394 years ago today, William Shakespeare, the man whose works continue to be the high points of narrative drama written in the English language, died in his home in Stratford-on-Avon just a few days before his 52nd birthday.

I have a sense of humor that leans heavily to the dark side, so when I think of favorite scenes from Shakespeare’s plays, my favorite among all of his scenes is towards the end of Julius Caesar, when the angry mob surrounds, attacks and kills Cinna the Poet in a case of mistaken identity with one of Caesar’s assassins who shares his name. I can imagine the Monty Python comedy troupe having a field day with this scene on a strictly absurdist level.  

There may be nothing worse in this world on an individual human level than being accused of something you simply didn’t do and feeling as if you have absolutely no recourse to defend yourself except to exclaim your innocence.  With this thought in mind, I find this to be a perfect opportunity to speak to the physician community about CMS’ expanded audit guidelines that are part of the Patient Protection and Affordable Care Act (PPACA).

I made a passing mention in a previous post about the expansion of recovery audit contractors (RAC’s) to the state level for Medicaid plans, in addition to expanding the focus of audit for the four national RAC’s already in place. It is important to internalize what this means on the individual physician level, namely that there are more sets of eyes on your practice than ever before.

While the worst of those committing fraud against the Medicare program or other insurances tend to rise to the top and get skimmed off quickly, it is my belief that the majority of physicians believe strongly that the services for which they are billing are commensurate with the actual services performed on behalf of the patient. Yet all the belief in the world will not help you if the documentation prepared in support of those billed services is lacking.

I’ve spoken before about the importance of reviewing documentation for E/M services. Perhaps it is also a good time to look at the documentation of the procedures you perform, both within the office and in other locations. Are your notes a complete picture of the procedure performed from beginning to end? If the procedure is so extensive as to require an assistant at surgery, does the operative report include documentation of the necessity of the assistant? Is the documentation signed, keeping in mind that any op report can be rejected due to a lack of signature under CMS’ new signature requirements? If the procedure note is handwritten, is it legible?

The same thing applies to medical tests and diagnostic services. Does the documentation currently in the patient’s file represent a 1:1 comparison with the services billed? If you are billing for interpretation and reporting, is your report documented?

When physicians hear the word “fraud”, a defense mechanism is usually triggered from their perspective that believes with every fiber of their being, much like Cinna the Poet, they are being accused of something they didn’t do. If you performed a service, fully document that service and go forward secure in the knowledge that you have evidence of every service performed on behalf of your patients and their welfare.

As delicately as I can, I’ll explain it to you this way: Cinna the Poet lacked documentation of who he was and what he did. How did that work out?

UPDATE (2/26/2010, 4:23 PM EST): Since my creation of the following post this morning, it has been learned that the Senate has adjourned for the weekend and will not be passing the temporary reduction freeze in time for the Monday deadline.   

The latest temporary measure was to be attached to another measure granting an extension of unemployment benefits for 12 million people whose benefits have run out. Jim Bunning, the senior senator from Kentucky currently in his final term, filibustered the bill based on the bill either not having equal cuts in spending to pay for itself or because the funds for the bills would not come from leftover money from an earlier stimulus package. The Democratic majority was unable and/or unwilling to break the filibuster, and the Senate has now adjourned until Monday. 

CMS has since issued a press release that states that they are instructing the MAC’s to place a hold on claims for the first 10 business days in March. It is believed that this will provide ample time for Congress to issue another temporary payment fix.  

It was 104 years ago today that my grandmother was born in the western suburbs of Philadelphia. Some of the only positive memories I hold of my childhood stem from the time I spent with my grandmother in her kitchen. She had a breakfast table in her kitchen that looked out upon her back yard. Just beyond her backyard was the Route 100 line, that sent trolley cars from 69th Street in Philadelphia to their final destination to the west, in Norristown, with many stops in between. It was easy to get lost in the great potential the world offers a small child standing in her backyard on a sunny day, with the subtlest hint of clouds in the sky and the clickety-clack of the trolley passing every 15 minutes. 

My grandmother left this world in April of 1994, In the nearly 16 years since, the memories I’ve carried with me of the time I spent by her side reappear at strange times. It could be the sound of a distant train or the smell of her veal recipe that I still make for my wife and son from time to time. Yet when her memory comes forward, after remembering a funny story or a brief glimmer of a moment in past time when the two of us occupied the same space, the very last thing I feel when such memories arise is loss, and the change in my life that losing this one person brought forward. One can only dance inside their head for an instant before the reality of subtraction appears before them. 

