We all know how extensive and confusing coding medical care is today and nobody knows that better than the hospitalist as if something is not coded right the hospital doesn’t get reimbursed so first place to look is “who did that coding” when you were admitted as a patient. Keep in mind he’s also preoccupied with “taking care of you too” <grin>. Sometimes it seems like these 2 priorities get changed around just by trying to do one’s job. If there’s a big problem in coding, then the hospital can get fined too. New codes arrive and the AMA adds them as needed and also some get dropped, revised and so forth.
To make matters even more confusing, insurance companies and Medicare don’t require exactly the same codes too, so the hospitalist has to be right up on their toes to make sure they don’t confuse those either, and a good example which occurred not too long ago were the consultation codes, insurers still sometimes honor them, Medicare, no. It would be nice if everyone did the same thing but this of course meant money.
The hospitalist certainly can’t stand to under code either as that results in less payments dollars to the hospital and if your care as a patient gets worse, then there’s a big issue getting addition procedures, time in the hospital and so forth approved as they “did not code you correctly” at the onset. This happens by accident too again with being distracted at times with the happenings at the hospital and trying to take care of you.
Now if you over code, here come the wolves to check for potential fraud and the Medicare contractors to maybe even conduct an audit and all will look right back over at the hospitalist and their coding assistants if they have them. That is actually a good idea to have someone verify and help the doctors with the coding as it grows more complex. As mentioned most do not get “coding” training in medical school either and it’s kind of an on the job training situation, although that is starting to change for doctors. There are plenty of training areas for billers though and have been for a few years now. There’s also the change of shifts at the hospital where more than one hospitalist is caring for a patient and these too have to coordinate. The Hospitalists have program they can research and look up coding changes, etc. and this has to rely on judgment calls with patient conditions too. Some systems “auto code” with medical record systems and the dependency sometimes on this feature can be up in the air, but usually the longer and more experienced a doctor becomes with the software they get better at it.
There’s a really good hospitalist blog out here called “ The Happy Hospitalist” and he does a really good job sharing his life experiences as well as coding hints and who better to read than one who’s doing it and he speaks in real life terminology. He also rants a little and tells you about taking an enormous amount of time to get records from the likes of Walter Reed hospital too, so very good reading.
If you are a patient at times it’s hard to know if you have been admitted or kept for observation and those are different codes for the hospitalist to be aware of too. Medicare requires a 3 day inpatient stay, so when patients are not formally admitted, they don’t pay. The place of service is important too so the codes apply there too as a 22 and a 21 code get interchanged just due to the patient’s condition and prescribed care.
Here’s on example cited from the Hospitalist Magazine below and as you can see the terms have to be very specific and if you had congestive heart failure and that’s how it gets reports claim denied as the insurance carrier says no, we want cardiac arrest listed and the payment is denied.
“Medical necessity denials often involve a mismatched or missing diagnosis. For example, a payor might deny a claim for cardiopulmonary resuscitation (92950) that is associated with a diagnosis code of congestive heart failure (428.0), despite this being the underlying condition that prompted the decline in the patient’s condition. The payor might only accept “cardiac arrest” (427.5) as the “medically necessary” diagnosis for cardiopulmonary resuscitation, as this is the direct reason necessitating the procedure. After reviewing the documentation to ensure that the documentation supports the diagnosis, the claim can be resubmitted with a confirmed and corrected diagnosis code.”
Now let’s add on one more element here with claim processing time and how the insurers make interest on claim money and this pertains to Medicare as all the claim contractors are insurance companies who process all of this.
Medicare Contractors Are Not Getting Their Act Together with Consultation Coding – Are Claims Falling into a “Black Hole”
The reason this happened is that many years ago it was determined to let insurance companies do all the IT infrastructure work and the government never had the opportunity to build it, unlike Social Security that has an IT system and is not reliant on insurance companies to process claims to include disability so in short we got what we paid for at the time, saved money without investing in technology but have a disruptive claim processing situation today as a result. In short we have the “pay me later deal” and there’s not much we can do but begin at some point with creating IT infrastructure and that’s what the government is doing, a bit at a time.
