Blended codes

The CPT coding system that is used by Medicare, Medicaid and commercial insurers have paid physicians different amounts for each of the five levels of office visits. Recently, Anthem Blue Cross and Blue Shield Ohio, a subsidiary of WellPoint, the nation's largest insurer, has thrown that system into an uproar by blending payments for level 3 and 4 visit codes into a single rate. The new rate as you can imagine is closer to the level 3 rather than the level 4.

Physicians who have invested the tens of thousands of dollars in Electronic Health Records (EHR’s) had found that they were able to document more of what they did and were therefore able to code for a level 4 rather than a level 3. That has been one of the key selling points to electronic records. But by doing this, insurance companies have had to pay more in claims.

Anthem is one of the largest insurers and owns 30 to 40 percent of the HMO/PPO market in Ohio. Since this accounts for a large majority of patients, most physicians aren't in a position to quit the plan in protest, but it has infuriated many doctors.

Comments made to Medical Economics about this change reflect the discontent of the physicians.

Internist G. Stephen Cleves, president of Queen City, denies that he or his colleagues have filed claims for any work they didn't do. "Before my EHR, I wrote on a piece of paper," he says. "When somebody came in who was diabetic, hyperlipidemic, and hypertensive, it was extremely difficult to document everything I said and did.

"The EHR allows me to do that. But now, Anthem says, 'Oh gosh, now that you're coding appropriately, we're going to pay you less.' So they've arbitrarily changed the rules. They make no differentiation between someone who comes in with a sore throat and someone who comes in with multiple medical problems that require fairly intense management, because they're paying the same for both."

This is another example of how unfair-bargaining continues to dominate the Healthcare field. If physicians could collectively bargain like most others, this would never happen. But as it stands currently, an individual physician trying to bargain with Anthem is like David fighting Goliath.

If physicians were to systematically code visits incorrectly, we would be subject to fines, jail, and exclusion from Medicare and other insurers. These insurance companies should be treated with equal standards.

Information on this story can be found at the following site in Medical Economics.
http://www.memag.com/memag/article/articleDetail.jsp?id=322627&searchString=Stephen%20Cleves