. Case in point: I went to see my medical doctor the other day. Just after being "roomed," as they say, the nurse checked my vital signs. Then she left. She shut the door on her way out and I was left staring at the back of it, where a sign was posted. After reading the sign, I immediately took a picture of it with my phone. Why? Because the sign was one of those really bad ideas and I had to share it.' />
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Dynamic Chiropractic – September 15, 2015, Vol. 33, Issue 18

Practice Policy (Gone Bad): The Sign

By K. Jeffrey Miller, DC, MBA

Every once in a while, you see something and think to yourself, That's a really bad idea. Case in point: I went to see my medical doctor the other day. Just after being "roomed," as they say, the nurse checked my vital signs.

Then she left. She shut the door on her way out and I was left staring at the back of it, where a sign was posted. After reading the sign, I immediately took a picture of it with my phone. Why? Because the sign was one of those really bad ideas and I had to share it. The sign read:

Patients and their insurance
are charged based on the number of
complaints and the time taken
during the visit.

Please help us to keep your premiums and co-pays low by limiting the number of complaints per visit. If your list of complaints exceeds the time scheduled, you may be asked to make another appointment to complete your visit.

Please be considerate of other patients who are waiting. Sick visits are not the time for prescription refills and checkups.

This is hands down the worst policy I have ever seen posted in a doctor's office, in any field of health care – and I have been in a number of doctor's offices.

Error #1: Marketing Nightmare

From a practice-management and marketing standpoint, the sign is a disaster. In essence, it equates to the doctor screaming to his patients, "Hey, don't waste my time!" We have all had patients who wasted our time. However, these patients are usually the exceptions and not the rule. Unfortunately, this sign is posted in every room for all patients to read as though they are all guilty of wasting the doctor's time.

risk ahead - Copyright – Stock Photo / Register Mark Excessive waiting has been a major patient complaint for decades. We waste more of the patients' time than they do of ours. The sign is an insult to patients.

Additional insults are levied in the final paragraph, which implies the patient is inconsiderate and possibly not as important as other patients who are waiting. This is despite the fact that the patient reading the sign probably spent a considerable amount of time waiting prior to being roomed.

The tone of the policy is anything but warm and friendly. Anyone reading the sign will not be expecting treatment from a doctor with a good bedside manner. Who would refer another person to this practice?

A sign reading, "Go away and leave us alone" would have served the same marketing purpose. (The brevity of this statement also would have allowed the letters on the sign to be bigger.)

Error #2: Financial Confusion

The policy is also a problem financially. The second paragraph of the notice begins with a statement that implies patients can control their insurance premiums and that co-pays differ based on the number of complaints.

This section of the policy can only lead to further confusion for patients about insurance procedures. Patients have minimal if any control over insurance premiums. Co-pays are generally fixed and do not vary based on the number of complaints.

This section also implies the patient can save money by not complaining too much. In reality, it encourages patients to suppress information and leave out details of their health history.

Patients also are threatened with the need of additional visits if their complaints require too much time. The phrasing includes, "to complete your visit." This is funny, as additional visits will not complete the initial visit. Additional visits will be coded and billed.

The final statement regarding "sick visits" not being a time for prescription refills and checkups discourages patients from seeking follow-up care for previous or ongoing problems. It also discourages wellness care. Once again, this could cause patients to suppress their history and concerns.

Error #3: Poor Risk Management

If a physician has paid even the slightest attention to risk management over the years, he will know many malpractice suits are not initiated over poor quality of care or bad outcomes, but over how patients feel they were treated as people. This is risk-management 101. Right after the doctor screams, "Hey, don't waste my time!" he should scream, "If you don't like it, sue me!"

Discouraging full disclosure of patient complaints, follow-up care and wellness care is not easy to defend if questioned. I would not want to go to court with these policies as part of my standard for patient care.

Error #4: Clinical Practices and Coding Don't Always Mix

I teach postgraduate orthopedic and neurological examination procedures. As a part of my teachings, I always include information on how to properly code examinations for billing purposes. During the tenure of my programs, I have often been amazed at chiropractic's lack of proficiency with the evaluation and management (E & M) coding system. However, we are not the only ones with this shortcoming. Medical doctors don't seem to understand the system, either.

From a coding point of view (E&M), the number of complaints and the time required for the visit are not the sole factors in determining code levels and charges. They are not even the major factors.

Evaluation and management codes are made up of seven components. Three of the components are key components (history, examination and medical decision-making); four of the components are contributing components (coordination of care, counseling, nature of the presenting illness and time). New-patient examinations require all three key components; established-patient examinations require two of the three key components.

A patient may have a number of complaints, but if the complaints are all minor, the degree of history, examination and medical decision-making will not substantiate a high-level code. If the patient has a cold, headache and a splinter, minimal efforts will be required under the three key components.

Time is a contributing component, but it of the least importance in every field, with the exception of psychiatry. Additionally, only the face-to-face time between the doctor and patient counts toward the time listed for a code. Time the patient spent with staff does not count.

The code my doctor assigns to my visit is always a 99214. The 99214 code is for a comprehensive established-patient examination. It requires significant contributions from multiple E&M components. During my office visits, the nurse records my weight, blood pressure and temperature. She records the reason for my visit and then leaves the room. The doctor enters just after this, reviews my chart, listens to my heart and lungs, and usually looks in my mouth and ears. That is it, unless I have a new complaint and he has to go further. This routine started with my first visit and has continued without change.

This level of service barely (if at all) qualifies for the 99202 (new-patient) or 99213 (established-patient) codes. The 99214 code is more than a stretch.

My doctor is not using the E&M codes accurately, but he is not alone. Inaccurate use of E&M codes has become almost epidemic. In fact, it has caught the attention of the Office of the Inspector General (OIG). On May 29, 2014, the OIG released a report titled, "Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010."

The title of the report alone says there is nothing good in the document. The report has prompted widespread audits of physicians in the Medicare system. Medical doctors are the primary focus, as every patient encounter they have involves an E&M code. Chiropractors also will have their fair share of audits.

The audits will have serious ramifications throughout health care. I mentioned the audits to my doctor and he seemed completely unconcerned. He told me that like so many other practitioners, he had accepted his last new Medicare patient. The doctors in the practice are now allowing established Medicare patients to "die off." This sounds like a reasonable plan – until you understand it will not resolve the mistakes already made. Medicare has no statute of limitations.

Another problem that will occur with the audits is the carryover of Medicare audits to private carriers. Inaccurate coding is a concern in both arenas. All too often, "As Medicare goes, so goes everyone else," further increasing the importance of proper coding.

Simple Solutions

While the sign opens a can of worms in many areas, there are a few simple solutions. First, the sign should be taken down. Second, the doctor should remember he is there to help patients; they are not wasting the doctor's time. Third, this doctor (and every doctor) should study the E&M coding system to gain understanding of how examinations are coded based on the seven key and contributing components.

Click here for more information about K. Jeffrey Miller, DC, MBA.

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