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Misunderstanding about Doctors' Medical Billing and Coding for Medicare

It wouldn’t be farfetched to say that doctors need to know as much about medical billing and coding as they know about their medical specialty. Efficient coding ensures the right payment for their services.

The move to make doctors’ Medicare billing records public has caused unease among physicians for the simple reason that the public fails to understand medical billing properly and high bills could be misinterpreted as physicians indulging in fraud.

How Medicare Billing Gets Misunderstood

The American Medical Association (AMA) has argued that people who get to see Medicare billing records of doctors could misinterpret the data, particularly if the numbers billed by doctors are large. It could be misinterpreted as fraud even if the physician was honest and only billing for the services rendered since the public could not be aware of how patient visits are translated to billing codes. They would not know that there is only a 1 to 5 scale for doctors to assign for routine visits. With around $12 billion in Medicare spending accounting for office visits each year, this is one of the major areas of income for physicians. Complicated visits are to be labeled with level 5 while short and simple office visits can be labeled with level 1. Level 5 visits are paid the highest.

Unusual Billing Patterns by Doctors

Much has been made of an emergency medicine physician from California who billed for a level 5 visit around 30 times for each patient in 2012. This had caused the medical board of California to even try to revoke the doctors’ medical license on grounds of charges of inadequate keeping of records, incompetence, and false statements. Doctors in California generally bill only for around two of such high-level visits per patient each year. This makes the billing of the aforementioned doctor stand out conspicuously and spark suspicions of coding based on the money the doctor wants rather than coding for the level of service offered.

There are other doctors too who have unusual billing patterns. It is estimated that around 1,800 doctors in the United States billed the highest possible for routine visits. Colorado too had a number of doctors who billed the highest for routine Medicare visits. One of them, employed at Denver’s University of Colorado in the infectious disease department as director of transplant, revealed that being a doctor in a facility where tough cases were referred from other hospitals required more time to care for each patient during office visits, which caused the higher coding.

Inaccurate Billing Causes Issues

However, some medical billing and coding experts believe that not all doctors are honest when they bill high, particularly in specialties such as gastroenterology and general internal medicine. The bottom-line is, doctors using the wrong codes knowingly or unknowingly could be eventually audited by Medicare and end up facing legal action or having to pay back Medicare. This highlights the need for precise billing and coding. On the other side of the spectrum, some doctors, under fear of facing issues due to coding higher than required, under-code and charge lesser than their services deserve. Here too, accuracy in coding and knowing the most appropriate codes for the respective services is vital.

Outsourcing Medicare billing could ease the pressure on doctors and also ensure accurate coding.

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