Nearly 200 years ago, the brilliant French historian Alexis de Tocqueville traveled the fledgling United States and observed that in lieu of hereditary wealth and aristocracy, we were building a society on individualism, market capitalism, and honoring the hard-working common man. However, in his 1835 book, he cautioned that laws could never be a substitute for public morality and that such a society was less endangered by “the great profligacy of a few”, but by the “laxity of morals amongst all.” Those words were prophetic. Individualism and market capitalism have enabled us to create the most technologically advanced healthcare system in the world, but Medicare will be bankrupt in less than 10 years. Although there are a lot of reasons for this dire situation, they include “a laxity of morals amongst all and the great profligacy of a few.” For all the deserved criticism of Medicare’s Merit Based Incentive Payment System (MIPS), the impetus for healthcare payment reform was that the system rewarded profligate spending by clinicians who still delivered only mediocre quality. Without an incentive to, “Do the right thing,” apparently, a lot of people didn’t.
Compliant Billing through Internal Auditing of the EHR
I was introduced to this problem early in my career. More than two decades ago, I was an Associate Professor at the University of Texas Health Science Center, Houston with 2 very small children at home. After another institution in the UT system paid a multimillion dollar fine for over-billing Medicare, all the Houston faculty members were summoned to a mandatory, in-person meeting and threatened with salary deductions if we “over-coded” for our services. I dutifully read the 54-page Centers for Medicare Services (CMS) “Documentation Guidelines,” which explained that physician payment for the Evaluation & Management (E&M) of a patient is determined by 3 key components, each of which has 4 levels of difficulty, within which points are assigned for very specific tasks. That meant there were 6,144 possible combinations representing the number of ways an office visit for a new patient could evolve. It just didn’t seem possible that a physician could consistently get this right. Apparently, I wasn’t the only skeptic. The American Academy of Family Physicians had 600 of their members assign E&M codes to 6 hypothetical progress notes, and compared their results to 5 professional coders. For new patients, physicians agreed with expert coders only 17% of the time, with the predominant error being over-coding. Physicians over-coded follow-up visits about half the time. I didn’t know anything about computers except that they did math, and truthfully, I am terrible at math, except for algebra word problems. I thought the physician E&M billing guidelines read like really a very long algebra word problem. It seemed to me that a computer could be programmed to correctly calculate the physician’s billed level of service and generate all the documents I was having to stay late at the office to produce (e.g. progress notes, letters to the referring physician, the summary list for the Joint Commission, etc.). Truthfully, I just wanted to keep my measly academic salary and get home to my young children on time. I sat down with a computer programmer and started working through the CMS guidelines book. In 1997, the Hermann Hospital Wound Center was the first of its kind (at least, that I know of) to perform “point of care” electronic documentation (in the room with the patient), using a system that internally calculated the physician’s billed level of service and collected discrete data about patients and their wounds. That was the genesis of what is now Intellicure.
Then, in 2000, CMS created the Hospital Outpatient Prospective Payment System (HOPPS), but left it up to hospitals to develop a method to calculate the facility E&M codes. In 2005, CMS proposed a facility billing system based on wound SIZE. That proposed system was never adopted because during a meeting with CMS, Intellicure President and CEO, David Walker, used Intellicure data from thousands of patient visits to demonstrate that, if implemented, 99% of wound center visits would be billed at the lowest level of service, but a system he designed which measured more than 200 elements of staff work produced a normal distribution of charges. The Intellicure electronic health record (EHR) company was only 5 years old at the time, but was the only company with reliable patient data that linked directly to billed services. There’s a reason why.
