Upcoding

Organized crime and US healthcare have much in common. Those on top make enormous profits. Those in the middle generally don’t see the inner workings. Those on the bottom are essentially powerless. Prices are inconsistent and rarely displayed. And periodically people get killed in the process. Unlike organized crime, however, we in healthcare assert we’re doing God’s work.

I type this as someone who straddles the middle/bottom line. I consider myself a well-intentioned cog in a money-sucking machine, which lately has been massively greased by electronic medical records. When I see patients in ERs, no matter where in the country, I then click buttons to describe my findings. These buttons are translated into codes, which eventually morph into bills, neither of which do I ever see.

I can’t even offer my patients estimates for what their care may cost. When I think I have completed a chart, generally additional prompts appear on the screen, sometimes suggesting I include more “ROS” (review of systems) or “PE” (physical exam) findings. This is a subtle way of saying: “If you click a bit more, we can bill more.”

I’ll admit, if I know the answers I click those buttons so the charts don’t hunt me down later, and so I don’t receive memos about my deficient charting. This is “upcoding” and my little contribution to the healthcare balloon. I keep practicing medicine because there are gratifying moments where we help people, I love my colleagues, and frankly, I’m not very good at anything else. But this aspect of the job really churns my stomach.

Recently I had a glimpse from the patient side. My wife is pregnant. She was scheduled for a 20 week ultrasound and being fiscally prudent she asked for a pre-ultrasound estimate which came to $356. We paid our co insurance of $142. Thankfully, the baby seemed pretty normal other than the finding of “pyelectasis,” a word invented by the medical mafia. A renal (kidney) pelvis dilated 0-4mm is normal. 4-10mm is pyelectasis, and above 10mm is hydronephrosis. Our baby has one renal pelvis that landed at 5mm. It turns out this is a common finding especially in male babies and generally just goes away over time.

As a result of that finding our bill jumped above $730 (our portion). During the ultrasound an expert in maternal fetal medicine entered the room for a recheck and to offer counsel. Unbeknownst to us, at that moment our bill estimate was out the window. We thought she was just being friendly and prudent, especially when proposing a repeat ultrasound at 32 weeks just to be sure… never mind that no prenatal urologist is going to address such a finding in utero. We declined her suggestion, despite feeling guilty about choosing to short-change our baby already.

This was a small glimpse of the medical experience, and probably some personal karmic payback. We’ll pay the money. I’ll even continue to practice medicine (unless this gets me fired).  But I swear that Pre-R will never treat patients this way.

For more on the topic: “Why Doctors Are Frustrated With Digital Healthcare

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