Podcast Episode 15: Wishes for the Holidays to Improve Healthcare
Episode Summary
These are our 4 wishes to improve documentation, coding, and healthcare from our hosts Neal Sheth and Dr. Piyush Sheth. There is also a free gift for our listeners. Use the following link to get the free gift:
https://drive.google.com/file/d/10tPZ81QkVMskZVKnUkqyzAikYQ6t58Nh/view?usp=sharing
Episode Transcript
NEAL SHETH: This is the 15th episode of the Unraveling Medical Coding Podcast and to begin, we would like to wish everyone health, prosperity, and a joyous Holiday season. As we enjoy the festivities that this season brings, our minds dwell on gifts, and in that vein, dad and I have 4 wishes we hope will improve documentation, coding, and healthcare if they come true. Also, during this podcast we are going to give our listeners a free gift that simplifies understanding Time Based Evaluation and Management Coding. So let’s get started.
PIYUSH SHETH: In fact, Neal, I have so many wishes but I'll narrow mine down to three and I know you have one yourself.
NEAL: So, what is your first wish dad?
PIYUSH: My first wish is for Simplicity. I am continually astounded to see how simple tasks become quite complex in EMR's. Has your EMR made your life simpler or more complex? At the end of the day, do you go home earlier and with more time to spend with your family? Are you seeing the same number of patients in the office per day that you did before starting to use an EMR when compared to after starting to use an EMR? Is the EMR software reliable or does it crash once in a while? Do you wish for an easier to use and less complex EMR?
In the 1980's, computers were hailed for how they would efficiently perform complex calculations and would save people enormous amounts of time. Unfortunately, we know that is not what has happened. Don't get me wrong! I love computers. I even used to do some programming so I know that the right coding can make the difference between an efficient software program and a clunky software program. Today, we seem to be glued to our computers at work, taking away from direct patient care. It also takes longer to document. Numerous studies have shown that physicians spend up to 2 hours or more at the end of the day just catching up on documentation, sometimes even taking work home to finish it there.
In contrast, look at Microsoft, Google, and Apple. They have focused on making stable, efficient, and user friendly programs with a minimalistic design. Microsoft Office is the de facto #1 office productivity suite in the world. Google search likewise is the most widely used search engine in the world and it's predictive algorithms are absolutely insane. Apple's iPhone and apps are awesome for their minimalistic design and ease of use and with a lot of power under the hood.
What if EMRs were that good. Do you ever wish that the Notes application in EPIC were Microsoft Word instead? I certain do. Almost on a daily basis. Inserting pictures, tables, and form fields, would all be more efficient and easier. If you use EPIC, try inserting a table and then formatting cell colors, borders, or fonts. It is truly archaic. In fact, I became so frustrated with the standard note templates in EPIC that I designed a spreadsheet table as my note template. I was told that no one has ever done that and that it could not be done. Well, I did it and it works! When compared to standard EPIC note templates, it is more streamlined and organized the way I think. My printed notes are around 4 pages whereas the standard template notes in EPIC usually exceed 10 pages. Both have the same information. Would you as a healthcare provider read a 4 page note or a 10+ page note? Maybe this is why most healthcare providers either do not read other provider notes or just skim them. Is this fostering good communication between providers? Does this lead to better healthcare for our patients?
Let's get even more basic than that. If you have ever opened a patient chart in EPIC, you know how complicated the initial screen is. There is no minimalistic design and therefore the user experience suffers. Have you ever had to hunt through screens to figure out how to do a simple task?
Here is another example that drives me crazy. Sometimes a patient will come in with a history of uterine fibroids. When I try to search for "uterine fibroids" (pleural), no results are found. But when I search for "uterine fibroid" (singular), numerous results are found. Try searching for "kidney transplant" to add to the patient's past surgical history. There are only 2 results and both state "combined kidney-pancreas transplant." In fact, to add kidney transplant, you need to add "kidney surgery" and then in the comments section add "kidney transplant". In 2019, over 24,000 kidney transplants are performed in the U.S., yet it is not a search result in EPIC?
EPIC really has a very long way to go to become a great EMR despite it being around for almost a half century, since 1979.
NEAL: That certainly is a tall order and obviously won't happen overnight.
PIYUSH: I know, but the time to start a change is now!
NEAL: So, what is your second wish dad?
PIYUSH: I wish that there was more transparency in coding and billing. Currently, most physicians don't know how to code properly. The AMA holds the copyright on the CPT codes despite these codes being essential for billing services. Yet every year, we have to purchase CPT code set books that cost about $130 each. If we have to use CPT codes, shouldn't they be free to use. A 2001 estimate suggested that the AMA made $71 million in annual CPT code "royalties". In 2017, the AMA reported $140 million to the IRS on Form 990 as "royalties" which are most likely from the copyrighted CPT codes. Just think about this one minute. The ICD code set is free! But CPT codes aren't. In the software arena, this is the difference between proprietary software vs. open-source software. If you really want transparency, the AMA should distribute CPT codes free to healthcare providers.