A Commitment to Compliance
From the beginning, Intellicure committed to collecting data in structured fields so that we could harness the computer’s ability to “do the math,” because we wanted to have accurate, compliant billing. Doing the right thing when it came to billing and coding was THE POINT. Discrete fields document every aspect of the physician history, physical examination, and treatment plan, and then automatically and internally calculate charges using machine-interpretable fields so that the clinician does no additional work to figure out the billed charge. More than 200 elements of staff work are discretely recorded, so it is possible to understand patient acuity and staff reliability. As CMS regulations became more burdensome with arcane rules for calculating debridement charges by both depth and size, we programmed that logic, too. When cellular product billing required wastage and usage codes, we programmed those, and we developed a unique method for documenting the requirements of the various Medicare Administrative Carriers (MACs). Then in 2008, we were among the first 31 organizations CMS recognized as qualified registries for a new program called the Physician Quality Reporting Initiative (PQRI) which evolved over time to the system we now call MIPS. We funded a quality registry because there was no wound care specialty to do so, and funded the development of more than 20 wound care specific quality measures (13 of which have made it into the 2018 MIPS reporting period). We funded the data and analysis required by the American Medical Association to protect reimbursement for the physician supervision of hyperbaric oxygen therapy. We programmed clinical decision support for wound care relevant quality measures into the Intellicure EHR to optimize quality of care and quality reporting under Medicare’s new Quality Payment Program (QPP). Wound Centers agree to participate in the U.S. Wound Registry from which facilities can receive benchmarking reports and through which clinical research can be conducted.
Early on, we endured hours of conference calls with hospital coders, compliance officers and program directors who poured over our billing and coding algorithms. Competing EHRs didn’t have to go through all that, because they didn’t purport to perform correct billing through internal calculations. We published peer-reviewed articles about how we developed the facility billing algorithm and how the physician and the facility level of service calculations worked. Since then, we’ve published many articles about the way we’ve protected reimbursement and facilitated comparative effectiveness research. We have been committed to “Doing the Right Thing” for more than 20 years. As a result, we are NOT the biggest wound care specialty EHR. Sadly, it turns out, the market is small for organizations and clinicians committed to accurate, compliant billing and coding.
We can fix this problem
We live in a country that has valued hard work and the free market since the Mayflower let down her anchor. Our healthcare system is a business. As a result, we’ve advanced the frontiers of medical science and built the greatest medical institutions in the world. However, we have a problem. It’s estimated that at least 30% of Medicare billing is inappropriate but the Office of the Inspector General and many of the Medicare Administrative Carriers (MACs) say that an even larger percentage of Medicare billing pertaining to wound care is inappropriate. And we spend a lot on chronic wound care- perhaps $96 billion a year, according to a study we helped perform, published in Value in Health. Every time we over-utilize or fail to provide the standard of care, we are part of the problem.
We can fix this problem. We can decide to engage in transparent quality reporting. We can participate in national benchmarking. We can commit to Honest Outcomes Reporting. We can be clinicians who “Do the Right Thing” with registry reporting. We can preserve Medicare for us and the generations to come, and provide higher quality care. There is enormous pressure to keep the economic engine running at full throttle, but it’s a short-term strategy doomed to fail. Doing the right thing takes tremendous courage because it may mean reducing the bottom line. But, as de Tocqueville said, “Life is to be entered upon with courage.”
- Department of Health and Human Services. Office of Inspector General; Medicare Program; Prospective Payment System for Hospital Outpatient Services. Federal Register. 2000;65(68):18450-18451.
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- Fife CE, Eckert KA, Carter MJ. An Update on the Appropriate Role for Hyperbaric Oxygen: Indications and Evidence. Plast Reconstr Surg. 138(3 Suppl): 107S-116S, 2016.
- Fife CE, Gelly H, Walker D, Eckert KA. Rapid Analysis of Hyperbaric Oxygen Therapy Registry Data for Reimbursement Purposes: Technical Communication. Undersea Hyperb Med. 43(6):627-634, 2016. https://www.uhms.org/publications/uhm-journal/uhm-journal-ahead-of-print-public.html?task=document.viewdoc&id=1072
- Fife CE, Horn Susan D, Smout RJ, Barrett RS, Thomson B. A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index. Adv Wound Care. 5(7): 279-287, 2016
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- Gilligan AM, Waycaster CR, Bizier R, Chu BC, Carter MJ, Fife CE. Comparative Effectiveness of Clostridial Collagenase Ointment to Medicinal Honey for Treatment of Pressure Ulcers. Adv Wound Care (New Rochelle). 6(4): 125-134, 2017.
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- Fife CE, Eckert KA, Carter MJ; Publicly Reported Healing Rates: The Fantasy and the Reality. 2017 Sept 28. https://doi.org/10.1089/wound.2017.0743
- Nussbaum SR, Carter MJ, Fife CE, DaVanzo J, Haught R, Nusgart M, Cartwright D; An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds. Value in Health (2017) http://www.valueinhealthjournal.com/article/S1098-3015(17)30329-7/pdf