Clever title...but I have yet to decode coding.
I had a woman come in my office a few weeks ago with some small lumps under her skin on her arm. To get paid for this, I had to code the problem. Fortunately for me, I have an EMR and can immediately look up the code for the problem at hand. This works just fine when it is a common problem or symptom, such as shortness of breath, chest pain, foot pain, or migraine headache. Do you think I found a code for "little hard nodules under the skin on the arm"?
Why did I have to code this? Coding is how doctors get paid. Finding the proper code allows me to bill for fact that I addressed that problem in the visit. Improperly coded problems will be rejected by the payers, so I don't get paid for my work. I can do a wonderful job with my patient in the room, document perfectly, but the wrong code will result in an automatic rejection. So what do I do when the problem is like the one this lady had? I get as close as possible - "Subcutaneous nodules, NOS" - "NOS" means Not Otherwise Stated, which means it is just playing the game correctly. It is total BS.
This may seem like a benign little problem - which it was in this case - but it can be very costly to doctors and patients. A man called our office furious because one of our physicians did a physical on him and ordered a lipid profile, PSA, and blood sugar, but the insurer would not pay for these lab tests. The problem? He used the code for "Well Adult Exam" (which is what he performed) instead of "Screening for Lipid Disorders," "Screening for Prostate Cancer," and "Screening for Diabetes." Resubmitted, these charges went through without problem.
Another patient called because the colonoscopy I ordered was not being covered (but applied to her deductible) because I used (correctly) the diagnosis code: "blood in stool." If, however, I changed the code to "Screening for colon cancer," the procedure was paid for 100%. She is 50 and had never had a colonoscopy and so was due for a screening test anyhow. But I had given her cards to check her stool for blood, which came back positive - a finding suggesting higher risk for colon cancer. I had followed the rules. Silly me.
To make matters worse, the numbers associated with the diagnoses (the ICD-9 Codes) are changed on a regular basis. This means that the Hypertension code (ICD-401) is no longer paid for, but the code ICD-401.0 is paid for. We generally find out about these through rejections by the insurers - the changes are too numerous for us to remember.
Here's another mystery: If I order a rapid strep test that comes back positive, I can't say the strep test was done for the diagnosis of Strep Throat (ICD-034.0) or it won't get paid for. If, however, I use the diagnosis of Pharyngitis (ICD-462) it is paid for. The "logic" of this is that if you know the patient has strep, why would you do a strep test? This makes no sense, because the only way we can make the diagnosis in our office is to do the test. This "logic" holds for EKG's, and Lab work done in the office. You cannot use the test results to justify the test itself.
A physician friend ordered a PSA mistakenly on a man under 40. The test came back positive, and the man did, in fact, have cancer. The insurance company refused to pay for the PSA test, but they did pay for the treatment of the cancer.
A last area of insanity comes into play in a common pediatric situation. Infants with fevers are often admitted to the hospital to "rule out sepsis." I certainly don't want to wait for sepsis to happen (bacteria in the blood causing life-threatening consequences) before I admit the child, so end up admitting many children who don't end up having sepsis (thankfully). I cannot admit the child with a diagnosis of fever, as this is not a hospital-worthy diagnosis in the eyes of the payers (although it actually is a great reason for admitting very young infants). I also cannot use the diagnosis "rule out sepsis" - which is the sole reason for admitting the child. If I'm lucky, one of the lab tests will come back abnormal enough (high white blood cell count, elevated CRP) that I can use the code for that abnormal lab finding. But banish the thought that all the labs are normal and I did the work-up. I should have known they would come back negative and not admitted the child in the first place.
There are many times when I suspect disease and don't find it. This is what good doctors do. But beware! If you do what is right, you still can get caught in the coding labyrinth and become hopelessly lost.
The cynical among us suspect that insurers are not rushing to fix this confusion. When we submit the wrong code due to confusion or just lunacy, it means they don't have to pay. It is our problem, not theirs. There is no financial motivation on their part to fix this problem.
It would be nice if doctors were paid for doing a good job. But being a good doctor is not enough; to get paid, you need to decode the codes. And to decode the codes, you have to learn the mysterious language of idiots.