When I see a patient at the office, I spend time developing trust, forming a therapeutic alliance, thinking through their physical complaints, examining them, and applying the best evidence to formulating a plan for maintaining their health. It's a lot of fun.
Less fun is the part where I try to get paid. To bill an insurance company, I must use numeric diagnostic codes that best fit what I'm seeing, and I must pick a code representing a level of service, that is, how hard I worked.
The diagnostic codes are referred to as ICD-9 codes, and the service codes are called E/M codes. Not all ICD-9 codes are easily billable. For example, if a patient comes to see me for anxiety or depression, I can't bill for it. I can bill for "malaise and fatigue" (780.7), but not for generalized anxiety disorder (300.02) (supposedly it's possible, but, like the Loch Ness monster, it's always a friend of a friend of a friend who saw it).
Once I've pigeon-holed a patient into a set of diagnoses for billing purposes, I'd better make sure that there is a diagnosis code to "match" with any tests I order, or the patient will get a big bill. If I think a blood count is necessary, but I forget to write "anemia" (285.9), the insurance company won't pay for it.
In determining how I'm allowed to bill for a visit, I have, for a returning patient, five choices: 99211-99215. The level is determined by the number of "elements" I document, or something like that. These five E/M codes are determined by my documentation. I must document a "chief complaint" as any physician should, and then...well then it gets tough. I make notes in a chart based on a standard format used by physicians for decades, but parsing out what code is born from it is difficult. In determining the code, I must consider three parts of my note: history, physical exam, and medical decision making (remember, it's flu season, and I've got a lot of patients waiting...).
Included in "history" are several items, including past medical problems, medications, and a "review of systems" in which a doctor must document having tried to obtain information on 14 separate organ system. It's not clear to most physicians how much needs to be present for a particular billing level.
Physical exam is easy though. Sort of. I mean, we all do them every day, but the coders divide exams into categories based on how many organ systems were examined. These levels range from problem-focused (one area examined) to comprehensive (9 organ systems examined).
Medical decision making takes into account how much thinking you had to do, how much data you had to review, and how much risk there was. How is this determined, and how do you combine these three elements to get a code?
This helpful tool should clear things up.
If I want to get paid for my work, then while seeing patients and making complex medical decisions, I have to look over what I've written and attempt to apply some sort of complicated and nonsensical flow sheet. If I choose wrongly, payment can be denied, or worse, I can be charged with fraud.
So why would anyone want to practice medicine in the States?
Any real health care reform has to address this insanity.