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Clin. Cardiol. 23, 801–802 (2000)

Editor's Note

Paperwork and the Practice of Medicine

Key words: paperwork, medical practice

Towards the end of May, 2000, I received a reprint of the Heritage Lectures (No. 665, May 11, 2000) entitled "How Medicare Paperwork Abuses Doctors and Harms Patients." This was written by four individuals: Grace-Marie Arnett, Jonathan Emord, Lawrence Huntoon, M.D., and Robert Charrow. It was produced by the Domestic Policy Studies Department and published by the Heritage Foundation. I will not detail all of the document, but I want to focus on some of the comments of Dr. Lawrence Huntoon in his paper "The Medicare-Industrial Complex: A Practicing Physician's View," and on two sections in particular: "Stupid Rules" and "An Abuse of Power."

In "Stupid Rules," Huntoon states,

The Medicare bureaucracy has also perverted the medical record. It really is no longer a clinically useful medical record--it's a billing record. It has to be a billing record; otherwise, the physician will not be paid for his or her services.

That statement particularly rings true for me as an academic cardiologist making rounds on my patients with housestaff medical students and Fellow trainees. I spend most of my time documenting material that has already been documented by the housestaff and less of my time teaching cardiovascular medicine.

Huntoon goes on to indicate that bureaucratic persons are forcing doctors to make black and white diagnoses when, in fact, there are many shades of gray. Oftentimes the diagnosis is not clear on the initial assessment or even later on, for that matter. However, we are being forced to put down diagnosis codes that may or may not be correct. Huntoon points out that this promotes inaccuracy because the coding of erroneous diagnoses is encouraged. The bureaucracy has also changed the CPT coding system for services provided to patients: the Health Care Financing Administration (HCFA) is now using a single code for separate and sometimes distinct services, which it calls "bundling;" according to Huntoon, "Physicians call it fraud."

The second section, "An Abuse of Power," relates to fraud and abuse and how HCFA operates the system. Huntoon observes that "The masters of the old Soviet KGB had a slogan that the Medicare fraud and abuse cops seem to have fully embraced: 'Show me the man, and I'll show you his crime.' Grace Marie Arnett elaborates,

The modern practice of medicine is so complex that virtually every election made by a doctor in the course of treatment can be called into question if examined later in microscopic detail, either based on insufficient documentation of decisions, perceived overutilization, perceived underutilization, improper coding, billing for a service that is ancillary to a noncovered service, or some other among a myriad of regulatory issues. That is particularly so when Medicare limits the scope of its examination to physician patient records and considers the absence of written detailed justifications for treatment evidence of inadequate treatment and the need for reimbursement of Medicare fees.

HCFA now operates a system that is so complex and has so many regulations that any physician in this country could be singled out at any time and found to be in violation of some Medicare rule, regulation, or guideline. There are over 111,000 pages of Medicare regulations. Huntoon gives several specific examples that are quite frightening, including a raid on an east Tennessee hospital by many federal agents who were wearing flak-jackets and fully armed. In another instance, a physician and his wife, patients, and children were held at gunpoint by three armed federal agents. I suspect these examples are the extreme, but none of them should have happened.

In this system, it seems that the physician is guilty until proven innocent. Physicians who are accused of fraud and abuse can defend themselves, but generally this is quite an expensive undertaking. It is common knowledge that HCFA settles for double damages if the physician agrees, thus keeping the physician from paying triple damages and possibly serving a prison term.

Huntoon, who is President of the Association of American Physicians and Surgeons and is a neurologist in private practice in Jamestown, New York, finishes his piece by indicating that "When the mob does it, it's called extortion. When HCFA does it, it's called 'Operation Restore Trust' or some other euphemistic name. And, remarkably, this is done on a 'bounty' system whereby the recovering agency gets to keep a share of the loot." Fear of fraud runs rampant among American physicians. As a result, I suspect there is significant undercoding for services rendered. When this happens, those physicians who code at a higher level for their services (even though accurately) are considered the out-liers, and that will surely attract the attention of those interested in Medicare fraud and abuse. Huntoon further makes the point that even if the physician is accused of fraud and eventually cleared of committing any crime, the damage has been done to his or her reputation. In my opinion, the vast majority of physicians are honest and conscientious but nonetheless are living in fear of the bureaucratic mindset of the Medicare establishment. The American College of Cardiology is working hard on our behalf, and in a letter to Michael Hash, Acting Administrator of the Health Care Financing Administration, Dr. Arthur Garson, Past President of the American College of Cardiology, conveyed to him that there is great dissatisfaction within the cardiovascular disease community regarding the proposed documentation guidelines that primarily depend on the "counting" of history and exam criteria to support a particular level of service. The ACC is concerned that the excessive history and physical exam documentation requirements currently proposed will prevent the clinician from providing optimal quality assessment time with patients. Refocusing the documentation requirements away from extensive history and exam documentation towards assessment and medical decision-making will accomplish two things. It will facilitate and emphasize the physician's cognitive ability to solve specific medical problems, and it will encourage the physician to expand and focus on the assessment and planning portion of the documentation. This is the critical section of the patient's medical record, and should be the most relevant link to the level of the service coded. Dr. Garson goes on to say that the ACC wishes to explore ways to resolve these concerns and develop documentation standards that not only provide a clinician with the opportunity to document the level of service provided to the patient, but also to convey the physician's cognitive efforts in providing services.

For those of you who are interested in reading further about the Heritage Lectures, the paper in its entirety can be found on the web at

C. Richard Conti, M.D., M.A.C.C.

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