Sometimes you start a new rotation and next thing you know, it's three days later. Yikes. I should probably sleep now while I have the chance. An "early" day. Great. Last "early" day on Tuesday I was at the hospital until 10.
I got tapped on the shoulder by someone from the medical documentation office. I'd forgotten these exciting conversations when I was at the outpatient clinics. The documentation people are the ones who read our notes and try to figure out how much they can massage our diagnoses into more things to bill the insurance company for.
"You said in your note that the patient was complaining of abdominal pain. Would you say that was chronic abdominal pain?"
"I don't know."
"But you'd be willing to write the word chronic in the note?"
"Uh, sure."
"Great. Would you say there was a possibility of Crohn's disease?"
"I don't know."
"But you thought about whether she could have Crohn's disease."
"I guess the thought crossed my mind, but her symptoms didn't match up with Crohn's disease."
"But you would say you evaluated her for Crohn's disease?"
"I don't know."
"Did you make an evaluation that she did or did not have Crohn's disease?"
"Sure."
"Could you write that in the chart?"
"Why not."
"And is it possible she had appendicitis?"
"Anything is possible."
"Did you rule it out?"
"I suppose."
"Can you write that in the chart?"
"I guess."
"And this patient, how was her mental status?"
"Fine."
"So you evaluated her mental status?"
"Not in so many words."
"But in one word?"
"I don't know."
"Can you mention this in the chart?"
"Mention what?"
"The examination of her mental status."
"There was really no examination."
"You don't have to go into such detail."
"Okay."
"And I noticed in the chart she was a bit underweight."
"Was she?"
"She was. Might she be malnourished?"
"I don't know."
"And could we call that malnourishment caused by disease?"
"I suppose."
"Terrific. So you'll make these edits?"
"Do I have a choice?"
"No, not really."
"Great."
Thursday, February 17, 2011
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Holy shit, really? What's the point of all those 'suggestions'?
ReplyDeletegross... I feel like I have to take a shower now.
ReplyDeleteACK!!! How horrible. Now that was something about practicing medicine that I never anticipated having to do. Do you really have to go back to your old notes and add stuff?
ReplyDeleteSounds like you might want to be careful with how much you stretch the truth. Someone out there is keeping tabs...
ReplyDeletehttp://www.latimes.com/health/la-na-medicare-fraud-20110218,0,1872843.story
"More than 100 charged nationwide with Medicare fraud
A task force has brought criminal charges against doctors, nurses and healthcare executives. They are accused of cheating the government out of $225 million by making fraudulent claims, taking kickbacks or money laundering."
I don't think it's fair to say that he's "taking kickbacks". From my point of view at least, you get patients who can't afford treatment, so you try to defer as much payment to the insurance company as possible.
ReplyDeleteHooray! You are now an accessory to Medical Fraud! Depending on your state, you could go to jail! But they didn't catch this attempt to milk the system for more money--they instance of insurance fraud just increased the cost of health care, not actually resulted in prosecution for the crime that was committed.
ReplyDeleteWe wonder why health care costs are so high?
Thanks for being part of the problem!