Which brings me to today’s urgent topic. Over the past 6 weeks, the medical community has watched with a combination of anger and exhaustion as Congress has failed to definitively act on the issue of the 21.3% decrease in Medicare payments set to take effect this coming Monday. As I type this, yet another piece of legislation has been introduced to delay the pay cut until March 28th, which would create yet another window of opportunity to create a permanent solution to this annual occurrence. 

As I described in an earlier post on this topic, we have become desensitized to this process, as a white knight with long flowing hair, cleverly disguised as the latest legislative stay of execution, has until now always arrived in the twilight moments of the latest deadline. With the two days between now and March 1st falling on a weekend, the possibility exists that perhaps this is the time when the knight has either fallen asleep or found other worlds to save. 

While it is certainly within the realm of possibility based on past precedent that a temporary pay fix will pass before the Monday deadline, the sobering reality still exists that no fix may be coming. A question immediately appears in my head, wondering how many physicians have truly prepared themselves for this darker eventuality. If someone in this industry takes a moment to imagine the medical delivery landscape in a world where 21% of the largest payer’s receivables suddenly disappear like water vapor, it is more than likely a post-apocalyptic vision. 

Lou Reed, with a mix of poetry and a New Yorker’s gift for blunt assessment, once wrote “There’s a bit of magic in everything/and then some loss to even things out”.  The healthcare system now finds itself facing an unwelcome loss, while once again hoping for the annual act of prestidigitation that makes a pay cut disappear right in front of your eyes. While those of us involved in the industry can do all we can in the next few days by inundating Congress with faxes and telephone calls demanding a remedy to this situation, be mindful of what this change actually means to our system. Without that awareness, the reimbursement realities of today could become the memories and sense of loss of Monday.

In my spare time, I’m a sucker for black and white slapstick comedy. If challenged, I could probably recite every line and verbally recreate every scene from the Marx Brothers’ 1933 comedy classic Duck Soup, complete with Harpo’s pantomimes and horn honks. I also do a mean imitation of Curly Howard of the Three Stooges running on his side if prodded, just not right now.

What makes slapstick comedy gratifying is the belief that it exists strictly in the realm of entertainment. In real life, we tend not to see pie fights at society parties, wars won because the leader of the enemy country is being pelted into submission with fruit or adults getting hit square in the face while playing dodgeball. We tend to think that institutions can’t descend into complete and utter chaos due to one bad decision, yet the process looks really easy to accomplish with the right script, the right actors and a skill for setting up a humorous situation.

In the absence of an abundance of banana peals and squirt bottles full of seltzer water, the closest parallel we have to slapstick comedy in our daily lives is the decision-making process of our federal government, particularly in relation to its unctuous administrative giveaways to large American businesses. As an illustrative example, I present Palmetto GBA, which in the past two years has quickly risen to the top of the list as a California physician’s least favorite wholly owned subsidiary of Blue Cross & Blue Shield of South Carolina.

During the last presidential administration, someone in government decided that it would be a wonderful idea to take the assignment of Medicare contractors for some states and shift them to other contractors. As part of that decision, Palmetto GBA, who until 2008 had been responsible for some of the smaller states in this country, was given oversight of the state of California, which by itself is the 7th largest economy in the world. Simultaneously, the decision was made to move every provider to a National Provider Identifier (NPI). 

What was planned was a smooth transition from one carrier to another with an accompanying, long-awaited transition to a single provider ID number. What resulted in mid-2008 was comparable to Lucy and Ethel at the candy factory, with too little staff assigned to too big a task. This would be the perfect situation for high comedy were it not for the fact that it sent tens of thousands of medical practices in America’s largest state to the brink of bankruptcy due to long-delayed NPI enrollment applications and lack of staff to answer basic questions leading to resolution.

In the fall of 2008, a flurry of press releases emanated from Palmetto GBA in typical corporate style stating that the problems were being addressed, additional staff was being added post-transition and that everything was going to suddenly metamorphose into a fantasy land of fairies, elves, candy buttons, marshmallow clouds and rivers of pure chocolate.  In the roughly 18 months since, it can be successfully argued that the same problems still exist, only instead of NPI, Palmetto GBA has now demonstrated their lack of readiness a second time with their approach to the PECOS/referring physician database issue.

