1. Health Care Reform Everyone Can Love
A Simplified Approach to Medical Coding and Billing
Matthew Hahn, MD

2. Introduction Health care reform is divisive
Everyone agrees on the need to reduce administrative burdens
Medical coding and billing: administrative simplification desperately needed

3. 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

4. Introduction Streamlined medical coding and billing:
Save billions in unnecessary expenditures
Reduce waste and fraud
Reduce physician burnout
Keep doctors in private practice

5. 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

6. 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

7. Getting Paid: Current System
Step #1: the diagnosis code(s)
Rules vary from one insurance company to another

8. 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

9. 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

10. 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

11. 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!!!

12. Getting Paid: Current System

13. Current System: Getting Paid

14. Getting Paid: Current System
Step #2: E&M code
99213 pays $75
99214 pays $110

15. Getting Paid: Current System
Step #2: E&M code
The payment structure adds to the dysfunction
99213 pays $75
99214 pays $110

16. 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

17. Getting Paid: Current System
Step #2: E&M code
Distracted doctor!!

18. 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

19. Getting Paid: Current System
Step #3: Billing
Co-pay(s)
Deductible
Primary Insurance
Secondary Insurance
Remaining portion

20. A Better Way
Simplify Coding and Eliminate Billing Altogether

21. 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

22. 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

23. Legislative Ask: A Better Way

24. 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

25. 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