I am a retired family physician (FP) and do extensive traveling in my RV. Since I have multiple medical problems, I attempt to carry with a copy of my medical records with me. I am often surprised by the information that is included in the office dictation or the hospital record and wonder how that information was obtained since it was not elicited by asking me for the info.
Case in point number one: My hospital admission for asthma exacerbated by infection. I was seen and managed by a pulmonary doctor. Great care; my history was taken; I was treated for four days with several visits for the first two days, and good follow up in office.
I was admitted to an FP who consulted pulmonary. The FP was in the room twice. And he did not introduce himself. He listened to my lungs for 15 seconds on one occasion. My second visit was while using a nebulizer and I was observed for 10 seconds, and the doctor left and did not return. I am sure he reviewed my chart and was aware of my treatment and progress during my stay. I was amazed to find he billed Medicare for H&P, daily visits and discharge summary. His H&P had to be a copy of the pulmonary note and documented activities he did not perform. I would think this qualifies as upcoding and wonder if this the only way physicians can survive with the current low reimbursement rates?
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