Why I use a "billing timeout"

Many lament the influence billing has had on clinical notes. Combine that with copy/paste, and we’ve created a monster. I don’t disagree with them.

But with the 2021 / 2023 E/M updates narrowing their focus on only Medical Decision Making (MDM) or time, we have now a bit more freedom…and a way I see to simplify it all.

There are a few ways to approach professional billing, particularly MDM:

• Write your A&P and think about billing requirements while you do (which is distracting).

• Write your note and then review it to see what level of billing it supports (which is time consuming).

• Or document a whole bunch, hope it’s enough to satisfy billing, and bill mostly low or moderate levels to “fly under the radar” (which likely results in under-billing, could result in fraud, significantly contributes to note bloat and would cause me a lot of anxiety. People have bluntly told me this is exactly how they bill)

Furthermore, people will insert PB language like “I personally interpreted the images of the chest x-ray…” in their A&P or HPI which muddies that precious real estate that should be optimized for communication, organization and efficiency.

So, I use a “Billing time out” instead.

Before I sign my note, I stop and think “What have I done today? What level of billing will that meet? And what do I need to document to satisfy that?"

(Central to this is knowing precisely what is needed for professional billing…of which there are many misconceptions and the focus of my next video course for attendings)

I do this in a section of my note that is NOT copy/forwarded in my EMR so that it’s accurate and unique to THAT day. (The OIG has quoted copy/paste as a source of fraudulent billing).

I almost exclusively use Medical Decision Making. So, I have a dot phrase that inserts “Medical Decision Making:” and then I insert concise statements that would satisfy MDM:

(That’s satisfying a high level in the risk of complication column, and Categories 1 and 3 in the data column of the MDM chart)

Some may read that and think “That’s it?! A high-level note could fit in a tweet!” Well, remember you also need a “medically appropriate HPI and physical exam” and the rest of your note helps prove the medical necessity of that level of billing.

Sure, there might be a small amount of repetition in my A&P but this billing timeout:

• Removes billing language from the A&P, preserving its readability.

• Only takes a few seconds to dictate which is faster than reviewing my note to ensure I checked the right boxes.

• Gives me peace of mind that my note supports my level of billing.

• Makes it black & white for auditors (There is still plenty subjectivity to billing, despite attempts at being objective. I asked an auditor to review my notes, and using this method we had the highest agreement rate of any others she reviewed.)

Now I don’t do this for every note. I often know I am going to meet billing requirements through the natural language of my A&P. For example, if I’m managing 2 or more chronic illnesses (moderate) and managing prescription drugs (moderate) and I’m going to bill a moderate level, then there’s no need for my extra blurb.

I do also sometimes extend this “billing timeout” to utilization management statements… which perhaps I should do more consistently. But, that’s a bit of an evolving process - that might be a newsletter for another day.

That’s all for now. I hope that was helpful.

Please feel free to reach out and ask questions as they help inspire future issues!

Cheers,

Robert

When you’re ready, there are two ways I can help you:

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