Just a glimpse into the ICD-10 shows how to code the all-too-common problem of when people are injured on railway vehicles (which are not streetcars, mind you). I think it is fitting, when talking about ICD codes, to start with the area of train-wrecks...
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Adventures in Medicine
In the last post we saw how complicated the visit is from Dr. Ron's perspective, and how many things were working to pull him away from our hero, Chuck. So what about Chuck? What about his perspective? I ended the previous post with the statement: "All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn’t such a good idea. He just wants to make sure there’s nothing serious going on, and he wants to feel better." In other words, Chuck is interested in two main things:
What he wants to avoid is:
Please note that I could have used "dysesthesia" to keep with the "D's," but chose to speak English (a talent which many doctors lack).
Now, when Dr. Ron listens to the story of a patient like Chuck, there are three main tasks he focuses on:
- Ruling out serious problems (or assessing risk).
- Treating symptoms.
- Making a diagnosis.
He does this by listening to Chuck's story (his symptoms), looking for objective findings (via physical exam, labs, or other tests), and looking over Chuck's back-story (his past problems, symptoms, and risk factors).
From Chuck's vantage point, as long as Ron has ruled out bad stuff and makes his back feel better, he doesn't benefit from making a firm diagnosis. That's what Chuck thinks he's paying for (both from his wallet and from the precious moments of his life wasted in the waiting room). But here's where things start to get complicated: Ron doesn't actually get paid for the two things that Chuck wants the most (ruling out bad stuff and treating symptoms), instead he's paid for:
- Coming up with "diagnosis" (problem) codes to describe Chuck's situation.
- Coming up with "procedure" codes to describe what he did in the office.
- Doing his medical record in a way that "justifies" his codes to insurers (in case he's audited).
- Paying a bunch of staff to make sure this information is submitted exactly right, as any mistakes could result in denial of payment.
Ron's new fancy-schmancy computer record program is built to make sure all of the information needed to justify the charge is put in properly, and that the diagnosis codes and procedure codes are also properly entered so they can be electronically submitted to the insurance company. Ron likes the fact that it makes this easier, but it bothers him that so much of the note is just "packaging material" that obscures the most important part of the note to both doctor and patient: the plan.
To make matters worse, Ron has to find a code from the ICD-9 code list, which are specific codes that the insurers accept for treatment. This is sometimes hard, as the codes for common things (like weakness of the arms) are mysteriously missing, while codes for strange things (like being injured by a space ship) are on the list.
To "improve" this situation, the government is soon to introduce ICD-10, which will increase the number of codes by 500%, now including the important code for "burns incurred from flaming water skis" (it's about time).
Ron's EMR gets to these codes (relatively) easily because they are essential to be paid.
Additionally (and worrisome to Ron), the insurers are taking these diagnosis codes and problems on the list to measure the "quality" of Ron's care. Ron worries about this because payment is increasingly being linked to quality measures, and the folks doing the measuring are the ones doing the paying, which means they would benefit from measuring low. Another negative of having problems accumulating on lists is the all-inclusive nature of the lists, which include:
- Chronic disease (like diabetes, hypertension)
- Past events (heart attacks, cancer)
- Symptoms (back pain, fatigue)
- Risk factors (family history of heart disease, cancer)
- Abnormal test results (high cholesterol, low sodium, abnormal chest x-ray)
- Exam findings (heart murmurs, skin lesions)
- Minor problems (allergies, baldness)
- Acute problems (Viral infections, sinus infections)
This makes these lists grow quite large, which is often made worse if the acute problems are don't drop off of the list, which is often the case. Taking the time to clean up and organize records is something most doctor's offices don't have time to do.
What does this have to do with Chuck's Roomba-assisted back injury? Nothing good. Unfortunately, it makes Ron focus on the least important thing: the diagnosis (remember, Chuck really just wants to rule out bad things and feel better). It rewards doctors for finding problems and doing procedures to fix those problems. It also rewards Ron for putting things into the chart that makes it jumbled and confusing. Since Ron's pay is dependent on his documentation, he spends much of his time and energy putting information into the record, as Chuck sits and watches him type.
