Medicare’s projected costs in 1965, and the reality in 2015, are well-know. At first, the program reimbursed physicians for “customary, prevailing, and reasonable” fees, indemnifying valid but also unprovable claims. Given human nature, the result was predictable: fee inflation, unchecked consumption, and fraud.
In an effort to control costs and combat fraud, price-fixing and documentation requirements for patient care ensued. Patients and doctors became increasingly required to prove that their interactions were not fraudulent, like an auto insurer wanting to see a picture of the dent.
This month, America’s medical billing system began using the tenth iteration of the International Statistical Classification of Diseases and Related Health Problems, or ICD-10. For physicians, it is just another body blow.
In medical billing, every interaction between a patient and a physician is coded according to the diagnosis of the patient and the service provided. For example, testicular cancer is coded 186.9 under the old system, or ICD-9. With 13,000 codes, ICD-9 provided ample specificity to convey to government and private payers the reason for the patient visit.
ICD-10 has 68,000 codes. The additional specificity required across all diagnoses will require more physician time to research and document claims. The tattered, fat ICD-9 code book has been replaced by the searchable ICD-10 database. It is argued that greater diagnostic specificity will help payers get a more precise picture of the America’s health, control costs, and combat fraud, but coding which testicle is cancerous will have no effect on patient care.
Every medical service is coded with a five-digit CPT code. Under the old system, the urologist paired the diagnosis code 186.9 with the CPT code 54530 on an insurance claim form to get paid for removing a cancerous testicle. For office encounters, the physician is required to document the various elements of the evaluation, including the findings and the plan. There are five levels of reimbursement for an office visit. The more detailed the documentation in the physician’s note, the lower the risk of a fraud allegation and the higher the level of reimbursement.
Combining money, documentation requirements, fear of fraud allegations, and computers has led to a predictable result. Sore throat visits now run dozens of pages. Some electronic medical record software even prompts the note–building physician to add additional information to hit the next level of reimbursement. Much of the documentation is boilerplate and gibberish. A toddler recently seen in the emergency room was noted by the physician to be neither homicidal nor suicidal.
Turbocharging documentation has also created a new profession- the medical scribe. These are individuals who shadow doctors and document the doctor-patient interaction for coding purposes. They are mute interpreters for an unseen third party — the one paying for the visit. Diagnosis coding is already outsourced by many physicians; ICD-10’s complexity guarantees that physicians will become even more dependent on another make-work laborer of modern medicine — the medical coder.
The next job may be the medical photographer. With the widespread availability of digital cameras, health insurers, like auto insurers, may soon require visual proof of your claim. Be prepared to upload a picture of your testicles.
With carrots and sticks, the federal government is pushing America’s doctors into an electronic nightmare, and out of private medicine. According to a 2014 Physicians Foundation study, the percentage of physicians who owned an independent medical practice dropped from 62% in 2008 to 35% in 2014. This rapid shift is multifactorial, but offloading the cost and hassle of data entry to a hospital’s billing department makes employment increasingly attractive to physicians.
ICD-10 will give government and private payers more data to ponder, but it is unlikely to control costs or to improve access. Count on physicians becoming more bogged down with every patient encounter, hiring more people to cope with the increased busy work, and buying new software with new workarounds. And expect more physicians to quit private medicine. Lower production and higher overhead is never a good combination, especially for low-margin, small physician offices and patients who want affordable, accessible medical care.
The solution, of course, is to get third-party payers and their irksome codes out of small-dollar medical transactions, like office visits. Physicians could reduce staffing, lower their fees, and focus on their patients. Medical coding should be simple and confined to high-dollar events, like surgical procedures.
Cameron S. Schaeffer, MD, practices pediatric urology in Lexington and Louisville.