MDs Among Top Five Coding Abusers
Written by Editor   
Wednesday, May 28, 2014 08:09 AM

When people think of seeing a doctor, generally the first thing that comes to mind is an office visit. But not all visits are the same.  Doctors get paid more for more complex visits. Office visits for established patients are billed across five levels.  Three California Medical Doctors are among the top five nationally in billing for the most complex office visits, according to data released by Medicare.  

Most doctors' billing patterns to the Medicare program fall in the middle ground between simple and complex.  In California, only 5% of doctors' office visits for Medicare patients were billed at the highest level in 2012. It is unusual for doctors to determine -- and bill -- a large proportion of their office visits as complex.  The analysis of Medicare billing data -- which was made public for the first time last month -- shows that three California doctors are among the top five nationally in billing for the highest number of the most complex office visits. In addition, they tended to bill at the highest level significantly more frequently than peers in their specialty.

In Orange County a hematologist-oncologist, billed Medicare for 6,340 of these visits in 2012, the most of any doctor in the country and significantly more frequently than similar specialists nationwide. Almost 79% of his office visits were billed at the highest level, whereas other hematologist-oncologists only billed 12% of their office visits the same way.

In the Santa Cruz County community of Freedom nearly every one of a cardiologist patients received -- and was charged for -- the highest complexity visit. Mace billed Medicare for these high-level visits almost 10 times more often than other cardiologists in California, and the third most in the country.

Another cardiologist ranks fifth in the country for the number of times he billed the most complex type of visit to his office in Los Angeles. His average patient received four of these visits in a year, compared with the one visit typical of other cardiologists in the state.

Only 1% of California doctors billed Medicare at the highest level for all of their office visits for their established patients.  

It's not just the total number of visits that could raise red flags among auditors -- repeat complex visits by individual patients could also be a cause for concern.  One outpatient emergency medicine doctor is listed in Medicare's billing database as an outpatient emergency medicine doctor in Newhall, a suburb of Los Angeles. Typically, this kind of physician sees patients at an outpatient urgent care center for any range of simple, nonurgent complaints, like sore throats, to more urgent matters, like a broken wrist.  According to this analysis, his patients received -- on average -- 30 of the most complex office visits in 2012. The average for other emergency medicine doctors is one complex visit per patient.

In the mid-2000s, this MD served numerous times as an expert medical witness in court cases arguing that mold in residential units and work environments made his patients severely ill.  The California Medical Board tried to revoke his medical license in 2006 for "repeated negligent acts, incompetence, making false statements, and inadequate record keeping," according to legal documents. He was put on probation and permitted to continue practicing medicine but prohibited from participating in any litigation. He was found to have violated the terms of his probation by preparing reports for four patients in workers' compensation claims. He signed a settlement agreement in September that extended his probation until March 2015.


Problems can also arise from the billing set up at a doctor's office. Many doctors don't do their own billing. They dictate their office notes from a visit or fill out a checklist, and then a clerk in the billing department enters a code.  "Many times a physician is not even aware of what their claims are or how their claims are coded." 

There is also a rising trend in unintended coding errors that mirror the rise of the implementation of electronic medical record systems. Many of these systems include an automated coding function. A physician will type in medical observations and treatment protocols, and then an algorithm will determine the code.  "Those algorithms are subject to human error." "Some mistakes are being made by the electronic medical record vendors in how they designed the product that they're selling."  Still, according to Medicare rules, the ultimate responsibility for billing always rests with the doctor.

All established patient office visits are coded under a category called "evaluation and management." These visits are billed at one of five levels, with 5 being the most complex. Established patients are people the provider has seen at least once before. First-time doctor appointments are coded differently.