The Happy Hospitalist has a lively and cynical take on coding for hospital visits. See The $77 Dollar Question:
But if I don't document a family history in a bed bound 90 year old nursing home patient with pneumonia, then my payment from the Medicare National Bank for one hour of intense work would drop from $188 to roughly $111. My high level admission code 99223 would immediately be supported by only a low level admission code 99221 without the documentation of family history. And if I submitted a bill for a 99223, without a documented family history, I would have charges of fraud and abuse leveled against me in the court of law. The spirit of the law doesn't matter. My complex patient with very difficult decision making would only be legally supported as a low level admission without that family history documented. How much would I lose monetarily for not documenting family history in a highly complex admission?What Is a 99223 Worth?:
The whole process is incredibly time consuming leading in insurmountable loss of productivity and expense to the system of health care delivery. It takes away time devoted to patient care and creates insecurity in physicians who don't want to be accused of fraud.And My Special Bullsh*t Radar:
And when they invest in technology to figure it all out, they are accused of fraud anyways because the computer says they can bill more.
This is skeleton note that will get me the highest level of reimbursement for a MNB 99223 admission. It has every component needed to achieve the highest level of payment. But it doesn't end there. Not only should I rightfully be paid for my services rendered I also must document appropriately so that 1) the hospital gets paid at a maximum rate so my value to them increases and 2) I must document severity of illness adequately so my actual mortality is not higher than my expected mortality. So what do I need to change in my impression and plan?Photo Credit.
Lets go back and look at that again. For pneumonia, a higher DRG is achieved by documenting the specific type of bacteria. Now, the government says I need to draw blood cultures. It's a bunch of bullsh*t. It's a very rare day, if ever, that a blood culture changes my management. Community acquired pneumonia is appropriately treated with quinolones or ceph+mycin.
But to get the hospital to be paid more, i order a sputum culture, with the hope that a bacteria is cultured. Notice, the most common, streptococcus pneumonia does not pay more. Only the other stated bacteria (isn't that strange?). So I may not get lucky with a Legionella, or a gram-negative to boost the DRG payment. The DRG for simple pneumonia pays less than the DRG for pseudomonas pneumonia.