The push for major healthcare reform has exposed a number of schisms between physician groups and among physician specialties. Now, a seemingly minor regulation threatens to do the same thing.
Purging CPT consulting code draws mixed reviews
Under regulations that take effect on Jan. 1, 2010, Medicare will eliminate the Current Procedural Terminology, or CPT, code for consultation services that specialists use when they see a patient referred to them by a primary-care physician. Under the current billing, specialists are paid for evaluating the patient and then writing a report that the patients’ regular physicians use to guide their treatment.
The American Association of Clinical Endocrinologists, or AACE, however, says that the change will lead to reduced income for its members, and that will result in them seeing fewer Medicare beneficiaries with diabetes and will lessen the quality and coordination of care their patients receive. “It’s sort of a recipe for discoordinated, uncoordinated or poorly coordinated care,” said Jeffrey Garber, AACE president and chief of endocrinology at Harvard Vanguard Medical Associates. “We’re cognitive specialists, and they’re taking away the essence of what we do.”
Garber said endocrinologists whose practices don’t depend much on referrals from primary-care physicians might not be affected much—but, if the percentage is higher, “you lose.”
Not true, according to Lori Heim, president of the American Academy of Family Physicians and a hospitalist at
102-bed Scotland Memorial Hospital in Laurinburg, N.C. She said the elimination of the consulting code will be almost entirely offset by a 2% increase in reimbursement for codes relating to inpatient evaluation and management service and a 6% boost for ambulatory evaluation and management codes.
Heim described the consultation code as “overvalued,” and said it led to the CMS paying for paperwork—not patient care. In a Nov. 30 letter to acting CMS Administrator Charlene Frizzera, the AAFP said the rule changes could result, on average, in a 4% increase in most family physicians’ allowed charges to Medicare, and Heim acknowledged this increase means other providers will get a smaller slice of the Medicare pie.
“It’s budget-neutral, so it’s a shuffle,” Heim said of the rule changes. “The payment has shifted, but it’s not a wholesale elimination of payment. ... Some of the changes will lead to a small increase in primary-care compensation. But, if we are going to have a primary-care workforce in the future, we have to increase payment for primary care.”
According to CMS spokeswoman Ellen Griffith in an e-mail: “We have eliminated the consultation codes based on our findings that there is now little difference in the work involved in consults and the equivalent evaluation and management services and to eliminate the long-standing confusion between when a consult and an evaluation and management service can be billed. Moreover, we have used the savings from eliminating the consultation codes to improve payment for office and hospital visits. CMS will be conducting extensive outreach to physicians about how to comply with the new coding policies.”
The nation’s largest physician groups—the Chicago-based, 236,000-member American Medical Association, and the Philadelphia-based, 129,000-member American College of Physicians—are not taking sides on the coding change other than to seek a delay in implementation. The ACP calls for a delay to “be of a duration that allows time for a constructive dialogue” between the CMS and physicians to address all pertinent issues, while the AMA is asking for a one-year postponement of the changes.
On Nov. 9, the AACE posted an online survey for its 5,000 domestic members, and 1,083—21.7%—participated. The survey noted that, under the new rules, when an endocrinologist is called to a hospital to consult on a diabetic Medicare patient, instead of the average reimbursement of $202 they now receive, they will only get $180—or, if the scheduled 21.5% Medicare payment cut goes in effect, $147. Or, if a Medicare patient comes into their office with multiple comorbidities, instead of the average $227 payment they now receive, they will only get $180—or $150 if the cuts take effect.
Under these scenarios, 32% of the respondents said that they would reduce their Medicare inpatient consultation availability, while 21% said that they would stop seeing Medicare consultation patients in the hospital altogether. Half said they would reduce office consultations for Medicare patients, and 21% said they would stop seeing Medicare consultation patients in their office altogether.
Of those surveyed, 83% said diabetes care accounts for at least 41% of their practice; and 84% offer inpatient consultation for diabetics.
The AMA’s letter requesting the delay said an underlying cause for the CMS’ decision to eliminate the consultation code was that consulting physicians are no longer required to send referring doctors a report on their findings.
The letter also noted how discussions regarding the coding changes took place between 2006 and 2008, but Garber said the AACE’s understanding is that “there are some CMS bureaucrats who have wanted to move this along for a couple of years” and that it wasn’t necessarily being driven by the Obama administration.
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