So, for the 10 minutes in the exam room together, the majority of time is spent inputting information and finding diagnosis codes. Ron feels bad about this, a feeling that tempts him to do what many doctors do: order x-rays, MRI scans, and prescribe medications for a simple back strain. But Ron knows that these do nothing useful for Chuck and just raise the cost. Ironically, Ron's decision to do the right thing makes Chuck wonder about how good of a doctor Ron is, as he leaves with nothing to show for his time and inconvenience other than a sympathetic look, instruction to take ibuprofen, and a back exercise sheet. It seems like a waste of time and money.
Ron agrees with this assessment, wishing that he was rewarded for doing the right thing, not penalized. Both Ron and Chuck leave the visit frustrated. Chuck goes home to plot against his cat, while Ron moves on to the next patient, hoping for something a little more satisfying.
To be continued....
So, Dr. Ron wants to play for Simon Powell on "Doctor Idol," and Chuck ("Chuck," I mean) wants to play for the Mud hens. What's wrong with that? Nothing, actually, aside from their total lack of athletic and musical talent. What's wrong is the part of the stories preceding these winsome wishes of our dear compadres.
1. The Interaction
Both doctor and patient imagined a simple interaction between doctor and patient, as they are the only two humans physically in the exam room. Unfortunately, there are many other in the doctor's office and exam room in a non-physical, but very real, sort of way.
The outer circle is comprised of the entities or tasks that are taking Dr. Ron's mind out of the exam room. These include:
- Insurance companies, with their complex rules (more to follow on this) of payment and ever shrinking payments.
- The government, with it's growing involvement in the office in areas of measurement, regulations, and (above all else) bureaucracy. Ron feels their ever-growing presence in the office each day.
- The huge amount of paperwork generated by both of these entities (and others).
- The media, with it's hype machine built to sell advertising, not truth.
- Denials of claims (and decreasing reimbursement), which lead to...
- The need for higher patient volume, putting Ron further behind and giving Chuck more time to enjoy his waiting room adventures.
- The Internet with its double-edged sword of information/misinformation, leading to patient confusion and decreased patient trust.
- Specialists, who Ron uses to help him manage problems on his patients, but who often don't send him any information about those visits, do procedures that Ron doesn't always agree with, and are paid 3-4 times more than him (mostly through contracts negotiated by physician groups led by specialists).
- Hospitals, who alternately treat Ron as royalty (to get his referrals and ancillary orders) or dog poo (because he doesn't generate direct revenue for them like the specialists do).
Sitting in the exam room between Chuck and Dr. Ron are things which are immediately on Ron's mind, distracting his attention away from Chuck and his back:
- The threat of malpractice - while this is not high for Ron, as a PCP, he knows he's always one exam room away from potential catastrophe. The presence of these distractions make it harder to give the focus needed to avoid missing something important.
- Financial pressures - either running the business itself (like Ron does) or cowing to the demands of the hospital overlords (as many other docs do) put finances at the center of the universe in the exam room. Are all the possible charges being entered on each patient? Is he spending too much time with them and therefore decreasing his overall volume?
- CPT/ICD codes - Ron sees this as a trap, with it's incredible complicatedness, always seeming to give payers an "out clause." Patients try to convince him to leave off a diagnosis, while billers want him to include the second digit after the decimal on every one. Ron wonders how digits after decimals became such an important thing in his life.
- E/M coding compliance - Like most doctors, Ron realizes two things:
- That he is paid for documentation, not care. Having a specific number of bullet points in the history, review of systems, exams, and documenting certain thought processes are the things auditors look for when evaluating the records. Ron is forced to either put in a huge amount of information to justify the visit, or to "down code," charging less for the visit than he deserves to avoid documenting diarrhea.
- That no matter how hard he tries, he is never 100% compliant with documentation requirements. This is the ticking time bomb PCP's face, as they realize that non-compliance with the impossibly complex documentation rules, in the eyes of hungry auditors has another name: fraud. Ron prays that no auditor with an agenda looks at his charts, as he knows that any doctor could be used as a public whipping-boy.
