One way to help a lay person understand the mess we're in is to start by handing him or her this issue of Family Practice Management and pointing to “CPT Update for 2011: Immunizations, Observations and More.” The article, by Cindy Hughes, CPC, is not an indictment of the system; rather, it's just a concise and cogent explanation of some changes in CPT for the coming year. But imagine you have come to it with no prior knowledge of CPT coding, and you'll see what I mean. Imagine your patient's reaction:
“You mean you have to submit one code for the vaccine and one for the administration and two more if there are three vaccines in the one shot, but you have to use different codes if you didn't talk to the patient about it first except if the patient is an adult? What ... ?
“And what's this about Medicare assigning values to codes for immunizing kids even though Medicare doesn't insure kids, and other insurance plans may or may not pay for them? Can't you just charge for what you do?
“Then it says here in the part on time-based codes, ‘a unit of time is attained when the mid-point is passed,’ so 31 minutes is an hour. That sounds crazy, but if that's true, why does Medicare say that an hour is an hour? And in the part about how the time ‘must meet or exceed the typical/average time of a specific CPT code billed’ for Medicare, does that mean you have to spend more time than average to get paid for the average? That doesn't make sense either.
“Also, it sounds as though these new hospital observation codes are to help do an end run around other rules about hospital admissions. Is that what's going on? Is it legit?
“Most of the rest of this I don't even begin to understand, and I don't think I even want to know what these debridement codes are about; they sound gross. It's all so complicated, I don't know how you remember it. But what I really don't get is what all this has to do with being a doctor!”
That's when you'll know your patient has the idea; all you'll have to say is, “Right; and except for you and me here in this exam room, it's all like that.”