By Christopher Guadagnino, Ph.D.

Published March 2000

• React to this article in the Discussion Forum.

John Hansen-Flaschen, M.D., is chief of the Pulmonary, Allergy and Critical Care Division at the University of Pennsylvania, and is medical director of the Penn Lung Center. He is also an American Thoracic Society representative to the National Critical Care Reimbursement Working Group, working with HCFA and the AMA toward correct coding and auditing of critical care services

PND: What are your concerns regarding Pennsylvania Blue Shield reimbursement?

JHF: As the head of one of the nation’s largest pulmonary and critical care practices, I was surprised to learn only recently that Pennsylvania Blue Shield systematically downcodes professional charge submissions for critical care services. Their computers are programmed automatically to replace critical care first hour—that’s 99291—with a subsequent hospital visit—99233—after the first three charge submissions in a hospitalization no matter how long the hospitalization lasts or how many times a patient returns to an intensive care unit. This is also surprising and disappointing to me in that the systematic downcoding practice is not revealed in the current version of Pennsylvania Blue Shield’s procedure terminology manual or in any other document routinely distributed to Pa.’s physicians that I’m aware of. That raises a number of questions: How many other codes does Pennsylvania Blue Shield systematically downcode and when might they introduce downcoding practices in the future? No-one can know if they don’t reveal this in a straightforward way to the provider community. But we do know that health insurers elsewhere are systematically downcoding the highest level outpatient visits to lower level visits—level five office visits to level three office visits. In fact, we’ve recently become aware that physicians in Florida are suing Humana for systematically downcoding highest level outpatient visits to lower level visits in that state.

It’s even more confusing, in that Pennsylvania Blue Shield processes physician charge submissions for a number of other HMOs in Pa. that come under different names, for example, Independence Blue Cross’ Personal Choice here in southeastern Pa. So, some of physicians’ charges for critical care services are automatically downcoded and some are not. It’s very difficult for us to know which and when.

Blue Shield is continuing this activity even though the new CPT description of critical care specifically allows submission of 99291 and 99292, the two critical care codes on multiple days during a hospitalization, if the situation and the services warrant continued use of the code. Other insurers in the country that comply with national CPT terminology presumably are no longer engaging in this practice. HCFA has recently issued instructions to Medicare carriers that charge submissions for critical care services are not to be downcoded after a certain number of days if the service continues to warrant use of the code. So, the Pennsylvania Blue Shield policy is at variance with the current CPT description of critical care and specifically at variance with national HCFA policy for Medicare.

PND: Is this being done throughout Pa.?

JHF: To my knowledge, Pennsylvania Blue Shield is the only charge processor in the state doing this, but of course, they work across the state and process charges for many other carriers besides Pennsylvania Blue Shield’s. So, by all means, this practice stretches across the state of Pa.

PND: Who is affected by it?

JHF: All physicians who practice hospital-based medicine and at least occasionally provide critical care services in intensive care units or emergency departments or in other settings. That includes critical care specialists, surgeons, anesthesiologists, internists and family practitioners who may be called upon to provide direct physician care for the very sickest patients in the hospital.

PND: How did you find out about this practice?

JHF: I heard it as a rumor. Physicians in community practice told me they had discovered it in their explanation of benefits forms. So I went back and reviewed forms for our practice and found incidence after incidence where 99291 was replaced with 99233 after exactly three days of critical care service. So I called Brent O’Connell, senior medical director at Pennsylvania Blue Shield, and he conceded that their computers are currently programmed to make this substitution after the first three days of service.

PND: What is the economic impact of this practice?

JHF: Presently, Pennsylvania Blue Shield in southeastern Pa. pays $165 for critical care first hour—that’s 99291. And they pay $72 for a subsequent hospital visit, level three—99233. So that downcoding is a substantial loss of money for practicing physicians. More importantly to me than the dollars lost is the question of trust and integrity. In concert with other reputable physicians I support correct coding by providers and consider it unacceptable for physicians to code inappropriately or systematically upcode our charges. I think it’s equally reprehensible for a health insurance organization to systematically downcode. So the real damage here is to trust between providers who render services in advance of payment and health insurers.

