Every coder has probably heard a frustrated doctor come up with the following, "These E/M code guidelines are too confusing. I'll just pick one code and use only that code." What's worse, some of us have seen doctors do just that. These physicians can be called "Johnny (or for political correctness - Jane) One Note's." Johnny One Note, according to the story, was a guy that really believed he was a good singer but found it to difficult to practice scales or read music. His response was to sing in monotone. What happened is no one would sing with him and many avoided him.

That can happen to our Johnny One Note doctors too. Some of them think that by using one code, payers will be happy because they are saving money and patients will flock to them. As a result of so many patients, the doctor will have a thriving practice. The theory is to make up losses with volume. Nice idea but, given reimbursement trends, that is like buying a truck load of watermelons for a buck apiece and selling them for 75 cents each. Great sales, but you take a real beating in lost recovery for overhead costs. Surgeons say they can give on the E/M side and make it up in surgery. But they need to look again at the declining rates for surgery. You can be busy and still lose money.

The other problem for a Johnny One Note is that they often turn into a "flat-liner." I think you know what a flat-liner is in medical jargon. It's a patient who has gone critical and whose life signs aren't showing. What the doctors who chose to bill one code don't realize is that Medicare and insurance companies can and do track the services that providers bill. That provides an interesting picture of a physician's practice and may also lead to some interesting consequences.

One of the most recent things that such profiles have helped to cause problems for doctors is in quality of care. Some companies are turning such flat-liner profiles over to licensing boards to make the case that the doctor is not rendering good and appropriate care to his/her patients (an acute MI is really more than a level 2 service). The doctors involved indicate that the process was quite personally painful and word-of-mouth gossip had a negative effect on the practice.

Beyond the personal, there are effects on the practice. In this day and age, we are finding more and more that, as a leading attorney said, "non-substantive errors" are being used to generate audit findings and recoveries. That means that little things trigger big audits . A profile that shows only one or two E/M codes means something is wrong and if one thing is wrong other things are also likely to be wrong. Think about it. If a doctor only reports level threes that means s/he has overcoded some level twos. And if s/he is using the E/M's incorrectly, what else is s/he likely to be doing the easy way that will result in audit findings.

A doctor who increases audit risk for him/herself will also increase risk for his/her partners. There is no way an auditor is going to come into a practice and only look at one doctor's services. The auditor is going to look at the rest of the doctors. After all, if the partners aren't policing their fellow, maybe they are also doing something wrong.

Of course, not only do flat-line doctors increase audit risk, they also increase the workload of whoever has to negotiate the final audit recovery. In the PATH audits both under and overcoding was included in the findings. And while the OIG has backed off from that practice, not everyone else has. The point is that a false claim means anything that is false is a false claim. It does not mean that just the overcoded things are false. So negotiating a finding, if you are lucky enough to have that option, may include arguing for some tradeoff between payment for overcodes and additional reimbursement for undercodes.

There are a couple of other things to be considered. A flat-liner doctor brings the severity profile down. So when an HMO looks at the practice to try to establish a capitation rate, guess what? They see a practice with healthy patients that probably can be given a lower rate of payments. This also becomes a consideration in the valuation of the practice. Low recovery means low margin and lower valuation for the practice.

What about using only level 1-3 or 3-5 codes? Well, the University of Chicago case (only code levels 3-5 were on the charge sheet and lower codes weren't used) would certainly seem to show that limiting codes will cause problems just like Johnny One Note coding does. A profile of levels 1-3 for acute MI's, pulmonary embolisms and the like will lead someone to look more closely at what is going on.

A final thought: HMOs are often targets of complaints and suits for providing improper incentives for doctors to underutilize (see the Harris Methodist case in Texas). What will flat-liner services mean in defending themselves against such an allegation? It is likely that the prosecution will have an easy time showing the jury that the doctor wasn't providing correct and needed services.

The solution, of course, is to help our doctors get over their frustration by making the system as easy to use as possible and yet be an accurate reflection of the documentation and the service that they provide. Gentle reminders and continual education are necessary. For the stubborn, maybe you also need to get the doctors peers/partners involved. Or maybe showing them this article will help. We all need to remember just because we don't like to do something doesn't mean we don't have to do it.