As an illustrative example, one of our California providers, was having a problem with his Provider Transaction Account Number (PTAN). When our credentialing specialist contacted Palmetto GBA, the person answering the phone stated that the physician did not have an individual PTAN. It was shortly after this that the physician received a letter stating that the same supposedly non-existing individual PTAN was being deactivated. Further investigation revealed that this stemmed from a suite number in the correspondence address being entered incorrectly in Palmetto’s system, which in turn caused a conflict with the PECOS system, hence the threatened deactivation.

Mercifully, CMS has now delayed Phase II of the PECOS project until January 3, 2011, which gives Palmetto GBA roughly 10 months to discover another integral process for which they lack either competent staff or updated information. The lesson of California’s painful transition is still playing out, as the last 14 states in the five jurisdictions yet to go through administrative carrier transition are being delayed due to protests being lodged with CMS. This affects the four additional states that will be under Palmetto GBA after final transition. Spare a little pity for the provider communities in the Carolinas, Virginia and West Virginia after all is said and done.

All of this provides an abject lesson in governmental process. It is hoped in the future that legislative changes with profound financial side effects will more resemble a workable, functional business model rather than a 3-dimensional tribute to Larry, Moe and Curly.

Chalk this posting up to exhaustion.

It turns out that the annoying cough I’ve been fighting for the last week is actually bronchitis. For this, my urgent care physician prescribed a Z-Pack and $50 cough syrup that makes you drowsy. To spare the reader, I skipped the cough syrup for this post, as it’s a fine line between an industry blog posting and William Burroughs’ Naked Lunch. I’ll be brief, and hopefully effective.

Two updates of note came to light this week. First, on January 4th, Medicare was to implement a rule clarifying date of service and place of service rules for interpretation of diagnostic tests. These rules stated that the date of service and place of service of the interpretation of diagnostic tests should be when and where the interpretation was performed, and not the date and place of the performance of the test. Thankfully, on February 5th, this new rule was postponed indefinitely due to mass provider confusion. The policy could be reviewed at a later date for future implementation.

The second update follows up on my last posting here regarding the 2010 Medicare Physician Fee Schedule. Thanks to the snowstorms that pounded the East Coast this week, which led to a federal government

Being a person who renders opinion and advice regarding medical billing and coding issues, I have done my level best in this space to remain neutral as the political infighting continues in our nation’s capital with regard to health care reform in general, and physician reimbursement specifically. A glance at the calendar is changing my mind.

Today is February 5th, and being that this is the shortest month of the year (think of February as Tattoo and the calendar as Fantasy Island), I count that there are 23 days left until Medicare will begin instituting a 21.3% pay cut across the board for all physicians. Seeing as a cut of this magnitude immediately places countless medical providers is dire straits, and by extension our clinic-based medical infrastructure in jeopardy, one would think that this issue would be at the top of the list for a country that embraced “promote the general welfare” as a founding ideal of the nation. So it is with surprise that upon looking at the Congressional calendar for February that Congress is giving themselves a break for the entire week beginning February 15th. This drops the actual days to fix the problem to roughly 18, but anyone who has ever tortured themselves watching C-SPAN can tell you, U. S. Congressional work must be judged on quality of time spent, and not quantity.

Physicians are already taking a financial hit in 2010 with the Medicare’s elimination of reimbursement for consultation codes. As specialty organizations urgently lobby their members to contact Congress to issue a fix, Congress is snapping into action by taking 5 days off.

I spend my work days being a physician advocate. While it is not the place in life that I pictured for myself in my childhood, I think of myself as a very important part of our healthcare system as it is currently configured. Physicians spend 10+ years being trained to solve the myriad issues involved with the inner workings of the human body. We don’t contact a physician when we’re feeling great. A doctor is called when something is wrong. I object to this being  referred to as “A God complex” as so many do, as this is not a preordained royal imprimatur, but rather an outcropping of the decade or more of training necessary to understand and positively restore human beings to maximum function. I feel I owe it to a physician to take financial worries off the table and let them concentrate on what they have been trained to do.