- HIPAA - While Ron likes the fact that HIPAA keeps prying relatives out of the chart, he worries that he will mistakenly talk to someone who is not authorized and get into trouble. More worrisome is the fear of electronic communication or patient records getting out of the office, giving authorities another chance to take him down in public for something he has little control of, let alone understanding of.
- Quality measures - while these seem to be a positive thing, to reward good doctors, Ron always feels that the real agenda is to go after the "bad" doctors. He's worried that because he doesn't get rid of complicated or non-compliant patients, he will be labeled as an "underperforming" doctor, and get on someone's "doctors to avoid" list. He also thinks it will be used as a reason to lower his payment.
- Meaningful Use - It seems like a classic "bait and switch," where doctors are lured into using computers with money, only to use the information gathered on him with those computers to increase his chance of being labelled as an "underperforming" doctor, or making the job easier for auditors to hit him with the charge of "fraud."
All of this surrounds Dr. Ron with a series of barriers that Chuck must unknowingly cross to do the seemingly simple task of telling the doctor what's wrong. All Chuck knows is that his back hurts and that perhaps buying the Roomba wasn't such a good idea. He just wants to make sure there's nothing serious going on, and he wants to feel better.
We'll address those issues in our next post...
In case you missed my last post (some may consider it a blessing, like missing the season premiere of "Jenny McCarthy, the science Gal"), this is the star of the show. His name is "Chuck."
Why, many may ask do I use "quotes" when I use the name "Chuck." To this, I respond, that it's a "secret." Maybe you should get a "life."
So when last we left Chuck, he was in the office of his "Primary Care Provider," Dr. Ron. Chuck fell over his cat and injured his back. He didn't think he had a problem that needed a doctor's attention, but when he went to the Internet for answers (which everyone does, in case you didn't know), he only got more confused (and a little scared). He needed advice from someone he trusts, and, despite the wait times and co-pays, he likes and trusts Dr. Ron.
So, being the good soldier within the patient brigade, Chuck takes the whole afternoon off and sets his mind toward the exciting prospect of the hours of excitement at Dr. Ron's office.
Despite the seeming reality TV scene in the waiting room, Chuck is happy to be in a place where he can get concrete answers to his questions and an end to his pain. For Chuck, as with most patients, the visit to the doctor should go like this:
Step 1: Chuck tells the doctor his problem. Doctor Ron listens and knows what is wrong.
Step 2: Doctor tells Chuck what is causes his problem and comes up with a solution.
Step 3: Problem gone, Chuck can once again pursue his dream of being center fielder for the Toledo Mud Hens, and Dr. Ron is thrilled to be part of his success.
Not to be outdone in the expectations department, Dr. Ron expects the visit to happen like this:
1. Patient has questions and problems which Dr. Ron answers and solves (respectively).
3. Successful in medicine, Ron turns to his hidden fantasy: to compete on (and win) the popular "Doctor Idol" TV show. His patients are proud of him.
So what's wrong with these pictures (besides obvious anatomical inconsistencies, such as the regular disappearance of noses)?
While hard at work at building a new practice and (in the eyes of some) on my insanely misguided effort to build a medical record, I've been thinking. Dangerous thing to do, you know. It can lead to scary things like ideas, creativity, and change. I know, I should be satisfied with the usual mental vacuum state, but I've found it a very hard habit to kick. Perhaps there's a 12-step group for folks with ideas they can't suppress. Anyway, my thoughts have centered around explaining what I am doing with all of the my time and energy, and, more importantly, why I am doing all that stuff that keeps me from writing about important things like body odor, accordions, and toddlers with flame-throwers. I've really strayed from the good ol' days, haven't I? The problem is, I've grown so accustomed to my nerd persona that I end up giving explanations that are harder to understand. To combat this, I've decided to employ a technique I learned from my formative years: stories with pictures. My hope is that, through the use of my incredible drawing talent I will not only explain things faster (saving 1000 words per picture), but prevent my readers from falling, as they often do, into a confused slumber.
