BREAKING THE CODE IN MEDICAL NEGLIGENCE CASES

Transcription

1 BREAKING THE CODE IN MEDICAL NEGLIGENCE CASES ALEXANDER B. KLEIN, III The Klein Law Firm 2000 The Lyric Centre 440 Louisiana Street Houston, Texas Telephone: (713) Toll Free: (800) Facsimile: (713) State Bar of Texas 11 TH ANNUAL ADVANCED MEDICAL MALPRACTICE COURSE March 18-19, 2004 San Antonio CHAPTER 5

2

3 ALEXANDER B. KLEIN III THE KLEIN LAW FIRM 2000 The Lyric Centre 440 Louisiana Houston, Texas Telephone: (713) (800) Facsimile: (713) PRACTICE AREAS BOARD CERTIFICATION ADMISSIONS Medical, Hospital and Nursing Home Negligence; Pharmaceutical and Medical Device Litigation; Products Liability; Admiralty/Maritime Law; and Complex Personal Injury Personal Injury Trial Law Texas Board of Legal Specialization State Bars of Texas and Colorado; U.S. District Court, Southern District of Texas; U.S. Court of Appeals, Fifth Circuit EDUCATION South Texas College of Law, J.D., 1991 University of Texas, B.A., 1988 Sorbonne University, 1985 PROFESSIONAL ACTIVITIES PROFESSIONAL ASSOCIATIONS PUBLICATIONS AND PRESENTATIONS Member ( Present), Texas Pattern Jury Charges Committee (Malpractice, Premises and Products) College of the State Bar of Texas State Bars of Texas and Colorado Houston Trial Lawyers Association (Director) Texas Trial Lawyers Association (Director and Fellowship Member) The Association of Trial Lawyers of America Maritime Law Association Houston Bar Association Mr. Klein has presented various publications at the request of the State Bar of Texas, the Texas Trial Lawyers Association, the Harris County Medical Society and other professional organizations. BORN Houston, Texas, February 24, 1965

4

5 Breaking the Code in Medical Negligence Cases Chapter 5 TABLE OF CONTENTS I. SCOPE OF THE ARTICLE... 1 II. CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES (PHYSICIAN CODES)... 1 III. INTERNATIONAL CLASSIFICATION OF DISEASES, 9 TH REVISION, CLINICAL MODIFICATION (ICD- 9-CM) CODES (HOSPITAL CODES)... 1 IV. IATROGENIC CODES... 1 V. BREAKING THE CODE... 2 A. The Medical Bills... 2 B. Obtaining CPT and ICD-9 Codes... 2 VI. CONCLUSION... 2 i

6

7 Breaking the Code in Medical Negligence Cases Chapter 5 BREAKING THE CODE IN MEDICAL NEGLIGENCE CASES I. SCOPE OF THE ARTICLE Imagine a secret code used by doctors, nurses, and hospital administrators to document the patient s condition, diagnoses, surgical details, and medical errors. Imagine further that if these healthcare providers fail to provide the information in exquisite detail, the insurers will withhold payment for services. In fact, such a code exists and has been in place for many years. However, most lawyers (Plaintiff and Defendant) are wholly unaware of the code. This paper focuses on strategies for identifying and utilizing the information recorded by healthcare providers in the form of CPT and ICD-9 codes. II. CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES (PHYSICIAN CODES) CPT is Current Procedural Terminology, and was developed by the American Medical Association in Current Procedural Terminology (CPT) is a set of codes, descriptions, and guidelines that are intended to describe procedures and services performed by physicians and other healthcare providers. Every procedure or service is identified with a 5-digit code that is utilized for billing purposes. Each year, the American Medical Association publishes a new edition. The CPT book is broken down into the following sections: Evaluation and Management Anesthesiology , Surgery Radiology (Including Nuclear Medicine and Diagnostic Ultrasound) Pathology and Laboratory Medicine (except Anesthesiology) , Every bill created by every physician in the United States contains CPT codes. These codes must be submitted to insurers in order for the medical provider to receive payment. However, CPT codes often contradict the statements written in the patient s records by the physician or healthcare provider. Since the penalty for failing to properly code can range from non-payment to charges of fraud, physicians most often do all of their own coding. The codes are then used by the offic e staff to forward invoices for payment. III. INTERNATIONAL CLASSIFICATION OF DISEASES, 9 TH REVISION, CLINICAL MODIFICATION (ICD-9-CM) CODES (HOSPITAL CODES) The International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization s 9 th Revision, International Classification of Diseases. The ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. 1 2 The ICD-9 code manual includes: (1) a tabular list containing a numerical list of the disease code numbers; (2) an alphabetical index to the disease entries; (3) and a classification system for surgical, diagnostic, and therapeutic procedures (alphabetic index and tabular list). Hospital bills contain numerous ICD-9 codes that apply to diagnosis and treatment. It is noteworthy that various codes even relate to causation. IV. IATROGENIC CODES The term iatrogenic is an adjective that describes any adverse mental or physical condition induced in a patient through the effects of treatment by a physician or surgeon. Codes that contain the term iatrogenic typically refer to injuries caused by the physician or healthcare provider. There are approximately 38 1 The Healthcare Financing Administration (HCFA) requires the use of the HCFA Common Procedural Coding System (HCPCS) for Medicare claims. 2 The International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM) Coding System classifies diseases and injuries into groups of related cases which are used for statistical purposes. The system is based on the World Health Organization s International Classification, and is revised annually. This coding system provides for the translation of medical terminology into numbers of codes. Both alphanumeric and numeric characters are used to describe an injury or disease. 1

