Billing and the Review of Systems

Some parts of the current reimbursement system do not make sense to me. In particular, the "complexity" of an outpatient case is dependent on the number of "systems" checked. That is, regardless of what the patient comes in for, how we bill for that visit depends on whether we ask about all 14 organ systems. To be honest, I can't even think of what all these organ systems are, but in a complete 14-point review of systems, we ask about fevers and chills, nausea and vomiting, chest pain, shortness of breath, cough, weakness, urinary incontinence, swelling, muscle and joint aches, hearing changes, and a host of other particulars that likely do not affect the diagnosis or treatment of the patient at all. This is a bad way to do medicine; although we want to reward thoroughness, this is essentially saying that everyone should have everything checked on every visit, a mentality that pervades through American medicine as we order CT scans, ultrasounds, and MRIs with little justification, driving up health care costs. Furthermore, the clinical complexity of a case has nothing to do with this "review of systems." Indeed, most clinics maximize their billing potential by giving the patient a long checklist of symptoms so the doctor doesn't have to do this mundane laundry list. Attendings occasionally admonish me because I don't document in my note certain phrases to meet billing requirements. For example, family history can be essential in some diseases but irrelevant in others, and yet our billing schemes do not differentiate between the two (plus, I have blogged in the past about the utility of family history anyway). In any case, as a resident whose salary is fixed but whose role is to make the department money, trying to understand the quagmire of billing is intensely frustrating.