PND: What proportion of patients are affected by the downcoding?

JHF: That will depend in part on the type of practice and the hospital setting, and also on a patient’s clinical course through hospitalization. For example, if an individual experiences serious complications of major surgery and has a critical illness lasting six or seven days, three or four days would be systematically downcoded at the end of that illness. If that individual subsequently recovers a little bit, only to return to the ICU one or two weeks later for a second critical illness, all of the days in that second critical illness would be downcoded. That individual might even make a third visit to the intensive care unit one or two months later in a hospitalization only for the physician to see all of those days downcoded. In fact, one physician may have received all three critical care days for the first visit to an ICU and another physician seeing the patient for a first time during a second subsequent visit to the ICU in the same hospitalization would not be able to be paid for critical care services no matter what the circumstances of that second acute illness. Our practice here at the Hospital of University of Pennsylvania focuses on referral critical care. We take patients in transfer from other intensive care units at our hospital and by ambulance or helicopter from other intensive care units across southeastern Pa. The systematic downcoding affects as many as 40 percent of our total critical care charge submissions. In the United States we estimate that between $1 billion and $1.3 billion is paid for critical care professional services. So this is a very substantial CPT code, both in frequency of charge submissions and in dollars overall.

PND: Could the downcoding harm patients?

JHF: I think very definitely so, in two ways. Critical care service is the most intensive evaluation and management service currently recognized. Every patient who deserves critical care service is experiencing a tragedy of a lifetime. These tragedies occur at all hours, day and night, on weekends and holidays. These problems occur emergently and require immediate, effective physician response. If physicians after a long day are worrying whether they are to be paid or how much they are to be paid, I worry that they will not provide the best level of services they know how to provide under those circumstances. I think, in a more general sense, quality of care is eroding when physicians cannot trust insurance carriers to pay them fairly and honestly for the services they provide. One of the ways for physicians to respond to inadequate payment for critical care is to divide the care of patients among many physicians. If physicians know that they’ll only be paid for subsequent hospital visits, by using multiple consultants they can divide the care of that patient among five or six individuals, each providing 10, 15 or 20 minutes of service, rather than having one individual physician in charge provide comprehensive critical care service for the patient. That ends up costing the insurance carrier as much as or even more than the original critical care code and it divides up the patient organ system by organ system among many consultants moving quickly through to take care of their one fraction of a multi-organ problem. I think all of us would rather have a recognizable physician in charge, with a comprehensive overview of a patient’s problem, steering the ship forward. That kind of comprehensive care by critical care physicians typically requires 30 to 90 minutes of effort and that’s why critical care charges were developed in the first place—to encourage that level of effort and concern in the care of the very sickest patients in the hospital.

PND: Does the downcoding violate Blue Cross’ provider contracts?

JHF: I don’t know the answer.

PND: Is it illegal to downcode without evidence about specific claims?

JHF: I don’t know. So far we have not looked to regulatory or legal recourse. Our goal at the moment is to persuade Pennsylvania Blue Shield that fair practice is good business, to change this current practice and to take a stand against systematic downcoding of professional service charges at the charge processing level. Establishing a relationship of trust and confidence with providers across the state is good business for their company in the long run. So at this point our goal is simply to persuade.

PND: Can you appeal the downcoding?

JHF: Yes. In responding to our complaints and concerns, Pennsylvania Blue Shield has advised that a physician can appeal each individual downcoding event. In our ICU we generate an average of approximately 30 full pages of documentation every day in the care of critically ill patients. Administratively, it’s entirely prohibitive for us to appeal every single instance of systematic downcoding we encounter in our daily practice. We would have to identify the incidents from the explanation of benefits forms. We would have to obtain the inpatient medical record either during the patient’s hospitalization or afterwards while it’s being processed for a number of steps. We would have to have somebody knowledgeable enough about the chart to pull and photocopy pages from many separate sections that provide a complete picture of the patient’s severity of illness and the activity of the day, as well as our own two-page physician’s progress note. And we would have to mail that off for each individual episode. I can’t put a dollar value on the effort and expenses entailed, but it simply wouldn’t be worth it for us to do that. It could be three or four patients every day, seven days a week, 365 days a year. This would be a substantial effort for an individual to do it properly. Better to readjust our practice toward 15- or 20-minute service events and a larger number of providers.

