient, treat your patient and accurately detail every bit of information regarding the visit. 

While I wish I was still practicing medicine, the new changes in coding make my not working more palatable.  In many ways, coding has destroyed the profession I loved.  Physicians are not paid for caring.  They are not paid for listening.  They are paid for coding.  What a pity!

Thank God I was never audited by the government.  I did the best I could to code appropriately but, on a busy day, my responsibility was to listen and care for my patient and I’m sure my documentation suffered.  By giving you some insight into what goes on during and after your office visit, I hope to give you a better understanding of your physician and his/her staff.

Here’s your music and a joke. 

Boris Johnson dies…

His soul arrives in heaven and he is met by St.Peter at the Pearly Gates. Welcome to Heaven,” says St. Peter. “Before you settle in, it seems there’s a problem: We seldom see a Conservative here and we’re not sure what to do with you.”

“No problem, just let me in; I’m a believer,” says Johnson.
“I’d like to just let you in, but I have orders from the Man Himself: He says you have to spend one day in Hell and one day in Heaven. Then you must choose where you’ll live for eternity.”
“But, I’ve already made up my mind; I want to be in Heaven.”
“I’m sorry, but we have our rules.”
And with that, St. Peter escorts him to an elevator and he goes down, down, down, all the way to Hell.

The doors open and he finds himself in the middle of a lush country house garden. Standing in front of it his dad…and thousands of other Conservatives who had helped him out over the years…….
The whole of the “Right” was there. .
Everyone laughing…happy…casually but expensively dressed.
They run to greet him, hug him, and reminisce about the good times they had getting rich at the expense of the “suckers and plebs”. They play a friendly game of croquet and then dine on lobster and caviar.

The Devil himself comes up to Johnson with a frosty drink, “Have a Marguerita and relax, Boris!”
“Uh, I can’t drink any more, I’m watching my weight,” says Johnson, dejectedly.
“This is Hell, Boris: you can drink and eat all you want and not worry, and it just gets better from there!”
Johnson takes the drink and finds himself liking the Devil, who he thinks is a really very friendly guy who tells funny jokes and pulls hilarious nasty pranks. kind of like an Oxford undergrad.
They are having such a great time that, before he realizes it, it’s time to go. Everyone gives him a big hug and waves as Johnson steps on the elevator and heads upward.

When the elevator door reopens, he is in Heaven again and St. Peter is waiting for him. “Now it’s time to visit Heaven,” the old man says, opening the gate.

So for 24 hours, Johnson is made to chill with a bunch of honest,
good-natured people who enjoy each other’s company, talk about things other than money and treat each other decently.
Not a nasty prank or mean joke among them; no fancy country seats and, while the food tastes great, it’s not caviar or lobster. And these people are all poor, he doesn’t see anybody he knows, and he isn’t even treated like someone special!
Worst of all, to Johnson, Jesus turns out to be some kind of hippie with his endless ‘peace’ and ‘do unto others’ stuff.
“Whoa,” he says uncomfortably to himself, “Margaret never prepared me for this!”
The day is done, St. Peter returns and says, “Well, then, you’ve spent a day in Hell and a day in Heaven. Now choose where you want to live for eternity.”

With the ‘Jeopardy’ theme playing softly in the background, Johnson reflects for a minute, then answers:
“Well, I would never have thought I’d say this – I mean, Heaven has been delightful and all – but I really think I belong in Hell with my friends.”
So Saint Peter escorts him to the elevator and he goes down, down, down, all the way to Hell.

The doors of the elevator open and he is in the middle of barren scorched earth called Brexit Britain covered with garbage and toxic industrial waste…

He is horrified to see all of his friends, dressed in rags and chained together, picking up the trash and putting it in black bags. They are groaning and moaning in pain, faces and hands black with grime.
The Devil comes over to Johnson and puts an arm around his shoulder.

“I don’t understand,” stammers a shocked Johnson, “Yesterday I was here and there was a country house and we ate lobster and
caviar….drank cocktails.
We lounged around and had a great time. Now there’s just a wasteland full of garbage and everybody looks miserable!”

The Devil looks at him smiles slyly, and purrs, “Yesterday we were campaigning; today you voted for us”
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2 Replies to “CODING”

  1. Re: coding …so complicated and overwhelming! Our entire healthcare system needs to be reformed, I think. Would appreciate your thoughts and ideas on how to make it better! Sometimes I feel like we currently have many of the restrictions associated with socialized medicine, but non of the benefits. Your thoughts?

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