More Changes to Medicare

I am a terrible coder. I think I am a pretty good doctor, but when it comes to coding, the process of figuring out which billing code to pick to assign to a bill for an office visit, I am hopeless. No matter how many times I have had the rules explained to me, or how much feedback I have been given about specific visits, or which “pocket guide” to coding I have been handed over the years, I can’t seem to get it right. Even my errors are non-systematic. Sometimes I “over-code” (picking a visit level insufficiently supported by my note) and other times “under-code.” And the things I get wrong are all over the map – sometimes my history lacks some “elements,” sometimes my review of systems covers the wrong number of systems, sometimes my exam is shy an organ or two…you get the idea. It is very hard to get better if you keep doing different things wrong. Of course, this begs the question why doctors should be coding as well as doctoring, but that is an issue for another day.

For now, my deficiency explains why I was intrigued to learn that CMS recently proposed changing the rules governing the coding and reimbursement for physician office visits. Currently, we are bound to rules for so called “evaluation and management” (E&M) visits that date back to the mid-1990s. The rules align the 5 levels of visit intensity (each coded with a different billing, or CPT code) with required documentation. There are parallel sets of codes (and documentation requirements) for new patient visits and established patient visits. Did I mention that this guidance is 90 pages long? Each code carries a different level of reimbursement, and commercial insurers use the same codes (at different price points) to pay for care of their subscribers.

The new proposal pretty much scraps all of that. CMS is floating the idea of “collapsing” levels 2 through 5, and creating a single payment level for established patients and a single payment level for new patients, each of which is somewhere in-between what is currently paid for a simple (level 2) or complex (level 5) visit. The stated rationale is that physicians would be able to spend more time with patients and less time stressing over what to code (or typing clinically irrelevant stuff in the medical record to justify higher levels of billing). In the words of CMS, it will favor “patients over paperwork.” You can read all 1472 pages of the proposed changes to the Medicare physician fee schedule here.

Of course, as is the case with any scheme that “lumps” instead of “splits” there will be losers and winners under the new rules. Physicians who routinely see complex patients, or deal with complex issues, and have been appropriately documenting and coding higher level visits, will see a net decrease in their reimbursement; those who generally deal with simpler clinical situations will get a bump. That creates a potentially dangerous incentive to avoid sicker patients and the (unreimbursed) time they need.

To be honest, I am not sure how I feel about the proposed change. As a lousy coder, I welcome the simplification. On the other hand, I am concerned about access to care for complex patients. Mostly, all of this detail about connecting documentation to reimbursement is just a sad reminder of a fundamental problem with fee for service medicine. If we want to get paid for “piece work” then we have to prove we did what we said we did.

As I wrote back in 2013, I think we and our patients would be better off “If we were compensated for caring for a population of people, and judged on their health outcomes (appropriately adjusted for the prevalence and severity of their illnesses).”

I still think this is true.

What do you think?

5 thoughts on “More Changes to Medicare

  1. In this age of AI, there should be an algorithm that can adequately alert you to how to code a visit and alternately alert you to what documentation might needed to be added to meet your coding if it seems like you have up-coded a visit more than your documentation supports. You should not have to waste your days trying to remember the rules but focus on caring for patients.

  2. Most informed citizens, if interested in how healthcare works, and if led to understand that physicians actually code their own visits, would be as baffled as I have always been about how this ever came about. What box is checked by this system: working top of license? (Certainly not.) Objectivity? (I doubt it.) Accuracy? (I bet I’m worse than Dr. Nash!) Efficiency? (Ummm, no.) And so I share Dr. Nash’s ambivalence – I’m happy to see the status quo change, and yet this may negatively impact the patients who need us most. As is so often the case, however, the last buffer between economics and patient harm is our collective inclination to do the right thing, regardless.

    1. Thanks for your comment! I agree — the current practice makes little sense. I suspect that it started with the not-so-unreasonable practice of having doctors affirm what they did during an office visit. As with the parable about the frog in the increasingly hot water, we didn’t “jump out” as the rules got more complicated, and are now stuck with a job for which we are ill-suited.

  3. Hi, Not a Dr., just the daughter of an 82 year old who is a victim of the system. Not so much a “dr.” situation but more to do with what happens when they are in the hospital with no one doctor in charge but rather a different “Hospitalist” with no real skin in the game. A focus on “outcome” would have served my mom well. One better, a system based on “outcome” may help to avoid the hospital all together and reward doctors for a job well done! I hope your voices are heard!

    1. Thanks for your input. I agree! A focus on outcomes (especially patient reported outcomes) can focus care where it belongs — on the patient — instead of on tallying up all the activities of caregivers.

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