Tag Archives: Reimbursement

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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Adjusting the Adjustment

Measuring the quality of care and improving it over time is a fundamental obligation of healthcare providers. Increasingly, quality is also tied to reimbursement and is reported publicly. While I strongly agree with both trends, three recent articles point out some of the challenges ahead.

The common theme among them is that “risk-adjustment” is a hard thing to do. A brief diversion to provide some context.

There are two main ways to measure and compare quality. One is to assess processes of care, such as adherence to established best practices and evidence-based treatment guidelines. This is relatively easy to do, but is by definition highly reductionist. Clinicians understand that “good care” is more than the sum of a handful of isolated activities. Does anyone really think that good diabetes care is equivalent to measuring the HgbA1c level annually and making sure that everyone is screened for diabetic retinopathy? The other way to me is to assess patient outcomes, or how patients actually fare at the hands of different providers. This allows for comparison of endpoints that providers and patients find important, and frees providers to innovate. The challenge is that it is very difficult to separate the relative impacts of patients’ baseline characteristics from the care received in determining the outcomes.

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