PND: Why is Blue Shield doing this?

JHF: We were told that they audited some charts and had discovered that some physicians submit 99291 critical care service when the patient is not critically ill or the physician did not provide a critical care service. So this is a response to perceived coding abuse by providers. We’re not able to comment on that because they haven’t shared with us their data. It wouldn’t surprise me if some codes are submitted incorrectly. I have no idea how often that is done. But we do know that critical care service charge submissions to Medicare are down substantially in 1997 and 1998 compared to previous years even though the number of critically ill patients increased during those years. And we think the charge submissions have declined nationally because Medicare carriers have emphasized pre- and post-payment audits for critical care services during those years. My point is that two wrongs don’t make a right. Systematic downcoding is not an appropriate response to incorrect coding by providers.

There is another alternative approach that Pennsylvania Blue Shield could use to encourage correct coding by physicians that doesn’t entail automatic downcoding. That would be to put forward two separate fee schedules, one for practices that have adopted acceptable documentation and charge submission compliance programs and another lower fee schedule for practices that haven’t adopted an acceptable compliance program. HCFA has developed guidelines for correct coding compliance programs that can serve as a foundation for Pennsylvania Blue Shield and encourage practices to build internal safeguards into their daily activities.

PND: Who has the responsibility to expend the extra resources to insure that billing is not abused?

JHF: They could do their audits or they could financially reward practices that engage in acceptably established compliance programs. Or they could combine the two, paying a premium to those who have acceptable compliance programs and doing spot auditing to ensure that the compliance programs are working. Hospital of University of Pennsylvania, for example, has one of the most elaborate and best-developed correct documentation coding compliance programs in the country. We incur the full expense of that and receive no financial benefit for doing so. We’re subject to the same systematic downcoding as some other practice that may not be so attentive to correct charge submission.

PND: Both these suggestions would cost Blue Shield money. Wouldn’t that either raise premiums or lower reimbursements across the board?

JHF: It’s only worth doing if the level of abuse in the state is so high that more money is saved with correct coding than with the current situation. They can’t have it both ways. Either there’s a serious problem with incorrect coding, in which case it’s worth spending the money on an appropriate approach to encourage proper coding, or there isn’t enough of a problem to justify incurring the expense. And then they should not be systematically downcoding service charges.

PND: What avenues of recourse are you pursuing?

JHF: I spoke with a medical director at Independence Blue Cross and learned that the downcoding applies to Personal Choice, but not to Keystone Health Plan East, and that Independence Blue Cross would like to have the same policy applied to both of their major products. Subsequently, Independence Blue Cross put in a formal request to Blue Shield that they stop the downcoding process. That request hasn’t been honored. Also I turned to William McCauly, M.D., president of the Pennsylvania Thoracic Society, who teamed up with the president of the Pennsylvania Society for Critical Care Medicine. Those two organizations put in a formal request to Blue Shield to stop the practice. In recent phone calls we’ve learned that Blue Cross is not planning to change the policy at this time across the state regardless of current correct charge compliance programs. Our goal at this point, working through the Pennsylvania Thoracic Society, the Pennsylvania Society for Critical Care Medicine, and we hope also through the Pennsylvania Medical Society, is to persuade Blue Shield that fair practice is good business and that there are other, more appropriate ways for dealing with incorrect charge submissions by providers. We’d like to schedule a meeting with them in March to present to them the national Medicare data showing successful change brought about by auditing at the national level and discuss with them this option of financially awarding practices that voluntarily adopt compliance programs. I think we’ll also look to state regulatory options and we’ll be following with great interest events in Florida, where physicians are suing Humana over systematic downcoding. We’re hoping that reason will prevail.