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Health Care Reform Everyone Can Love
A Simplified Approach to Medical Coding and Billing Matthew Hahn, MD
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Introduction Health care reform is divisive
Everyone agrees on the need to reduce administrative burdens Medical coding and billing: administrative simplification desperately needed
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Introduction The Costs
Billing and insurance-related administrative costs: fifteen percent of total health care spending Frustrations drive many physicians out of independent practice, or to leave medicine altogether
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Introduction Streamlined medical coding and billing:
Save billions in unnecessary expenditures Reduce waste and fraud Reduce physician burnout Keep doctors in private practice
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Getting Paid: Current System
An Incredible Amount of Work for a Small Amount of Money Pay for a typical Medicare patient appointment is $75 The work in collecting that amount is absurd The complexity and structure have profound negative consequences
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Getting Paid: Current System
Step #1: the diagnosis code(s) Use of an incorrect code = denied claim 68,000 ICD-10 codes: finding the correct code can be a challenge
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Getting Paid: Current System
Step #1: the diagnosis code(s) Rules vary from one insurance company to another
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Getting Paid: Current System
Step #1: the diagnosis code(s) Diagnosis not covered: senseless Diagnosis not determined until the end of the appointment, after the service (the appointment) takes place
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Getting Paid: Current System
Step #2: E&M code An estimate of the amount of work performed during an appointment Why do we need E&M codes? Many millions of medical appointments per year…billions $$$ Government wants to know what they are paying for
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Getting Paid: Current System
Step #2: E&M code How to estimate the work of a medical appointment? All doctors are taught the same standard format to document a medical encounter History of Present Illness = chief complaint (CC) + history of present illness (HPI) + review of systems (ROS) Physical Exam = organized by body system SOAP note = subjective, objective, assessment, plan The amount of work that takes place in a medical encounter should be reflected in the amount of documentation
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Getting Paid: Current System
Step #2: E&M code Calculated using complex three-part formula History Physical Exam Complexity of Medical Decision-Making THE PROBLEM: The E&M calculation is more complicated than the visit itself!!!
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Getting Paid: Current System
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Current System: Getting Paid
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Getting Paid: Current System
Step #2: E&M code 99213 pays $75 99214 pays $110
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Getting Paid: Current System
Step #2: E&M code The payment structure adds to the dysfunction 99213 pays $75 99214 pays $110
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Getting Paid: Current System
Complexity of coding systems: Creates need for new industry: coders and billing staff Increases overhead costs Drives doctors to see more and more patients Large payment differential between codes combined with increased overhead Creates obsession with obtaining the highest coded visits possible Up-coding: $11 billion over ten years Fraud: 2015 $1.9 billion Creates huge need for auditing/auditors
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Getting Paid: Current System
Step #2: E&M code Distracted doctor!!
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Getting Paid: Current System
BUT THAT’S NOT EVEN THE WORST OF IT!! Step #3: Billing The billing system is worse than all the rest
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Getting Paid: Current System
Step #3: Billing Co-pay(s) Deductible Primary Insurance Secondary Insurance Remaining portion
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A Better Way Simplify Coding and Eliminate Billing Altogether
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Legislative Ask: A Better Way
Simplify Coding and Eliminate Billing Altogether Step 1: Diagnosis codes Standardize rules throughout the entire medical system Eliminate diagnosis-related denials
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Legislative Ask: A Better Way
Simplify Coding and Eliminate Billing Altogether Step 2: E&M Codes Reduce five codes to two Simplify code definitions Reduce multiple code sets to just one
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Legislative Ask: A Better Way
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Legislative Ask: A Better Way
Simplify Coding and Eliminate Billing Altogether Step 3: Eliminate Billing Altogether Each insurance company issues a payment card, like an ATM card, and all payments are made at the time of service, eliminating billing entirely
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Streamlined medical coding and billing:
Save billions in unnecessary expenditures Reduce waste and fraud Remove a huge source of frustration, wasted time, and distraction for every physician Keep doctors in independent practices
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