All I need to do is write a final diagnosis, right?

American ER Doc Gone Walkabout Episode 007

Once upon a time, in a far off land in the northern hemisphere, I could take care of someone really sick, a STEMI for instance.  I could write a note:  a 55 year old came in with chest pain, he looked bloody ghastly, he had a low blood pressure and a little CHF and an awful looking STEMI on his EKG.  I treated him (actually, in those far off days, we mostly did stuff that didn’t much help, and hoped for the best) and he got admitted under the care of a cardiologist (who similarly, hoped for the best).

Since he looked ghastly, I didn’t ask about  nor record whether the pain was sharp, or burning, or crushing, or anything else.  Nor whether it radiated to his neck, back, or testicles.  Nor did I ask or record whether his Aunt Matilda had ever waltzed in Australia, and been ill with dropsy.  And, though I checked his pulses, and looked for signs of failure, and listened for a third heart sound (I once heard one on a recording, but never in a noisy ER), I didn’t look for toenail fungus, or rashes, or look at his tympanic membranes (I actually once did see an internist look in the ears of a dying man with a ruptured AAA).

And then, when I finished up his paperwork, I wrote down “99285” – our code for a level 5 ER visit meaning:  this guy was pretty sick, I did a bunch of stuff, and spent a bunch of time – so pay me a reasonable amount of money.  Please.

Tassie was pretty interesting:  the (handwritten) medical records – this was before cutbacks in healthcare funding in Tassie had eliminated pens from the ER – were better organized  than I had been accustomed to before “structured” – i.e. checklist – records, and later electronic records,  arrived in the US, but the organization was dictated by medical convention – not by billing and legal liability.  I wasn’t much into the conventions, and wrote notes that were a bit more concise than many of my younger colleagues.

But I was delighted to never write a line that was inserted solely for billing or legal purposes.  My, how refreshing and how civilized.

So, you Aussies are missing something – charging for medical service.  Here’s how we do it in the US:

After I finish working with the patient, I’ve got to complete the chart with all the bits and pieces needed for billing.

If I’m working at a paper chart place, most of the stuff is checklists – the “structured chart”, with some handwritten narrative to sum it up.  At the EMR places, we “drop in a macro” – and then switch the negatives to positives where appropriate.  You might imagine that in the course of multi-tasking, it’s pretty easy to drop in a macro and, especially where an abnormal finding isn’t pertinent to the current complaint, neglect to turn some routine negatives positive where they should be.

Anisocoria and heart murmurs seem to be particularly susceptible to being recorded as normal, even when present – often going for many visits between episodes of being correctly noted.

Use of checklists and macros is also subject to pure fantasy and fabrication:  from a role that I once unwillingly played as an atrial fibrillation patient, I received billings from an ER Doc, internist, and cardiologist – dutifully noting my normal heart and lung exams in some detail – but knowing perfectly well that in fact no physician had laid a stethoscope on my chest.  And, a bill for an anaesthetics pre-sedation evaluation, which had consisted solely of a grinning young man, holding a large syringe filled with white stuff, saying:  “So, ‘ya ready?”

Back to billing:  The whole billing process is driven by counting the number of bullets for each item:  at least 4 characteristics of the Present Illness, at least 2 items in each of ten systems for ROS and physical exam, at least 4 items in the differential diagnosis with one or more serious or life threatening.  We get points for the social and family history, and points for reviewing medical records and talking with consultants.  We can charge extra for time in critical care, and for individual procedures.  After assuring that we’ve accumulated enough points, we then get to check off the appropriate codes that are then used to generate the bill.

If we don’t have enough of the correct check boxes we’ll get the chart back (all 10 kilos of paper) or the electronic version, with little notes as to what is incomplete.

Of course, this doesn’t allow for, or give billing credit for,  a really detailed exam focused on one system:  the extensive psych interview, detailed ocular exam – with pressure, slit lamp, dilated fundus, etc:  or an extensive neuro exam – we’re doing general exams that only require (for billing) 2 observations of each system.  No extra credit if you make 50 detailed observations in one system.

Everything has to be explicit:  anybody with a little medical training could see what my differential diagnosis included, based on the labs and CT’s ordered – but I don’t get credit unless I explicitly write it down in the differential.  And all of those credit points add up to determine if I can charge a Level 4 or Level 5 charge, which may be worth well over $100 difference in the allowed charge.

On the other hand, when this system developed in the 80’s, it didn’t take rocket science to predict that many doctors would quickly realize that if all I needed was a completed checklist to get paid an extra $100, I could take a simple problem, recognize explicitly on paper that it could be a marker of a more serious problem, ask and record a couple extra questions, and a couple of extra exam findings (recording that the ears are present, and have ear canals is worth about $15 by my calculation) and rapidly ramp up my income.

The suits who were the brightest guys in the room and developed this system that allowed the billing coders to merely count the checkmarks to arrive at a code, managed to convert a slightly efficient system with lots of guys sending in reasonable bills, and a few abusing the system, into a system that generated very high charges for minimal clinical work that was overwhelmed by paperwork and overwhelmed the written useful clinical information with written data (not information) used only for billing.  And is pretty universal in the US – converting a majority of US physicians into paperwork drudges.

It’s not limited to emergency medicine.  I recently counted lines on a clinical note from cardiology clinic that had 700 printed lines, of which only 4 (unfortunately in the middle, not as a summary at the top) were actually generated by the cardiologist and contained the useful clinical information for the visit.  All the rest were macros dropped in, or cut and pasted from other visits, or auto-generated lab reports available elsewhere.  Complete ER charts in the EMR hospitals commonly run to 800 – 1000 lines for a routine problem.  Try finding the useful information.

The whole billing issue is independent of paper or electronic records – the process of generating the codes and the required supporting documentation is equally laborious in either system.  When later searching for useful medical information, the paper charts tend to be poorly organized and often unreadable.  The electronic records are well organized, but often have the useful information buried under too many layers of stuff that has no real medical usefulness.

All in all, though, I was sad to leave Tassie and return to the land of unending paperwork, but happy to have the EMR where I could actually read a legible chart and find the pathology reports when I needed to.

Next time:  Emergency Imaging in Tassie

ER doc walkabout Rick Abbott LITFL 700

American ER doc


Rick Abbott (aka American ER doc gone walkabout ) has been an ER Doc since 1973 and has bad wanderlust.

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