So, here goes.
Adventures in Health Care: Part 1 - The Participants
This is a patient. Let's call him "Chuck." Chuck is not really a "patient," he's a person. Many doctors believe that people like Chuck don't exist outside of their role as "patients," but this has been proven false (thanks to the tireless work of Oprah and ePatient Dave). But since this story is about Chuck's wacky adventures in health care, we will mainly think of Chuck in his role of "patient."
Why are people like Chuck called "patients?" Some people think it's to put them in their necessary subservient place in the system. I think it's just to be ironic.
Chuck is a generally healthy guy, but occasionally he does get sick. He also worries about getting sick in the future, and want's to keep himself as healthy as possible. This is when he uses the health care system, and when he is forced to be "patient."
This is Chuck's Family. It's the main reason he wants to stay healthy and avoid being a "patient." He has a lovely wife, two adorable children, and a cat that likes to ride around the house on a Roomba. I suspect you've heard about the cat; he's gotten pretty famous. Chuck's family wants him to stay around for a long time so he can pay bills, share his expert opinion on whether an outfit makes his wife's butt look fat, lecture the kids about the dangers of drugs and Cartoon Network, and answer his cat's voluminous fan mail. He would also like to live to be able to see his grandchildren (although he's not sure his kids will survive that long).
This is Chuck's doctor, Dr. Ron. Dr. Ron is a "primary care provider," or PCP. Ron never particularly liked being called a "provider," but the peer pressure from the insurance companies and the other "cooler" doctors (specialists) have made Ron accept this name without thinking any more. Primary care doctors are also called "generalists," but are known to hospital administrators, insurance company barons, and the "cool" specialists as:
- Referral sources
- The ones to blame
- Cannon fodder for insurance contracts
- The guys who can't afford the cars we drive.
Like most primary care doctors, Ron is very, very busy. He doesn't feel like he's got much of a choice, as it's the only way he can make enough to pay his student loans and still have enough for his loan on his Kia. This causes the following deadly consequences:
- Spending all day seeing patients in the office gives him little time for anything else.
- He doesn't answer questions over the phone, instead making patients come in for anything that takes more than three words to answer.
- This makes his office visit workload even heavier, and makes the average visit be about less "exciting" problems.
- Ron then wonders why his patients come to him for such small problems.
Last week, Chuck hurt his back (while trying to avoid his cat) and wasn't sure what to do about it. He didn't initially go to the doctor, but did what most people do when they have a question: checked the Internet. He doesn't like doing this, though, as it usually confuses him more. Besides, he's heard that doctors get mad if you look things up on the Internet.
He gave up trying to find answers on his own, called Dr. Ron's office, and was set-up with an appointment. This meant that he had to take time off of work, wait in the office for a long time, and then fit all of his questions into the brief time Dr. Ron is in the exam room and not focused on documentation. This usually is about 30 seconds. But this is what Chuck, and everyone else in the country is used to, so Chuck puts up with the inconvenience this causes, dutifully paying his copay for those precious 30 seconds of attention.
In truth, Dr. Ron is not too happy with this arrangement. He went into medicine because he thought it would be cool to help people, have awesome knowledge nobody else knew, and to make his mom proud. He likes taking care of people, but is finding less and less of what he went into medicine for. Each year it seems like he spends less time with his patients, and more time with his computer.
This got much worse in the past few years as the government decided all doctors should be using computers in a “meaningful and useful” way. Unfortunately, “meaningful” and “useful are defined by the government, not doctors and patients, and Ron is not quite sure if the government wasn't just being ironic when they decided on these definitions.
Despite the difficulties, Chuck likes Dr. Ron, who seems to spend more time with him and listen to his problems more than other doctors he’s had. A few times Dr. Ron spent a whopping 5 minutes talking with Chuck and answering his questions. This made Chuck feel a bit guilty, as Dr. Ron seemed pretty tired and stressed out.
(To Be Continued....)