And, this would have to include everything related to CPT codes. The RBRVS system of RVU's should be freely available. Only then can physicians realize the disparity in RVU values. Without that transparency, most physicians are ignorant of incorrectly valued procedures. Sure, the AMA has a RUC (RBRVS update committee) but most physicians do not know the process of how to ask for changes to the RVU values.
Physicians have been so marginalized from this whole process that Medicare and the AMA make changes that affect every healthcare provider without much input from said providers. We should take back the control we relinquished decades ago.
NEAL: But dad, I'll play devil's advocate. Why would the AMA make CPT codes free when it is such a great revenue source?
PIYUSH: To be honest, I really don't feel the AMA represents physicians. There are 1,341,682 physicians/medical students/residents/Fellows in the U.S. today. Only 250,253 physicians belong to the AMA, which is around 15% of practicing U.S. doctors. So why are most of the rules for coding being made by the AMA and Medicare?
NEAL: I see your point. Ok so, what is your third wish, dad.
PIYUSH: My third wish is that we fix the Balanced Budget Act - Conversion Factor debacle. Honestly, how many years have physicians seen the Conversion Factor remain stagnant or decrease, essentially not even keeping up with inflation. Healthcare providers are working much harder to make the same amount of money. The days of "Oh, you're a doctor so you must be making a lot of money" are gone. With working harder, work satisfaction is plummeting. In fact, some physicians have difficulty paying off their student loans years and even decades after going into practice. Medicare's push to reign in healthcare costs is squeezing providers and hospitals even more. Smaller hospitals cannot keep their overhead down and are forced to close or merge with larger systems that can provide cost savings on a larger scale. Now, even the larger systems are starting to feel the crunch. There has to be a better way. It's going to take people with vision to change this downward spiral we are on.
NEAL: Wow!
PIYUSH: Yeah. I know I am aiming for the stars but when your healthcare system is faltering, looking up is a good first step.
As promised, we are going to give our listeners a free gift. In my book Coding Solutions General Surgery that is available on Amazon, I designed an easy-to-understand simplified way to perform Time Based Coding for Evaluation and Management Services. In our show notes, I’m placing a link to that pdf page. My book also contains numerous efficiencies for Medical Decision Management Based E/M Coding, Split / Shared services coding, and just about everything a general surgeon would need to code accurately and efficiently, all aligned with work RVU’s. It’s also much more affordable than resources directly from the AMA.
Now, let’s switch roles Neal. What is your wish for improving our healthcare system.
NEAL: Well, I’ve got one wish, and it has everything to do with when providers actually get paid: I wish that CMS would reduce the Medicare claims run-out period to less than the current 90 days.
PIYUSH: Hmm, so what does that actually mean.
NEAL: Well, you see dad, you would think that the moment that CMS approves a claim, then they would cut a check and send you the payment. But this isn’t how it works, in fact, after a claim is approved, there is a mandatory 90-day run out period to ensure that there is time to make any adjustments to claims, such as an appeal that changes the payment amount, an additional service that is billed to a claim, or a payment revision by CMS.
PIYUSH: It seems sensible to have some run-out period, otherwise we might constantly be asked to pay back excess payments from Medicare.
NEAL: It is! There has to be some run-out period in between claims, but I think that the 90-day period is too long. It’s actually a legacy of when appeals to claims would be done over snail mail, giving plenty of time for back and forth between CMS and the provider. Of course, nowadays pretty much every claim is appealed electronically, making the communication time much faster. And, CMS has gotten much better about approving or denying adjustments in a timely manner.
To make things worse, other payors tend to follow the CMS run-out period, and sometimes have even longer periods, I know of one payor that has a 180-day run-out. This means that for most providers, at minimum there is a three-month delay from when you bill for a service, to when you can actually book the revenue. There are a lot of negative downsides to having such a long run-out:
One: It can be difficult for providers to understand their revenue/cost to provide care in real-time, because you don’t know the final payment until months later.
Two: Because of the time-value of money, you are actually receiving less revenue 90-days later than if you received the revenue earlier.
Three: This run-out period is only for fee-for-service payments, so every other payment is built on top of this delay. For example, the run-out period for some value-based contracts can be a year or more, since bundled payments need to wait for all claims in a payment period to be submitted and for the claims run-out period to end before they can make a period. This is crazy! How can a provider manage cost of care with a year-long delay?
PIYUSH: Hmm, this is a great example of a hidden bit of healthcare infrastructure that affects every aspect of care. How long would you want the run-out period to be?
NEAL: I’m not optimistic of any change, but I think the run-out can be reduced to 60 days without much difficulty. Of course, this would mean CMS adjusting its entire payment system, and as we know the government is much more prone to inertia than even the healthcare sector at large!
PIYUSH: Fair enough!
NEAL: That’s it for this episode. Please check out the other episodes. Don’t forget to rate and review us and subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please share this podcast with friends or colleagues who you feel would benefit from learning about medical coding and documentation. Stay safe, stay healthy, and wishing you Happy Holidays.