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Billing Fraud Incentivized By Coding

Posted Aug 26 2008 11:11am
I'm not sure what to make of this post at "Every Patient's Advocate." It follows up on a Steven Cole OpEd in the Dallas News , in which he points out that doctors prescribe medicines and order tests just to justify higher reimbursing billing codes.

There are certainly some medicolegal reasons for ordering tests and prescribing medications, many of which can be addressed by working on the communication skills of physicians.

But billing?


The codes in question are 99213 and 99214. The principle is that you're pretty poorly remunerated for these visits, so you may as well capture what you've already done; document up to the code appropriate for the complexity of your patient.

Studies show that most primary care physicians underbill 99214. This is an established patient code; new patients have a higher documentation requirement and physicians tend to overbill the equivalent codes.

Get that; physicians underbill the one and overbill the other because the documentation requirements are different and they generally do not make the effort to learn all the details of billing. Physicians do not generally consider documentation and billing important parts of their calling.

So that must be why they prescribe drugs and order tests to get paid more... Yaaaaaa, riiiiiight!

Well, Dr. Cole is an allergist. I don't know how his colleagues behave, but I certainly know about primary care physicians. It's not what he describes. But even if we were to accept the notion that physicians practice patterns are affected by reimbursement rules, then all I have to say is "the trouble with incentives is that they work."

The CPT coding system was devised to distribute resources according to the effort required. Somebody underestimated the effort required by primary care and most especially the degree of risk assumed in primary care. But fraud is not worth it at our compensation rates. Physicians are smart enough to figure out whatever stupid system of regulations is thrown at them. Don't blame the physicians, blame the inadequacy of the regulation.

And as far as patient advocates are concerned, you have just shown me yet another ugly aspect of consumerism in medicine. Throw your efforts at improving the medicolegal environment, increasing transparency of the charges, and use primary care docs as your best advocates to guard against the worst that American medicine brings to bear.
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