One City Built to Last

estimates that around 90 percent of his
office visits are level 5.
"Yes it was inaccurate in 2012," he conceded,
blaming his coding problems, in
part, on Medicare's lack of billing categories
tailored to urgent care. "Medicare
gave us a call. 2013 is going to be a lot
more accurate."
Experts, however, said that it was
implausible that an urgent care doctor
would never see patients with minor ailments.
Other urgent care centers in the
region, including some run by emergency
specialists, have lower proportions
of level 5 visits, ProPublica's analysis
showed.
"Bring in the logic police," said Shelley
C. Safian, who teaches medical billing
and has written textbooks on the topic.
"Even an emergency room in a hospital,
not everybody is a level 5."
Im earned $237,600 from the government
for his level 5 visits in 2012, plus
patient copays. Im is still a Medicare provider
in good standing, according to the
program'sPhysician Compare website,
and Medicare declined to respond to
questions about him.
Farhoomand offered a similar explanation
to Im's for why his patient visits
were predominantly coded at the top
level. All told, the San Diego-area internist
billed Medicare for more than 2,100
level 5 visits, one of the highest tallies in
the nation.
"I have a predominantly geriatric population,
and I do mostly chronic critical
illness, so all of my patients have, like,
multi-organ failure, heart failure, diabetes
with multiple complications, etc.
etc.," he said. "I'm savvy enough that I
handle most of their issues myself, and
I use specialists only for procedures and
such things."
Farhoomand is facing a 2013 accusation
by the California medical board of
gross negligence in his prescribing of
controlled substances, a charge he denies.
"No good deed goes unpunished," he
said. "I wind up managing most of their
chronic pain."
He said he is in talks with the board to
settle the accusation.
Experts say there are plenty of flaws
with the way Medicare reimburses doctors.
The program pays a premium for
hands-on procedures, such as inserting
a pacemaker, but undervalues the decision-making
at office visits to sort out
the cause of a complaint and the proper
treatment, some say.
Dr. Christine Sinsky, a Dubuque,
Iowa, internist has shadowed more
than 50 physician practices to assess the
way they are organized and has written
about the topic. She said she worries that
as Medicare imposes more rules and requirements,
the focus is shifting away
from patients' needs and toward checking
boxes on electronic health records.
These systems are designed to keep better
track of doctors' services but have
been linked to upcoding.
"Physicians are very afraid of being an
outlier," Sinsky said. "I have a lot of compassion
for physicians who are struggling
with the billing rubric, because it is
sometimes a force pushing us away from
what we know is best for our patients."
Indeed, some health professionals
blamed billing issues on electronic health
systems. Arizona optometrist Serge
Wright was surprised to learn that 959 of
his 2012 office visits were coded as level
5 — and that he'd charged the top rate
more than all the other optometrists in
the state put together.
"Wow, that sounds distorted," he said.
Wright speculated that the coding
could reflect a switch to a new electronic
medical record system a couple of years
ago.
"I don't think I ever used a 99215 [level
5 visit code]" until then, he said, noting
that the new system is supposed to check
whether enough documentation has
been entered to justify each charge. "In
the past, without the electronic records,
it took more time to keep track of all of
the elements of an exam to code it. I think
everyone was undercoding at that point,
myself included."
THE SUIT MAGAZINE p.13