Be mindful of the patient: Would you want to get an unanticipated bill or unclear diagnosis?

May 13th, 2019 / By Jean Jones, CPC

The Boston Globe is running a series of articles about patients being billed for out-of-network providers in the healthcare setting. The articles detail how patients get hit with a surprise bill for out-of-network providers and their frustration with having to battle illness as well as huge unexpected expenses.

The article details a patient that had a routine colonoscopy and was charged for some out-of-network expenses. We all go in for our routine medical services—As my grandma used to say, “An ounce of prevention is a pound of cure”—but we don’t expect that any part of a preventive, routine procedure like a colonoscopy would be considered out of network.

As healthcare consumers, we have all seen the rise of insurance deductibles combined with dwindling insurance coverage. Personally, I budget my $3,000 family deductible every year and I am fortunate to have a health savings account. Our family tends to visit healthcare providers more frequently once our deductible is met, but we still think long and hard about going to a clinician even after satisfying our deductible. 

I see the impact of this issue as a consumer, but on the flip side, I see the effects of rising costs and declining reimbursement in my work as a healthcare professional. I have been around the healthcare industry my entire adult life. I typed out claims on an old-fashioned typewriter and signed UB82 forms by hand. I remember the day a new program launched called “PQRI”—Physician Quality Reporting Initiative. Fast forward to today, and we have MIPS—Merit-Based Incentive Payment System. 

I recently presented at the annual conference of AAPC (American Academy of Professional Coders). In preparing for my talk, I did some research on MIPS. I love how the MIPS measures of today work in conjunction with the aims of National Quality Strategy (NQS), especially the domains for cost as it relates to MIPS measures. The aim is to reduce the cost of health care for government and employers, as well as patients. This sounds great to a lady that must budget her family deductible every year!

A simplified version of MIPS goes like this: Clinicians report on the measures they qualify for and in turn they receive financial incentives. I am just scratching the surface here, as the incentive process is complex. Essentially, MIPS is a program where clinicians can report a series of codes and receive payment based on a complex algorithm.

An example of a NQS domain categorized for cost and efficiency is MIPS quality identification 146, a measure that clinicians report when screening mammograms that have the impression of “probably benign lesion.” Every MIPS measure has a rationale statement, and after reading the one for 146, I had the same feeling as I had when reading the Boston Globe articles. Here is the rationale for measure 146 as per the CMS website:

The “probably benign” assessment category is reserved for findings that have a high probability (≥98%) chance of being benign and should not be used as a category for indeterminate findings. Inappropriate designation of findings as “probably benign” can result in unnecessary follow-up of lesions that could have been quickly classified or delayed diagnosis and treatment of cancerous lesions. Published guidance documents emphasize the need to conduct a complete diagnostic imaging evaluation before making a probably benign (Category 3) assessment; making it inadvisable to use the probably benign categorization when interpreting a screening mammogram. Immediate completion of a diagnostic imaging evaluation for abnormal screening mammograms eliminates potential anxiety that women would endure with the short interval follow-up that is recommended for “probably benign” findings.

The key phrase here is “making it inadvisable to use the probably benign categorization.” Providers are reporting probably benign on their screening mammograms.  I am not a clinician so I am not sure of their rationale, but according to MIPS measure 146 it is not advisable to use this category. I appreciate the section of the rationale that states there is potential for anxiety in women receiving the news of a potentially benign category (I am sure that I would be one of those women). 

The impact of unclear diagnoses on billing is addressed in another great article on the topic of surprise medical bills, this time in The Wall Street Journal. The article details a scenario where a highly suspicious lesion was found:

“Other times, surprise bills arise when a patient unknowingly received some care the health plan didn’t consider preventive—even if it resulted from a finding made during a screening. For instance, doctors may order more views of suspicious masses they spot as they are doing screening mammograms. This then gets appropriately billed as a diagnostic mammogram, which deals with existing symptoms, rather than a screening, which is for people without any specific signs of risk. For patients, that shift could mean new fees.”

The suspicious lesion can be reported under MIPS measure 146, as there is a category for “suspicious lesion.” It isn’t a “probably benign” designation, but it still might impact the patient in terms of cost. The cost reduction related to MIPS measure 146 is due to the fact that unnecessary tests could be ordered for a “probably benign” category.  The probably benign category is known as Bi-Rads 3 and based on a quick Google search, there is a lot of confusion for everyone concerned.  Here is a great study on the subject published by the National Center for Biotechnology Information.

In closing, it is always helpful to think about how the diagnosis or follow-up care will affect the patient. The patient could receive an unanticipated bill or have anxiety around the “probably benign” category. I am excited to see how NQS and MIPS will help the healthcare system as a whole. As a consumer, I hope for the days when I don’t have to worry about how I am going to pay for a bill or when an unclear diagnosis is more clearly communicated. On the clinical side, I would run a report on HCPCS 3343F and have much needed discussions around MIPS measure 146. This is an inversion measure, so you will meet the criteria by not reporting probably benign language. As coders, this is a concept that we are used to, as the guidelines state we aren’t even able to code, “rule out or probable language.”  PQRI has evolved into the complex MIPS system which aligns beautifully with the NQS domains. I will leave you with this final thought: If you work in the healthcare industry, think of yourself as the patient receiving a bill that you did not anticipate or an unclear diagnosis..

Jean Jones is a coding analyst at 3M Health Information Systems.