I had five doctors in my family ranging across four different medical specialties. I find the scientific healing of the sick to be a fascinating world, not only for what is known about the human body, but what remains unknown as well. Had I been a better student (a FAR better student), it’s very possible that I could have ended up on the clinical side of health care rather than the administrative. As it is, my mind is geared more for appreciation of physicians rather than the occupation itself. Having said that, with the current insurance landscape, the work I and others on this side of the healthcare industry explore through on a daily basis (when exactly this became an “industry” rather than a noble trade, is long forgotten), from tracking down every possible dollar of reimbursement to helping design defensible documentation for medical services, takes on increased importance. None of us should gain any joy from knowing that our doctor is up in the middle of the night not solving the problems of a sick patient, but rather contemplating their financial future.

If you’ve been in this industry for any length of time, you become desensitized to the annual rite of Congress reversing a well-publicized physician payment cut. It is analogous to a long-term hostage-taking, where after a while being chained to an oil heater in a basement, being beaten and tortured and living on bread and water becomes a new standard by which to measure “normal”. If no one else is going to stand up and say it, I will. This latest deadline to end all deadlines isn’t business as usual, and it’s not something we should just get used to and coexist alongside, awaiting the usual temporary solution. It’s sick, it’s depraved and it has to stop.

The last seven days have brought forth an interesting mix of stimuli to me.

I attended a coding seminar in Las Vegas, flying out last Saturday and returning on a night flight on Tuesday. As the conference industry has expanded in Las Vegas, I’m always struck by the juxtaposition of professional conference attendees and degenerate gamblers on display in any casino in the city at any given time. After absorbing three days of industry knowledge in this environment, it slowly became harder to decide whether the constant ringing in my head was coming from the inundation of sudden knowledge or from the cornucopia of slot machines.

The cab ride home from the airport was interesting Tuesday night. Apparently, the addition of GPS in modern taxis has not increased the sense of direction of cab drivers at nearly a comparable level to skyrocketing cab fares. I had $12 in my pocket, and thanks to the circuitous route taken by the cab driver, the fare was up to $16 and I was still ten blocks from my house. Thankfully, ten blocks from my house is where my bank’s ATM is located. I took some money out, paid the driver begrudgingly for her impeccable navigational skills, and walked the last 10 blocks in 14-degree weather without a coat while carrying my bag. To all the muggers of the world, this is my way of telling you that you missed your chance for an easy mark. After 4 blocks of sub-Arctic marching, I could have been knocked out with a bouquet of Gerber daisies.

Over the last few days upon my arrival at home, I have been reading a biography of the band XTC, whose lead singer suffered a nervous breakdown from excessive touring. I briefly felt his pain in the hours after the walk home. As I read this story, my 3-year-old was pretending to be Batman, complete with cape. He does this by running back and forth between the kitchen and living room of my house. To finish out my week, I arrived at my desk this morning and was told it was time to relocate within the office, along with about 15 of my coworkers. I have gone from the spacious cubicle enjoyed while creating previous posts here to a work area that faces a blank wall. All I can think is “At last the bells finally stop ringing; where are my crayons?”.

In this week of over-stimulation, it seems a good time to look at the equally chaotic reimbursement landscape now that Medicare has ceased payment on consultation codes. Rather than panic, I’d like to suggest an alternate route for specialty physicians who now face a decline in revenue due to the elimination of these codes for Medicare billing. Rather than pining for payment opportunities that have disappeared for good, now is the perfect time to give a second look at the documentation you create for the E/M services that still exist.

I ask the physician who may be reading this to pull out one piece of documentation from a random patient they have seen today and look it over. Does the documentation give a useful, reimbursable and defensible narrative centered around the patient’s chief complaint? Is it a collection of sentences telling a story, or a morass of acronyms like “C/O”, “WNL” and “Ox3″? Could this documentation be better based on the code chosen? Conversely, could it have been reimbursed at a higher level had you correctly documented the service performed on behalf of the patient?

If physicians can look at the documentation for their E/M services and come to the conclusion that to the best of their ability, they have accurately captured the services performed in a narrative format, and that the clinical language of the chart has a direct correlation to the billing language chosen (the reported CPT code), the perception of the amount lost as a result of a consultation code not being available suddenly changes. While medical necessity remains the main driver in the selection of a CPT code, an opportunity may exist for financial stability with a simple review of a medical record. With consultations billed to Medicare now a thing of the past, there’s no time like like the present to take another look.