In which db screams at the world of coding courses and the RUC


Category : Medical Rants

This morning I received 2 emails which made me scream. These emails were advertisements for 3 day courses on coding and reimbursement. They were targeting Anesthesia. The course costs $795 plus $200 for workshops. Obviously attendees add on travel and lodging.

They will have many attendees, because our reimbursement “system” is an obscene, arcane, confusing, illogical mess. So we have a reimbursement system which is so obtuse that 3rd parties make money “teaching” physicians and their office managers how to “optimize” billing and collection.

The RUC has taken a reasonable idea and corrupted it. Or is RBRVS really a reasonable idea? Here is the problem, our current billing and collections depend on following indecipherable rules. The rules are so complex that conflicting rulings occur in different regions.

As I have written many times, we need a reasonable time based approach. Now I do know the potential problems of a time based approach, but it seems to work for lawyers, accountants, plumbers, electricians, etc.

In the meantime, leeches will develop courses to teach us how to game the system. I hope that makes you want to scream.

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Comments (8)

The issue runs deeper than the leeches trying to game the system through teaching. The unintended consequence is that doctors reflect this attitude in their interactions with patients. With a genuine need to support their practice, and themselves, they are constantly looking for ways to up code patients to achieve higher reimbursement.

I will spare you my corporate culture rant. Let’s just say doctors reflect the environment and the people they work with, as in any group.

I would love to buy a doctor’s time. Let’s sit down, chat about my health and past health issues, and order those test we, after the discussion, deem necessary. Let the insurance pay for the test, but not be the sole source of the doctor’s income.

We need some sanity to a system that is totally out of control. Doctors don’t like it, and patients don’t like it.

Steve Lucas

I don’t understand how people say that doctors don’t like the system that they have to game. My experience from undergrad to medical school is that if you don’t game the system, you can’t continue.

It fascinates me that what looks to me like a house of cards, maintained only by the money, and extremely laudable efforts of good intentioned intelligent people, can continue.

The things like coding are why I look more and more closely at becoming a GP who works alone, and gets cash up front when I begin practicing. The system is ludicrous, and if there is a way to opt out, I will attempt to choose that way.


I think there may be a potentially lucrative business opportunity for consultants who can assist new and experienced physicians to opt out of the system and open up viable cash-only micropractices. There is now a critical mass of physicians who would love to do this but don’t know how to work outside the system. Many are leaving practice for employed positions where they don’t have to deal with this stuff. I think there may some who would jump at the opportunity to buy some sort of “micropractice franchise” or other turnkey system to remain in practice free of the Byzantine coding and reimbursement system imposed by government and other payors. Any interested entrepreneurs out there?

I am glad you are working to keeping the momentum going.The current CMS RUC alliance is a target well worth going after if the current reimbursement mess is going to change.Maybe the tipping point will be when enough physicians opt out of the current system and we get paid like other professionals and the whole house of cards is blown over.Well we can hope anyway.

you can bill based on time, you just need to document the total amount of time and know the thresholds for each level. inpatient and outpatient differ in what qualifies as time spent.

What I found interesting about the comments is that we have a patient, med student, retired doctor, and skeptic all agreeing that the system is broken. What is further interesting is we all agree people are willing to pay a doctor for their time.

Comments regarding changing the private practice business model, that would have drawn negative responses a short time ago, are now considered as options.

While some consider unlimited spending on medical care their goal, clearer minds understand this is not an option.

The really difficult task will be transferring this debate from the blogs to the general public, and those in positions of making decisions.

Steve Lucas

anon 10:28.

That is not true. You can not bill based only on time. The Guidelines from 1995, 1997 do not allow that, except for several very specific situtaion. You cannot bill a 99211-99215 (out patient clinic codes) or 99221-99223 (in patient follow up codes) based on time alone UNLESS you clearly document
1) total time of the encounter
2) that greater than 50% of the total time was spent on counseling the patient regarding things like prognosis, expectations, options, risks etc…
3) You have to specifically document what you counseled the patient about.

If you did not spend greater than 50% of the time counseling the patient you can not use time as the basis for any of these codes.

The 1995, 1997 guidelines have “guidelines” on which level of service to bill based on the total time used.

If, and only if you do these three things can you bill based on time.

The only other codes that I am aware of that allow you to bill based on time are critical care codes (99291, 99292).

Prolonged service codes (rarely reimbursed as far as I know)

Discharge codes are based on time, greater than 30 minutes spent on discharge (99238) or greater than 30 minutes spent on discharge (99239)

My use of codes is mostly limited to inpatient, but these are the rules as I understand them

happy hospitalist
certainly there are restrictions when using time based billing, and you are correct regarding the stipulations. i apologize if my post was interpreted to mean that there were no restrictions to time based billing. it was not meant to serve as a reference for time based billing, but rather alert people to the option of time based billing so they could look it up. or wait for you to post the specifics. 🙂

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