8 Breaking the Code in Medical Negligence Cases Chapter 5 separate ICD-9 codes that pertain to iatrogenic conditions. For example, ICD-9 code refers to accidental puncture or laceration during a procedure, accidental perforation by catheter or other instrument during a procedure on: blood vessel, nerve, organ. These codes routinely appear in billing records, but the existence and significance are often overlooked. V. BREAKING THE CODE In order to break the code, you must have the medical bills and copies of the code books or access to online services that furnish CPT and ICD-9 coding information. A. The Medical Bills ICD-9 and CPT codes appear in all bills prepared by healthcare providers. It is prudent to obtain all billing records from all medical care providers, including subsequent treaters. This is particularly noteworthy because subsequent treaters and physicians called for consults routinely include codes pertaining to iatrogenic injuries. CPT codes are most often selected by the physicians. For example, physicians routinely utilize coding sheets that contain sometimes hundreds of different codes with descriptions for the physicians to check at the conclusion of an office visit. These billing sheets are then given to staff that prepare the bill. Send a Request for Production seeking all coding sheets utilized by the physician and/or clinic in connection with coding. Most often, this Request should be sent after you have reviewed the initial codes and take the deposition of the Defendant or healthcare provider. In other words, there is no sense in alerting the Defendants to any billing code issues until after the trap is sprung during deposition. Codes are utilized regardless of the patients form of payment. Consequently, even fee for service patients will be presented with bills that contain CPT codes and/or ICD-9 codes. In the hospital context, bills contain numerous ICD-9 codes that are selected based upon information provided by physicians, nurses, and other hospital staff. Frequently, the billing codes may be selected by an individual that had little or no patient contact. However, that individual typically had significant information about the care that was provided and the condition of the patient. The billing codes often reflect information that the healthcare provider may otherwise have been reluctant to include in the medical records. However, the information is contained in the billing records because the insurers will not provide payment without receiving detailed coding. Employees in the billing department understand that more codes mean more money. Also, the software at various insurers recognizes when the codes are incoherent or incomplete. As a result, coding tends to be exceedingly accurate, with little or no thought given to the risk management implications. Every code from every bill should be identified and compared to the information that was recorded in the patient s records. Many medical negligence cases arise because a particular healthcare provider fails to devote adequate time and attention to make the correct diagnosis. A detailed review of the billing codes often reveals that the healthcare provider devoted significant thought to the preparation of the bill, but the treatment records tell a different story. A conflict between the billing codes and the medical records defies explanation or excuse, and often makes impossible what would otherwise have been the best defense. B. Obtaining CPT and ICD-9 Codes The CPT code book (primarily used by physicians) is published by the American Medical Association and is available at at a cost of $ The American Medical Association updates the book annually. CPT codes are also available free at The ICD-9 code books (primarily used by hospitals) are available at for approximately $ The Texas Tech Medical Center at El Paso offers a free ICD-9 code database with search engine at VI. CONCLUSION Over the years, we have found billing codes that drastically impacted liability and causation. These billing codes contain the impressions of physicians and healthcare providers and are chosen contemporaneously with the provision of care. The billing codes are as significant as medical record entries or deposition testimony because the codes represent extensive descriptions of symptoms, diagnoses, treatments, and even the cause of particular conditions. The significance of billing codes cannot be understated. Breaking the code is an indispensable step toward the goal of conclusively establishing the Defendants negligence and maximizing damages in every medical negligence case. 2