Coding Mastodons
Sid and his partners sat around the conference table upstairs from the clinic. They met monthly at 6:30 AM so they could dispense with the clinic business and go off to hospital rounds and then get back to clinic by 7:30. Patient care is always first. Go to the grind.
Paul, their manager was sharing bad news.
The practice had accepted the burden that they needed a manager. So, they hired him and paid him almost as much as they made. In fact, the manager made more than Sid since he was a low producer.
That’s how this group of Sid’s had decided each should be paid. The more money you brought in for the clinic, the more you got to take home. It made some sense to Sid. If you killed the mastodon, you should have first go at the good bits. Sid was a hunter.
Sid looked around the table as Paul was preparing his bad news. Doctor Jones, older than Sid by a good ten years and probably just as cynical as Sid would be in ten years had his system. He ordered a ton of labs (done by the clinic lab, thus generated revenue) and added two diagnoses to the problem list with every visit. This allowed him to charge for a complicated visit, when it took only 15 minutes, like most of Sid’s. Jonesie had figured out how to get a good share of the meat.
Whenever Sid saw one of Dr. Jones’s patients, he did his best to clean up the duplicate diagnoses off the problem list, since it was all so much gobbledy gook. Three diagnoses of heart failure with different modifiers didn’t help Sid understand this poor creature. But such custodial work didn’t add to Sid’s income, so he pretty much just shrugged and gave up.
Then there was Doctor Payne who could truly see 40 patients a day. It didn’t seem his name drove folks away. Maybe it drew them?
Sid had watched him. He was amazing. One-line notes in the chart, always a prescription, often a narcotic, but he got them in and out. Lots of ways to bring down the beast.
All the calls for narcotic refills that came in when Dr. Payne was off were a burden, for sure, but again, Sid kind of shrugged. He so appreciated hunting with this tribe. Figuring out why the 70-year-old needed 90 hydrocodone a month wasn’t billable for Sid, so, shrug. He just needed to pay attention to the hunt.
But now Paul needed Sid’s attention.
Paul had been a worthwhile investment for the group, Sid had decided. Paul had hired another billing clerk, they were up to four now, and they worked upstairs and were out of sight. But they sure seemed happy on their lunch hours. The clinic was seeing some increased income, so maybe all was good. Sid accepted that you had to spend some to make some. It takes effort to bring down big game.
Sid knew not all clinics paid their doctors this way. But this was pretty much the pervasive medical culture, though Sid smiled to himself, maybe it was Neanderthal. If you “do more”, that is charge more to Medicare, Medicaid, and the better paying insurances, you make more. If you deliver Medicaid babies it would pay about half what Blue Cross paid. But delivering a Medicaid baby paid at least a thousand bucks, 20 times more than one office visit. And you got to do it in the middle of the night so you could still “produce” in the office hours.
Maybe that’s why Doctor Smith was sleepy now, nodding off almost as Paul was starting his news. Was he really sleeping? He did more deliveries than any doc in town, even the Ob Gyns. And he got lots of the good bits.
Sid was always a low charger. What the doctor charges is submitted in the code and then the billing ladies sent the code off for payment. It might be what you do, or it could be what you code. Either the mastodon died, or it didn’t. Sid wished for the good old days. Instead of this mish mash why couldn’t it just be simple hunting on the prairie?
The doctor’s coding was what Paul was talking about now, what they had charged, what they had coded.
Medicare had come in and audited all of their Medicare charges. A doctor’s charge to Medicare must be reflected in the notes of the visit. Medicare is the big government health insurance for the elderly. They have the right, because they are the government, to come in and audit your books. It seemed the clinic’s numbers didn’t add up.
“So, their findings, when they looked at a sample from the last six months, they found we had miscoded 23% of our visits. They then extrapolated that to the last five years, and they say we owe the federal government $1.3M. But…”
There were too many expletives for Paul to finish his sentence. Sid watched Paul’s small smile as his colleagues blustered their umbrage for five minutes. Sid knew he had two hospital patients to see and 30 minutes of records to review before his first patient an hour from now. He interrupted his senior partner’s rant. “Can we get to the chase?”
Paul smiled at Sid. “Yes. These are the usual findings from an audit such as this. Actually, 23% of coding mistakes is a bit below average. We will have further conversations with them. I expect the final reconciliation to be in the low five figures, maybe less.”
The umbrage started to boil up again.
Sid nipped it. “Do you need anything from us at this point?”
Paul smiled again. “I have decided to implement a coding improvement process with all of you. Should this happen again, having such a process in place will greatly improve our standing.”
The questions bubbled up.
“We will pull ten of your appointments from the prior month and have them reviewed by a professional coder. You will get their recommendations. We hope this will improve our performance.”
