A young PA had recently begun working in a busy emergency department, and although he was handling the medical aspect well, he was continuing to get flagged on documentation reports. This PA reviewed the reports and noticed that his documentation had cost his employer about $20,000 in lost charges that year. He began to sense pressure from his employer that if he did not improve his documentation, he might lose his job. One day while discussing a patient's case with his attending, she mentioned to him that because this patient had been admitted to the hospital, more in-depth documentation would be required in the chart. She said he would need to go back into the chart and "beef it up." As the PA turned back to his computer, he thought, "Well, I didn't exactly look inside this patient's ears as she had come in for a diabetic foot ulcer. What do I document?"
BACKGROUND
Many of us may have been in similar situations and have asked ourselves if billing our patients based on documentation really was the best approach. Our current system has evolved from when it began about 50 years ago, when the American Medical Association (AMA) put together Current Procedural Terminology (CPT) to standardize patient evaluation and management. Originally, no fee schedule was associated with this coding, and inevitably payments grew quite large. In the 1980s, the government set a fee schedule limiting physician reimbursement.1 In 1995, the Centers for Medicare and Medicaid Services (CMS), the federal agency that manages the Medicare program and is the largest and most important third-party payer, decided that payment would be determined primarily by documentation. CMS then created levels of service, which range from 1 to 5.2 CPT determines the final billing level by the sum of three major components, which are composed of seven subcomponents.3
Health information management (HIM) professionals code and classify medical data found in charts to determine billing levels. Their profession holds them to ethical standards to ensure that patients' health information is safe, documentation is accurate, and billing is appropriate. HIM professionals are expected to ask providers for clarification on conflicting, incomplete, or ambiguous information. They are also expected to identify and refuse to support or participate in practices that wrongly increase payment or distort records. Their goal is to make sure medical organizations receive the best payment to which they are legally entitled, keeping in mind that it is unethical and illegal to increase payment by misrepresenting the patient's clinical picture (that is, by intentional incorrect documentation or omission of diagnoses/procedures). Finally, they are expected to stand up against any dishonesty, fraud, or abuse. This includes identifying improper patterns of retrospective documentation to boost reimbursement or encouragement of documentation that does not justify the diagnoses.4
As health providers know, billing errors caused by poor documentation
may lead to costly audits and legal penalties. Both underbilling and overbilling are regarded as fraud by CMS. On top of that, underbilling can have considerable financial ramifications for the medical organization. As HIM coders are legally bound to what is documented, health care providers should understand the important part they play in the billing system. A study by Kapa and colleagues estimated that in a class of 48 residents, approximately $8,660.94 in underbilling occurred weekly.3 The study then postulated that if equal patterns of underbilling and overbilling occurred, the annual total of lost charges would be $450,368.64.3 This does not happen only during a provider's early years in practice, as audits of hospital services often reveal that physicians who may be good at selecting the level of service for office visits have a hard time when billing inpatient consultations. These physicians may pick a level 3 service, which is midrange in an office but the highest in the hospital.5 Horner and colleagues found that billing mistakes are frequent at the resident and faculty level.6 Kikano and colleagues performed a study of 84 family practices, and errors were most common for new patient visits. Underbilling and overbilling occurred at comparable rates.7
THE CURRENT SCENE
In an ideal world, everyone would abide by regulations and not act in ways to increase personal gain at another's expense. In the late 1980s, however, insurers began to suspect possible abuse of the system, especially because third-party payers were not present during physician-patient visits. And now, 20 years later, the accusations continue. Doctors are blamed for increasing costs and exploiting the system by overcharging for their work.1 A US hospital can collect higher Medicare reimbursement by labeling slight chest discomfort as angina rather than chest pain. Improving efficiency or quality of documentation is more difficult than taking advantage of such loopholes.8 Any health care provider would probably agree that the time needed to achieve high-quality documentation is much greater than the time available.9 Columbia/HCA, the largest US hospital firm, paid the government $1.7 billion in settlements for fraud, the payment of kickbacks to physicians, and overbilling of Medicare. In March 2004, Tenet paid the government $22.5 million to settle one of numerous cases, some of which included allegations for performing cardiac procedures on healthy patients, offering kickbacks for referrals, and exploiting Medicare loopholes.8