A Continued Attack on Physicians?

  • by: |
  • 10/19/2012
An emergency room physician offers his perspective on the supposed problem of upcoding:

This is where it gets interesting. The feds and some consumer watchdogs view this trend as clear evidence of fraud and abuse, that the physicians are “upcoding” the visit levels to increase their income. On the other hand, I’ve spent the last decade trying to educate physicians on how to document the patient encounter so that you can accurately capture the legitimate value of the service provided. So I look at that trend and think to myself “Job well done.”

From the perspective of a practicing physician, the rules that govern the documentation required to capture a service level are deliberately onerous and designed to produce downcodes. They require the doc to collect far more data than is actually necessary based on the actual condition of the patient. You forget to check one box, you leave out one required element, and despite the complexity, gravity and risk of a patient’s condition, you will not be paid for the service. For years, we have been losing money to these archaic rules (they date from 1995), and we have been struggling to stem the leakage of revenue from our practices.

The industry responded to these rules by developing tools to comply with them. The first thing was to have professional coders. Prior to 2000, a substantial majority of ER charts were hand-coded by the physician; now that is quite rare. Then we got templated paper records which prompted the docs to get all the required data points. Now we have EMRs which do the same thing more efficiently. It’s no surprise that as an industry we have gotten better at meeting the guidelines.

And then there is the fact that the ER is a different place than it was in 2000. Our patients are older and sicker. We do more in the ER than was true in the past. Patients are rarely directly admitted any more, but rather get the majority of their admitting workup done in the ER. I don’t know how much of the skew in the above graph is due to these factors, but they shouldn’t be disregarded.

But I don’t like where this is going. The government is desperate, understandably, to save money on healthcare expenditures. They seem to have assumed their conclusion that the increased coding levels is fraudulent and unjustified, and there seem to be few voices disagreeing with them. Furthermore, there is some inappropriate upcoding, and it’s very easy for a patient with an egregious bill or a certain physician (or group) who pushed the envelope too far to be held up as anecdotal proof that doctors are all a bunch of thieves.

Read the full piece here.


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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