This gets a little more complicated too with mergers and acquisitions over the last 2 years especially as the companies that have acquired others, algorithmically changed business models and so on, are not the same companies today. When this occurs with insurers processing Medicare claims it gets sticky as one end of the company profits from decisions and processes another division makes and that’s a tight spider web right there.
The image above is a Medicare Contractor who of course as you can see lobbies the government and has specific email addresses to facilitate assistance. I’ll continue to beat this into the ground but the only way lawmakers can do a better job and not be caught with their shorts down all the time is to use better and smarter technology like Wall Street and other businesses do and they would also have more control with knowledge when dealing with lobbyists, this is just a plain simple fact and doesn’t take a brain surgeon to figure out that the more knowledge you have up front the better meetings and negotiations will be conducted without all the crap from the 70s rounded up that has no place today.
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There’s much more too this as hospitalists also have to coordinate with family practice doctors as well with coding to ensure that both are corrected assessed and shoot your family practice doctor over the weekend may not have one clue if you have not contacted them to know you have been admitted if the information flow is not there. In short if a claim is denied or has a problem in addition to running to the hospitalist about your condition they will check their coding, like the Spanish Inquisition at times.
Again while doing all of the financials of admitting you they are also looking for areas of safety to help make sure you do not get a hospital acquired infection for one example and get you out the door as soon as possible, especially with Medicare as utilization committees sometimes act like Monday morning quarter backs and reassess how every patient case was handled. Those get tough too as Happy talked about last year in a Peer to Peer meeting. This was a tough one as nobody on the entire committee could figure out what United Healthcare wanted documented with their managed Medicaid contract and keep in mind they want to get more of these and are making record profits at United as well as their CEO.
In his case here, we have an active discussion over what is observation (and how it is coded) versus being admitted as an inpatient (and how it is coded). Reimbursement rates vary for each scenario, so it falls back to a committee, who is also confused on how all of this works. Contracts change with insurance carriers too. As Happy mentions, he and his coding people keep seeing claims denied, day in and day out. We all know what happens when claims are denied, nobody gets paid and some of this rolls back to the patient, doctors, hospital to make it up, everybody loses. One other item worth a mention here too is that the hospitalists and ER doctors are usually first up to become beta testers on medical software and much of it is related to revenue cycling with patient care algorithmic formulas. It gets complicated and this is why we are seeing a huge increase in scribes at hospitals today.
So hopefully this helps describe who they come after with coding at the hospital and with the move to empowering patients I satirically ask is this going to be the next plateau that payers shove over to have us ask how we have been “coded” <grin>. I mention this fact as everyone can’t seem to get this right with educating patients and getting more involvement. Intuit used to think I didn’t like them with their product that works with PHRs or as a stand alone for keep track of medical expenses until they finally did their own study and found out the reality out there about patients not being tied into software as such and shoot I find doctors and patients who don’t know even what a PHR is all the time so in essence consumers were just not interested and it was beyond where they either wanted or had enough time to explore.
One more item here worth a quick mention too is that “hospitalist companies” are being bought up by private equity firms too so they are looking to make money on investing in doctors “who can code right” and turn a profit for them so in addition to the hospital they have one level up that is very interested in how profitable they are, shoot do we forget about patient care at this point ? It’s crappy reality that exists but again keep this in mind.
Anyway the coding nightmare is not going away any time soon and hopefully this gives some awareness here as to the other side that both hospitalists and ER doctors deal with. Their time is limited and they go as far as they need to go with technology to get paid and the consumer is not much different here either as long as the bills get paid and when payers shift this complicated system back over to doctors and patients it’s a mess to understand and as a patient you get this bill with all kinds of codes that offer no clue as to what went on. Sometime legitimate mistakes end up making hospitals and doctors look fraudulent too and we come back to the interpretation and use of codes for this and the example quote above is a great example of this complexity.
If you have read this far you may probably understand a bit better as to why I made my post about a cease and desist for calling consumers and doctors “stupid” as those at the top of the helm directing this are in the same boat are are what I label as the “non participants” that lack sufficient Health IT literacy and yet create rules and regulations that are sometimes impossible to comply with. There is nothing better than “hands on” when it comes to Health IT today as proof of concept a t tool for total reliance is burying a lot of those who don’t “got” it. BD