Voldemort vanquished? It may be happening in medicine.
Medicare used the summer doldrums, when traditionally Washington is in its swampy seasonal lull, for an announcement that may revolutionize medicine as we practice it. That’s a lot of hyperbole for a proposal that saves no money, costs no money (revenue neutral), and has no effect on the actual practice of medicine. This virtual bombshell has the potential to save us from the Voldemort we have been losing an epic struggle with for years – our own “he who must not be named” – E&M coding.
Begin our story with the villain entering for his introduction on stage right. E&M codes have become the fundamental measure of how everyone determines how much to pay for medical services, and the coding definitions have been carved down to a level of detail and precision that is mind-numbing. There were 2 interpretations of the guidelines on how to use these codes – in 1995 and 1997 – and both systems are “acceptable” to use. That alone tells you how illogical this process is. This “coding by counting bullet points” devolves a clinical and highly interpersonal encounter between a physician and a patient into a quantifiable series of structured data. The result is a process completely incompatible with the practice of medicine as it should be, but the specified actions and documentation are required in order to be paid. Physicians have been forced to learn a complex and irrational process to sustain their financial base, and much (most) of their clinical time is devoted to visit coding and its required documentation. Few physicians have mastered it, and since experts who review records and professional consultants disagree about E&M coding, it is not clear that anyone can be expected to do this both efficiently and well when the standards are so extrinsic to logic and workflow. E&M coding is complex and expensive as well as psychically draining for the professionals who use it. Major evil.
But a parallel cruelty has been the dreaded and ubiquitous audit used to enforce the despised process. Too many physicians have been bludgeoned to submission by these retrospective reviews with “extrapolation” to visits unexamined and ultimately being forced to pay large financial penalties for doing their professional work correctly. But even more physicians have been intimidated by the fear of audit and consistently undercode. They prefer underpayment for the work they due to the trauma of hiring lawyers and accountants if they are targeted for one of these notorious audits.
Now enter Harry Potter on stage left – otherwise known as CMS. In a revolutionary development, CMS has proposed that Medicare will have one fee for all 4 of the physician E&M office codes 99212-99215. They have done a detailed financial analysis and have set the new fee – which is scheduled to go into effect January 1 – to be revenue neutral. They will pay the same amount for these services as they do now, but the requirements for the documentation minutiae will disappear, and the overhead and paper work will be reduced dramatically.
First the (very) good news. Even though payments are “neutral”, physicians benefit tremendously from overhead reduction and administrative simplification. CMS estimates that it will reduce overhead by 7%, but those of us in practice realize that it will almost certainly be much more than that. The psychological effects of not having this albatross will be powerful even though they cannot be measured as well. Finally, this represents the very real hope that progress notes may once again become progress note, not billing justifications masquerading as a clinical document. This is a win-win-win that would also “go viral” -whatever CMS does, all the other insurers will be sure to follow. Thank you, Harry Potter (disguised as Seema Verma, CMS administrator).
But we must pause. There are problems with this proposal. ACP has come out against it because of its imperfections. They correctly note that it does not share its blessings evenly amongst all physicians and there are both winners and losers among various specialties. Podiatrists oddly enough are the biggest winners, and ACP is concerned that the cognitive areas with high acuity patients, such as geriatrics, are the biggest losers and it will discourage high intensity care of complex patients. They want changes, modifications, improvements, and testing with a careful eye on making sure that the physicians who take care of our frail and sickest are not adversely affected by this new program.
The comment period is over, and CMS has not announced if they will still roll this out on 1/1/19 or delay for more tweaking based on comments such as those from ACP. My sense is they may delay, but this train has still left the station and is coming. The effect that this will have on the practice of medicine should be profound and positive for all of us who have been fighting this battle on the front lines for so many years. I can see the light, and it is not far. Thank you, Harry. Goodbye Voldemort.
