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Wet Read — The black art: Billing

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When you get something for nothing, you just haven’t been billed for it yet.

—Franklin P. Jones

I think Mr. Jones was on to something there. I’m sure he billed for his time to scribe that little gem, and The Saturday Evening Post paid him in bullion. I have been thinking about billing a good bit lately; how can you not? Health care reform has everyone a little bit crazy. I think we all knew the system was heading for some serious revision, and, in that regard, you can’t always pick your poison. Often someone picks it for you.

Here’s some of what I have been losing sleep over. Many folks have reviewed the current “fee-for-service” reimbursement and have written about how it is destined for failure. Can’t keep functioning this way. The replacement systems are going to reward us for… Well, I don’t think anyone knows that, yet.

I’ve heard some thought about billing somewhat similarly to current E&M coding. This is intriguing to me. So, you read a study and you say, “Well, that wasn’t so hard. I didn’t break a sweat. Not very complex. I’ll call that a level 1,” and you’ll get paid at some low level. Or, you’ll have to think a lot, and your head will hurt, and the old studies will be confusing, and the clinic notes won’t make sense, and you’ll say, “Well, that was harder. I need a break. Call that a level 2,” and you’ll get a few more dollars. And maybe it ramps up to a level 3 (sweating now), or a level 4 (AAAGGGGHHHHH!). I don’t know. The unfairness of the current system has always been somehow inherently obvious to most of us; you hope you break even on the easy ones, because there is, carefully hiding in that stack, a real time sump. You might get lucky and pull out a “search and destroy” cervical spine on someone who complains that their arm tingles when they sleep funny on it, ordered as a cervical MR with and without, and nothing more than a little bulge at C4-C5, while also in that list is a new exam on a patient referred to get their neurofibromatosis evaluated. Oh, and by the way, they’ve had 4 surgeries, and they brought 11 old disks to “help you.” Billed the same, but the effort? No comparison.

There is no perfect system, of that I am sure. Some fixing may be a good thing. How many of you have witnessed cherry-picking? That incredible skill of looking through the worklist and finding all the normal abdomens, chests, or heads, or minimal degenerative disease spines. I, on the other hand, am cursed. I do exactly the opposite. I reach in and get the most vicious stuff pretty consistently. I think I might like knowing that I can get some level 4 billing for those. I am an optimist, but I doubt that’s going to happen on my watch.

Time to get back to “reducing the stack.” Mahalo.

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By C. Douglas Phillips, MD, FACR| December 04, 2013
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About the Author

C. Douglas Phillips, MD, FACR

C. Douglas Phillips, MD, FACR

Dr. Phillips is a Professor of Radiology, Director of Head and Neck Imaging, at Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY. He is a member of the Applied Radiology Editorial Advisory Board.

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