PEDIATRICS Vol. 108 No. 4 October 2001, pp. 999

COMMENTARY:
Should We Be Teaching Residents How to Bill for Their Outpatient Services?

The article entitled "What if Residents Could Bill for Their Outpatient Services" by Ng and Lawless¹ in this month's issue of Pediatrics describes the potential impact on a pediatric outpatient clinic if billing sheets completed by residents were used as the actual source of sending charges to third-party payers. Current Procedural Terminology codes generated by a blinded review of the resident's outpatient notes were compared with those produced by the resident. For acute care visits, resident codes disagreed with those of the reviewer 62% of the time with 83% of the disagreements resulting from under coding by residents. The authors estimated that this under coding would have resulted in a 1-year reduction in collections of $43 676. Residents' accuracy in coding did not improve with additional years of training. Using a sophisticated model employing relative value units (RVUs), work relative value units (RVUws), ambulatory payment class (APCs) reimbursement rates based on national Medicaid data, numbers of residents in the program, visits per resident, and resident time in continuity and acute care clinics, the authors estimated that the total yearly revenue for the outpatient clinic that could be generated by residents billing correctly would be $4 516 123. First-year residents could be expected, based on the model, to generate $67 239; second-years residents, $87 593; and third-year residents, $96 072. We are not told how accurately the faculty supervisors of these residents actually coded for the services that they performed in the context of their supervisory duties or how this compared with the hypothetical amounts derived if the residents' shadow forms had been used to generate bills. Although not surprising, these findings will be interesting and provocative for continuity clinic directors and preceptors.

Of course, training programs that receive graduate medical education dollars from the Health Care Financing Administration (HCFA) are not allowed to bill for services performed by residents. Teaching physicians and the departments they work for can bill only for those services that they personally perform and not for those that they merely supervise. (A "primary care exemption" loophole allows billing under very specific circumstances for services not personally performed by the teaching physician.) Many institutions are (like my own) fortunate enough to have "compliance officers" who protect academic medical centers from penalties that could accrue by making sure that only those services personally performed by the attendings are billed for and that such billings accurately reflect the service provided. Of course, since neither the compliance officers nor the FBI agents from whom they protect us have the time or inclination to actually observe what services attendings are personally performing while in teaching settings, the real issue comes down to "documentation," ie, compliance with recording the necessary number of "elements" of the history, physical, and medical decision-making to justify a particular Current Procedural Terminology (CPT) code. Indeed the medical record in most centers is no longer a document designed to communicate medical information from one member of the patient's care team to another for the benefit of the patient's health, but rather a document to prove that the attending has not cheated the third-party payer into paying for something done by a resident. Teaching attendings, who find themselves arguing with their compliance officer about whether they have personally "documented" enough elements in the note to justify a 99 213 or 214 instead of a 212 for the 1-year-old who might have had bronchiolitis or pneumonia but turns out to have a cold, may long for the days when they argued over the relative merits of the Problem-Oriented Medical Record compared with the "Source"-oriented one. What would Dr Weed² have to say about the "Compliance-Oriented Medical Record?"

So what should we be trying to teach future pediatricians while they work with us in continuity and acute care clinics? Ng and Lawless argue that "pediatricians in training need more preparation for the financial issues of practice management that they must face in the real world." But I wonder. Are we succeeding so well in making them experts in differentiating the child who is "sick" from the one who isn't; in counseling parents about their infant's sleep problems, temper tantrums, or risk of injuries; in recognizing which children or parents are depressed, victims of violence, or at risk for suicide, and in being competent care providers for children with special health care needs, that we can afford to give up some of that time and instead spend it teaching them how to correctly code a clinic visit? After being coached by coding experts, faculty physicians probably are in a position to teach a resident how to "game" the system. Reminding a resident that we actually did look at the skin of the child with a high fever and "teaching" her that recording the absence of a rash or petechiae counts as an "element" that must be counted in determining the correct code may be a legitimate function of a clinic attending. But given the time constraints of teaching in the clinic, what is our real mission: making sure that that she knows why examining the skin of a febrile child is an important thing to do or making sure that her coding is correct?

There was a time when an attending's signature below that of the resident meant that she had used her judgment in deciding which parts of the history, examination, or decision-making she should repeat. There was an assumption that the attending could actually be trusted to make this determination based on the clinical situation, how well she knew the patient, her appraisal of the resident's skills and knowledge, and that she took responsibility for everything that was done as well as the outcome. I don't know how good the evidence is that this trust has been widely abused in pediatric outpatient clinics, but we are now told that billing on this basis is fraudulent and can subject us to severe penalties or even criminal charges. You can bill only for what you document as having personally performed. (If you have attended compliance training and signed a form attesting that you have done so, your institution has no obligation to stand behind you or support you if your documentation is challenged by a payer.)

The additional time required for the actual personal (repetitious?) performance of the key elements of the history, physical, or decision-making as well as the documentation has to come from somewhere. I worry that it is coming from the time formerly devoted to teaching. Is this an improvement in medical education? Wouldn't it just be simpler all around if we did it all ourselves and let the residents watch? If we didn't have residents, would we need compliance officers?

Residents can't be expected to learn everything that they need to know to be competent pediatricians during their residency. Adult learning theory suggests that it is not until one perceives a need to know something that one is really able to learn it. Most residents (in contrast to first-year practitioners) seem to have little interest in learning about RVUs, APCs, correct coding, and the like. Perhaps learning that incorrect coding puts them at risk for the wrath of the compliance officer or the Office of the Inspector General (OIG) or, because they undercoded, the wrath of their practice manager or even that doing so could subject them to charges of "enticing" more children into their practices, is something that can wait until they actually are in the (God help them) real world.

Paul C. Young, MD
Department of Pediatrics
University of Utah School of Medicine
Salt Lake City, UT 84132

FOOTNOTES

Received for publication Mar 26, 2001; accepted Apr 10, 2001.

Address correspondence to Paul C. Young, MD, Department of Pediatrics, University of Utah School of Medicine, 50 North Medical Dr, Salt Lake City, UT 84132. E-mail: paul.young{at}hsc.utah.edu

ABBREVIATIONS

RVU, relative value unit; RVUw, work relative value unit; APC, ambulatory payment class; HCFA, Health Care Financing Administration; CPT, Current Procedural Terminology; OIG, Office of the Inspector General.

REFERENCES

1. Ng M, Lawless ST What if pediatric residents could bill for their outpatient services? Pediatrics 2001; 108:827-834 [Abstract/Free Full Text]
2. Weed LL. Medical records that guide and teach. N Engl J Med. 1968;278:593-99, 652-657