Sid left the meeting with quite a few questions unasked. But he had never had a beer with Paul. The smiling gnome seemed to understand the system. Sid was just beginning to.
As he walked across the wet street to the hospital, he wondered, if the clinic was already below the average for bad coding, just how much could they improve? But Sid was perplexed by statistics and quality improvement processes. This was totally foreign to the practice of medicine he had learned.
Sid opened the door to the hospital and went up the stairs.
Everything a doctor does is coded. Doctors are paid based on what they code. Can’t you see the problem? Sid screamed this to himself before the first landing.
If surgeries pay more than office visits, won’t more doctors want to be surgeons? And what we need are good family docs helping patient avoid chronic problems. But those codes pay shit.
And if surgery codes pay 100 times what spending 30 minutes telling a patient this surgery probably won’t help you, what do you think the surgeon will say?
Sid went into the ward fuming. He did the visits, talked with the nurses, then wrote his orders. As he did, he considered another coding folly.
Codes submitted by hospitals, though they may be for the same exact service as done in a clinic, were paid 50% more by insurers. It was the “institutional fee” thing. When Sid had learned this, he had first blown a gasket, then rolled his eyes. He was learning the absurdity of the game he was playing. Oh, to be hunting mastodons.
It was like his small band had discovered a weak mastodon, trailing the herd, but another, larger band of hunters had shown up on the plain. Who would get this meat? Who would live? Sid wished it was like the good old days.
As he went back down the stairs, he had calmed down. He knew there were other models. The Mayo Clinic paid docs a flat salary. No incentives to do more. But that wouldn’t fly here. He’d tried it. We still hunt. And we eat what we kill. Mastodon meat can keep you alive.
A month later Sid got his coding report from Paul. Three of his ten reviewed visits were miscoded. Two were coded too low, and one should have had a surgical code included.
Paul was in his office.
“So, what do you think I should do with this?” Sid dropped the two-page report on Paul’s desk.
Paul was again smiling. “It looks like you should code higher and remember to include any surgical procedures.”
Sid looked down at the bland carpet. “Does under coding come up in Medicare audits?”
Paul capped his pen and leaned back in his Office Depot chair. “Of course. Any code not justified is flagged.”
“So how many of those audited visits were under coded?”
Paul was not smiling now. “They don’t share that information. They just tell us our accuracy.”
Sid stared at Paul. The no longer smiling gnome continued. “They assess the accuracy of coding and assign a fine based on the percentage of mistakes.”
Sid did not smile. “So, if most of those mistakes were where we should have charged more, but mistakenly didn’t, we still get fined?”
Now Paul gave a slight smile. It was like he felt some comfort to be discussing the details of a Medicare audit with someone who cared. “That’s why they negotiate. We’ve got it down to about $9K now, so you know.” Paul put his hands behind his tilted back head. He was gloating.
Sid knew the next patient was waiting. He just looked at Paul, so proud of himself. He wondered about just what he was doing. If it was about harvesting meat, he understood the purpose. But this? He thought of his tirade in a millisecond.
I learned the origins and insertions and innervations of all the muscles in the human body. I learned the bones, they were easy, and I learned the sensory dermatomes. I know all the foramen of the skull and what goes through those holes. I learned the embryology of the gut rotation and how the testes descended from the kidneys. I know the doses of hundreds of pharmaceuticals, and what the drug companies claim they do. I’ve read their weak double blind crossover randomized trials. I know the side effects of most of these drugs I am expected to prescribe, and I pay attention for them in my patients. I know the value of the blood tests and radiology tests available, and I order them based on their value for the condition of my patient. And now I am expected to know how to communicate this for my reimbursement. Through codes? Through the seven branches of decisions with 3-5 variables at each branch on a little laminated card?
So, I order lots of tests and the reimbursement code is higher. Does that make me a better doctor? Does that make my patients healthier?
Do I freeze off the benign skin tags and get paid more? Are they healthier?
Maybe it makes me, and you richer.
Sid felt his internal millisecond rant winding down with the slow blink of his eyes. He looked up at Paul, leaning back before him.
“I got to go.” Sid went off to the next waiting patient.
And Sid saw patients. All morning he saw patients. He finished his recording halfway through his lunch hour, so he trotted across the street to the hospital cafeteria. A saran wrapped half sandwich was a buck fifty, and he could eat it and walk. So, he did.
He saw the new billing lady smoking her cigarette as he went out. He’d already unwrapped the ham and cheese, so he moved in her direction and thumbed the plastic wrap into the garbage can next to her. She exhaled a big puff.
“Well, you caught me!”
