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.
Continue reading More Changes to Medicare
I spent a couple of hours today discussing a topic that has become increasingly important in the world in which we live, and which would have completely mystified an earlier generation of physicians. The subject was “attribution.” Simply put, how should one decide which patients “belong” to which doctors? On a more technical level, what algorithms should be employed to connect patients, or episodes of care for those patients, or specific quality measures pertaining to those patients, to particular physicians?
Here’s why this is a hot topic. CMS is moving rapidly to alternative payment models. Medicaid is transitioning to a capitated system. Commercial payers are entering into “risk” arrangements with providers. All around us, fee for service is losing sway and is being replaced by a spectrum of new ways to pay for care. In the “old world” of fee for service, whoever provided the service got the fee. There was no mystery about how the dollars should flow. In the “new world” all that changes. In many instances, payments are linked to quality measures. So, for example, physician groups or integrated health systems may be subject to penalties or earn bonuses depending on how “their” patients do. Too many readmissions? Penalty. Excellent blood pressure control? Bonus. Simple enough in theory but complicated in practice.
Continue reading Who’s in Charge Here?
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
I wrote recently about the release of physician billing information by CMS and noted that news organizations had quickly provided tools to look-up individual physicians. Propublica an “independent, non-profit newsroom that produces investigative journalism in the public interest” has gone one better. In keeping with their mission to “expose abuses of power and betrayals of the public trust… through the sustained spotlighting of wrongdoing” they recently posted a more powerful online tool for analyzing and viewing the CMS data along with a companion story of what they found by using it. Continue reading More Sunshine
Last week, with little fanfare, the federal government made public all of the “Part B” Medicare expenditures from 2012. For the first time, it became possible to view – by physician – the types of services being billed, the number of each type, the charges, and the actual payment from Medicare. Continue reading Medicare Physician Payments
I really do not understand how Congress “works.” While it busied itself with passing a law that fails to fix the clearly broken “sustainable growth rate” formula for Medicare physician payments, it added in a surprise for the entire healthcare industry: a provision that mandates a delay in the adoption of ICD-10 by CMS. Continue reading Now What?
It has been freezing cold in much of the country for the last two months, but things have been heating up in the controversy over the implementation of ICD-10. First, a quick primer for those of you who have not been following this. Continue reading Why does ICD-10 feel so bad?
I have come to believe that fee for service (FFS), at least in its current incarnation, is an unsustainable model of financing health care. Pick up any newspaper or journal and you are likely to see that I am not alone. The reasons are as numerous as the faults of the present health care landscape – high costs, poor quality of care, unhappy patients, and unhappy providers. Continue reading Providers in the Insurance Game
I was invited to give a talk about “patient satisfaction” at a recent OB/Gyn Grand Rounds. I have written previously that “satisfaction” is a pretty low bar, and so I spoke instead about the patient experience. Continue reading Evaluating Physician Performance