Do you tend to undercode? You're not alone

Bill Thrift, MD, a family physician in Prescott, Ariz., says his office frequently undercodes claims after treating patients with multiple, complex problems. He's just anticipating what insurers might reject.

"One of the hardest things for us to do is really charge what we're worth," he said. "We're not aggressive at working the system."

Weary of fighting with insurers, fearful of getting audited by Medicare, or merely unsure about what they can code for -- for whatever reason, many physicians habitually undercode.

A recent study has quantified how much family physicians don't put on their bills. The numbers raise questions not only about undercoding's effect on a physician's income, but also about its effect on quality measurement programs that use claims data to determine how well patients fare, and what sort of cash bonus a doctor might receive as a result.

The coding study, by researchers at the University of Wisconsin Medical School, found that family doctors manage an average of 3.05 problems per patient visit. But they record only 2.82 in the chart, and 1.97 on the bill.

"I have been tending to undercode my visits, and I didn't really realize it until this project," said Cynthia Haq, MD, a family doctor in Madison, Wis., who was one of 29 physicians whose charting and billing methods were scrutinized. "I often undercode ... and write down one or two [problems] when there might be four or five."

Family physicians tend to accept that they advise patients on a variety of issues but will be compensated for only some, knowing insurers will look at some CPT codes but ignore others if they feel additional payment isn't warranted for the same visit. Physicians don't have enough time to record every facet of a visit if the system doesn't reward that kind of thoroughness, Dr. Haq said.

But in some cases additional coding could result in more income, experts say. The Wisconsin study found family physicians, in particular, don't often bill when they counsel for mental illness, substance abuse or tobacco addiction, because they don't think reimbursement is likely.

Though 29 physicians may seem like a small sample, many say their experiences are typical. Dr. Thrift, who wasn't part of the study, said he spends about 30% of his time on matters related to emotional problems but many payers reimburse family doctors reluctantly or not at all for anything that looks psychiatric. "We are very good at [counseling]," he said. "All [family doctors] do it, and all of the time, and we don't get paid for it."

In other cases, physicians want to shield patients from possible adverse actions if insurers learn about emotional problems or addictions, and leave those conditions off the bill or chart or both, according to the study, which appeared in the September-October Annals of Family Medicine.

Doctors should record the level of service they provide, despite their doubts about payment, said John C. Nelson, MD, MPH, president of the AMA. It is "no wonder physicians are apprehensive about appropriately reporting complex procedures and services they provide for fear of health plan retribution, given current health plan business practices of downcoding, bundling and reassigning physician CPT codes to reduce or deny physician payment," said Dr. Nelson, a Salt Lake City ob-gyn.

But if primary care physicians are telling insurers about only a portion of what they do, quality measurement programs may not work to their potential, experts said.

"Most of the time looking at claims data, you don't know what took place at the encounter," said Josie Williams, MD, an internist and gastroenterologist and co-chair of the Physician Consortium for Performance Improvement, a large group of quality experts periodically convened by the AMA.

Charles M. Cutler, MD, head of national quality management for Aetna Inc., said claims data can still be useful for tracking adherence to certain best practices ranging from child vaccinations to mammogram rates. He said he'd be " happy to hear about" ideas for better measurements from family physicians.

But Dr. Cutler, an internist, added: "I don't know one could ever measure the universe of what a family physician does."

Dr. Thrift, for his part, is trying to survive in that universe, even if he understands that payers never will know everything he does for patients. After one recent patient visit, he decided to be a bit bolder in his billing.

The patient, who has developmental disabilities, talked about her anxiety and sleep disturbances and the medications she takes for them. Dr. Thrift checked her blood pressure and explained the importance of controlling it. But for the bulk of the visit, he spent time cutting her painful toenails, because he knew the payer did not cover trips to a podiatrist.

In what he calls a "risk" and a "gamble," Dr. Thrift decided to add the toenail trimming to the bill using a CPT modifier -- a $20 charge. It was a very tiny but, in his view, a long-overdue step in the direction of opposing self-downcoding.

"This is the first time I've tried to bill for it, and I've done it a zillion times before," he said. "Whether they'll pay for it is something that remains to be seen. Let's see if I can do it."