Sid knew that voice. He vaguely remembered a couple round scars on her cervix from previous biopsies that had turned out benign. But not her name.
“Caught?”
She had a winning smile and good posture. The past intimate revelations were lost. “Rhoda” She said her name, with a winning grin, like she knew Sid didn’t.
“Yes,” Sid didn’t fumble. “Are you the new coder?”
Rhoda flicked an ash. “That’s me.”
Sid took a big bite of the little sandwich and chewed fast. He had some food in his mouth when he said. “We should talk about coding sometime.”
Her laugh was so brassy it echoed from the bricks behind them. She took another puff, exhaled, and said, “That’s the weirdest pick-up line I’ve ever heard.”
Sid was surprised. Pickup? “No, really, I’m trying to figure out this coding thing. You’re the expert. I figured you could help me out.”
Rhoda tossed her butt into the landscaped garbage can where it might melt Sid’s saran wrap. She shook her head. “I’m the newbie. I can’t help you with coding. I just do what they tell me.” She looked him in the eye. “If that’s what you’re looking for you’ll have to go somewhere else.” And she strode across the street. Sid finished the ham and cheese and did his four block loop that took just fifteen minutes.
It’s embarrassing when you don’t know what you’re looking for. Hunting mastodons, you look for their brown fuzzy hump above the rise and you slow down and check the wind. But coding? Increased income? Improved quality? It’s such a mess. He kept seeing patients.
But a week or so later he had gotten a coroner call and there was Rhoda, in the alley, smoking again. He could have sprinted across to the Hilux, but he turned as she exhaled and flicked ash. “I really do want to talk to you.”
She smiled. “That’s better.”
Sid ran across and did the dead body. When he came back there was no Rhoda in the alley, just ten more patients to see and code to end his day.
He did some research. It seems the coding part of medical care was a big deal. There were software programs that would up code for you, and there were companies who would code for you and there were venture capital companies buying up doctor’s practices to increase their profitability. He doubted any of this would come to small town Paradise. But he also came across a study of the “coding experts” like Paul had contracted to send their charts to for review. The study found only 60% agreement between them when they looked at identical chart notes. So much for experts.
Maybe this mess was all based on the American medical system’s commitment to paying medical services only for what they did. This had been long embraced by doctors. The socialist concept of paying doctors a flat salary for their services had been fought by the AMA. No, doctors were not fungible. And since we have successfully kept our services dear, we should be funging the payments. Sid felt the skepticism growing in him. He knew family docs like him were on the low end of the IV pole. Code payments were driven by Medicare, and specialists drove these negotiations. And the AMA was complicit. Sid knew that family docs, generalists got paid less because there were 60 specialties on the committee and only 5 primary care representatives. He was getting an idea about the US Senate.
Sid felt some pride that he hadn’t paid any dues to the AMA for years. Then a niggling thought came, shouldn’t he try to change this bullshit? Shouldn’t he get on the inside? Shouldn’t he go to work to slay the monster instead of hanging back and carrying the spears for the others? But this game was so big. It was so big, and he was so small.
Sid finished with his patients and did the dictation, the charting, the document reviews, the prior authorization forms, and he headed out to his family.
Rhoda was ahead of him in the hall. “Hey Rhoda.”
Sid gave her a ride home. It was a dismal duplex over where he’d lived when he and Martha had first come to town. Rhoda’s car was at the shop. “Thanks doc. Maybe next time.” Her brassy laugh didn’t echo off anything. He saw her profile as she turned. He didn’t remember his cursory examination of her young breasts for cancer, like there might be any. At least that’s what he had coded for when he saw her as a patient back when. Sid didn’t remember such. He had trained his mind to put everything, all the naughty bits at least, into little Tupperware containers in his mind, only to be brought out when the right guest was in the room. But she was pretty.
Sid drove home feeling lost. He didn’t know if there was any help. This coding thing was driving him crazy. But there was the family.
The next day a young man seemed to be very interested in the new electronic medical record Sid was still trying to figure out. The young man did not have chlamydia, though Sid wasn’t sure the nerd had ever had sex. He wouldn’t share his sexual history, just his worry about a “discharge”. Sid suspected a nocturnal emission was mistaken for an STI symptom that the guy had Googled. Sid tried to explain that a good history could save a lot of money and testing, but the nerd would have none of it. So, Sid swabbed and ordered the test.
“Does that program code for you?”
Sid stared at him as he removed the gloves. “No, it doesn’t. We didn’t want that feature.”
The nerd’s head bobbed. “So how long till I get the results?”
“Can you wait 15 minutes?”
“So, you guys do PCR?” Sid was wondering just who the hell this guy was. A “mystery patient” from some insurance company? Or just a really truly health care tech nerd. “You can wait in here or out in the waiting room. Your choice.”
