Category Archives: Medicare

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.

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Not Your Father’s Medicare

When the Affordable Care Act (ACA) was passed in 2010, the most contentious provisions – which are still the subject of challenges in federal courts – were the establishment of state-wide insurance exchanges, the “individual mandate” that compels eligible citizens to buy insurance, and the expansion of state Medicaid programs. Less well appreciated, but arguably more important, were a wide range of reforms to the Medicare program. Summarized here, they touch on almost all aspects of the program, but I want to concentrate on just one.

The law directed CMS to move Medicare from a strictly fee-for-service (FFS) payment model (“paying for volume”) to one in which the quality of care was factored into the payment received by hospitals and physicians (“paying for value”). As I have written previously I believe this is the right move. There are just too many challenges to improving care and lowering costs that derive from “straight” FFS that is disconnected from any assessment of quality. And while you may not have known that they grew out of the ACA, the payment reforms themselves have gotten a lot of attention. Penalties for readmissions, requirements for physician quality reporting, pilot programs for bundled payments and accountable care organizations are just of few of the Medicare reforms. Even though they currently influence a small percentage of overall Medicare spending, these changes may already be having a big impact on how care is delivered.

Continue reading Not Your Father’s Medicare