Have some extra cash you’d like to send to the government?

No it isn’t tax time. But failing to follow Medicare rules when submitting claims could result in a paycheck for Uncle Sam. In fact, you could have to return money that you’ve already collected from the government. I know three practices that have done that this year, and all for the same reason. What was the reason? Billing for student services. What kind of students? Nurse practitioner and physician assistant students. Students are not licensed and enrolled in Medicare or in any other third-party insurance company and you may not bill for their services.

 Some groups think that if the supervising mid-level provider countersigns the note, or indicates that they saw the patient as well and agreed with the student’s assessment and plan, that they can bill a service under the supervisor’s provider number. Nothing could be farther from the truth. Student services are never billable. It doesn’t matter if the student is a medical student, a PA or NP student, or a physical therapy student or the smartest, brightest, most promising student in the world. You cannot bill for their services.

 But groups want to have students involved in the care of their patients. As a service, they like to take a PA student or an NP student to give those students practice experience. If they do this, only the service provided and documented by the licensed mid-level provider may be reported. A student may document what a staff member may document, which is the review of systems and the past medical, family and social history as long as there’s evidence that the billing provider reviewed this. Most practices want the student to have a fuller experience. I agree with this. Allow the student to see the patient and document the service. However, the supervising clinician must see the patient, examine the patient and document the work performed. When submitting a claim for this service, base the claim only on the work done by the licensed professional and the note documented by that professional.

 Student services are never billable. Unless you want unless you want to send money back to Uncle Sam, don’t make this mistake.

The ICD-10 Emperor Has no Clothes

Previously published on kevinmd.com

The howling about the delay of ICD-10 was loud and fierce. It seems the quality of healthcare in the United States depends on our ability to use 68,000 diagnosis codes. The rest of the world has switched to ICD-10, and we alone insist on using an outdated coding system. Here’s a secret. The World Health Organization’s version of ICD-10 has about 16,000 codes, equivalent to ICD-9-CM. The rest of the world is not using ICD-10-Clinical Modification set, which has 68,000 codes. Only we, in the US, are considering that. The Canadian version of ICD-10 has about 16,000 codes, but the physicians do not use those codes for billing and reimbursement. They use a more limited code set of about 600 three-digit codes. Let me repeat this: the WHO version of ICD-10 that the rest of the world uses: about 16,000 codes. Our version, developed jointly by the CDC and the American Hospital Association has 68,000 codes.

 ICD-10-CM is going is going to add significant cost and complexity to physician practices without any benefit to the patient or physician. Perhaps facilities or payers need this level of detail, but we on the medical practice side do not. Selecting an ICD-10 code in an electronic health record will add 1-3 minutes to each patient encounter. Is that a reasonable use of physician time? If your mother or child is in the exam room, wouldn’t you prefer that the doctor spent that time with your family member, or you?

 For years, I listened to the experts say that we needed greater granularity and detail in our diagnosis coding. The transition from ICD-9-CM to ICD-10-CM increases the number of diagnosis codes from about 14,000 to 68,000. That is significant additional granularity. But, when I studied ICD-10-CM in order to teach it to physicians and coders, I realized the ICD-10 Emperor has no clothes.

 My objections to ICD-10-CM are that it includes needless specificity, absurd adherence to taxonomy, unnecessary detail about injuries and insufficient additional information about chronic illnesses to justify its use.

 In ICD-9, there are about a dozen codes for acute or chronic conjunctivitis. There are about 50 in ICD-10. Here are four: unspecified chronic conjunctivitis, right eye, unspecified chronic conjunctivitis, left eye, unspecified chronic conjunctivitis bilateral eyes, unspecified chronic conjunctivitis, unspecified eye.

 Coding for gout explodes from about a dozen codes in ICD-9 to over 150 codes for gout in ICD-10-CM, differentiating chronic gout, lead induced chronic gout, drug induced chronic gout, chronic gout due to renal failure, other secondary chronic gout, acute idiopathic gout, acute lead induced gout, drug induced chronic gout, chronic gout due to renal impairment, and other secondary chronic gout. Each is reported by joint and acute gout by with or without tophus. Idiopathic gout right knee, idiopathic gout left knee, idiopathic gout unspecified knee. Or, chronic gout, unspecified. You don’t believe me do you? Get out your ICD-10-CM book and compare the codes using the search function on the WHO website for ICD-10. http://apps.who.int/classifications/icd10/browse/2010/en

 Of the 68,000 codes over half are for injuries and accidents. Is it a laceration with or without a foreign body, which side, initial or subsequent encounter? Is the fracture at the upper or lower end of the ulna? What type of fracture is it? The mainstream media focused on the external cause codes “struck by a parrot.” But, these external cause codes are the least of our worries as we attempt to use ICD-10-CM in medical practices. And, I assure you, “struck by a parrot” is not in the WHO ICD-10 code set.

 Now I’m sure that in response to this post you will show me the chronic care codes that have increased specificity and provide additional information for physicians health systems and payers. I know they exist. Great, let’s use a version that includes those codes without all of the other detail.

 If Stark was the full employment act for lawyers, and HIPAA was the full employment act for consultants, then ICD-10 is the full employment act for coders. Much of the outrage against ICD-10 came from my fellow coders and consultants. I am sure that some of them have a deep-seated belief that ICD-10 is better. And, coding is the job coders have selected to do, and coding in ICD-10-CM is a fun, interesting activity for coders. Not so much for physicians.

 In the 1986 movie, “Star Trek IV the Voyage Home” Dr. McCoy says, “the bureaucratic mind set is the only constant in the universe.” You remember the scene don’t you? Our heroes are in a shuttle…. well, maybe you don’t remember the scene. Dr. McCoy wasn’t talking about ICD-10-CM, but we can imagine his reaction to it. “Dammit Jim, I’m a doctor not a coder.” But, in medical practices today, the physician typically selects the CPT code and the diagnosis codes that were the reason to provide the service and the diagnosis code that is the indication to order tests. ICD-10-CM will do little more than increase the bureaucratic side of physicians’ lives at the expense of their being doctors.