“I’m fine here.” Sid carefully logged out and locked the screen.
He got through two more 99212’s (simple visit codes) before the test results came back. He told the young man the negative results as he sat absently in the chair.
“So hey, if you guys want help with the programming or a patch for coding, I think I could make you some money. I know the language these guys use.” He nodded at the dark computer terminal.
Sid walked him out.
But a chance meeting in the hall with Paul, the highly paid administrator occurred. “This guy said he could augment our program and add in coding, make us some money.”
Paul looked downward, like Sid had offered to sell him his first born. “Sorry, we’ll have to do it the legit way, through the contractor.”
Sid shrugged. Paul sighed with no smile. “If we hack in now, we’ll be on our own. They’ve got us by the balls. We buy their package, so we have to stick with what we got. There’re a million hackers out there who can do this. I get their emails every day. The next Medicare audit would be a nightmare.” Paul shuffled off. Sid had gotten a glimpse. It wasn’t big mammals they were hunting. But it was big money, at least from this small-town perspective. He really didn’t think it should all be his. But just some of it, what he deserved.
Sid felt pretty good about his afternoon patients. He might have helped a couple and hadn’t really pissed any off, so that’s good. And he got out in time to pick the kids up from swim practice and have a family dinner.
“How was your day, Dad?” His youngest asked. She was nearing middle school, but not there yet, maybe fourth grade?
“Just fine.”
She dipped her soup and mumbled toward the table. “How the hell can a person go to work in the morning and come home in the evening and have nothing to say.”
“What?”
She looked at him. “It’s just a John Prine song.” And she smiled.
And Sid was devastated.
This shit was just too much. He finished and went out to the garage.
There was just a mess on the tool bench. Nothing to fix, no project waiting, just a mess to clean up. And it was cold.
He threw some odd screws in the trash and wiped off the table saw. Maybe the problem wasn’t the coding. Maybe he just didn’t like being a doctor. But he’d enjoyed his time with patients that afternoon. He loved it when he could help folks, maybe make a difference in their lives. Why couldn’t he share that at the table? He had come home in the evening with nothing to say.
What was weighing him down? Should he just go fix hay balers, his alternate career path? But he was pretty comfortable. He just knew it could be better. He looked around his cluttered garage and knew it could be better too. Maybe he should change the oil in the old motorcycle.
He had learned to awake quickly when the beeper buzzed, or the bedside phone rang. He could get the call go in and do the delivery, come back, and Martha wouldn’t even know in the morning. So, he picked up the receiver and said softly, “This is Doctor Hawthorne.”
The brassy voice was unmistakable. “Doc, I need your help. Can you bring gloves?”
Martha hadn’t noticed. She slept soundly. Sid was up and having breakfast as the kids scrambled about. Martha guided them and the middle schoolers got in his Hilux and the littler ones headed down the hill. He dropped the older two off three blocks from the school so no one would see the rusty shame. He looked carefully for footprints or trampled cars, but all was in order. Then he headed south into his daily grind.
“Hey Doc, I owe you.” She had said as he left. He’d skinned the gloves into the kitchen garbage can. “Do you want me to up code your visits this month?”
Sid looked at her in the loose robe. The boyfriend was in the bedroom. They had the lube, but he’d brought the gloves. It hadn’t been easy, the retrieval. But the years of delivering babies had taught him the importance of positioning. He hadn’t once thought about how this could be coded.
“No, you don’t need to do that.”
The brassy laugh burst out. “Hey doc, you deserve it. You can’t code for what you just did.”
Sid laughed too. And he left.
The dark street led to the Hilux but for some reason he looked up. He saw furry backs moving beyond the treetops. They were headed south toward the hospital and his clinic. But they just moved quietly above the dark leaves. He heard no cracks or crushed things as the massive bodies moved. They were silent, but really big.
After he dropped off the kids and turned south, he started to look for footprints or signs of the moving herd. He saw none. Traffic was light. He worked his way down to the doctors parking lot where his rusty Hilux was notable. Sid smiled as he thought of his stain on this herd of shiny high dollar cars.
He could have turned down Sixth, but there was a light at the bottom, so he cut across Monroe to drop right down to the doctor’s lot. In the middle of the street on the steep side hill has a mound. He knew the Hilux wouldn’t clear it and he could put one wheel on it, but maybe it was too solid, so he stopped. Sid set the brake and got out. He checked and the little rusty Toyota didn’t roll so he trusted it.
The mound was still steaming. He touched it with his work shoes. It was bigger than his spare tire. Shit on the way to work. Big shit.
He drove over it and headed down to the lot. Work to do.
