The Math of E/M Coding: When Does 5=1?

My typical Medicare patient expects me to deal with 5 or more problems in a single routine visit.  There are usually around 3 old ones (e.g., diabetes, hypertension, hyperlipidemia) and at least 2 new ones (e.g., low back pain, fatigue).  For those who come with handwritten lists, there may be as many as 10, including every health question that has come to mind over the past 6 months (Should I take a holiday off of Fosamax? Should I add fish oil? Do I need another colonoscopy? Is the shingles shot any good?).

Physicians who do procedures get paid for each one done to a single patient on a particular day. Medicare’s rule for this – the Multiple Procedure Payment Reduction Rule (MPPR) – says doctors should be paid 100% for the first procedure and 50% for each subsequent procedure up to 5. However, for those of us whose work is primarily cognitive rather than procedural, there is an important exclusion:  the multiple-payment rule does not apply to E/M codes.  In fact, the definitions of 99213 and 99214 unambiguously state, “Usually the presenting problem(s) are of . . . complexity.” Note the “(s)”! It clearly creates a double standard that favors doing procedures and places thoughtful solving of patients’ problems at a disadvantage.

So in my case, 5 or 10 or more separate patient problems equal one payment. The “(s)” in the AMA’s CPT book is the most outrageous injustice to primary care of this generation.  Because of it, the AMA’s CPT committee is accountable for even more damage to primary care than is their RUC!  Think how different life in primary care would be if the “(s)” were removed and you were paid 50% for each additional patient problem you addressed in a single office visit!

The AMA’s CPT committee is quite sophisticated in dealing with multiple procedures and regularly adjusts its coding to reward proceduralist physicians with targeted CPT codes.  For example, there are unique CPT codes for 1,2,3,4,5, and 6 coronary artery bypass grafts. For podiatrists, there are individual codes for nail debridement of 1 to 5 toes and a separate one for 6 or more toes. Dermatology has become a rich field by taking advantage of this coding tactic. The most recent example is CPT coding for Mohs surgery, for which the AMA has awarded a separate procedural code for each slice up to 5.  Is it any wonder that my patients are now presenting with 5-slice Mohs (never 6) on simple basal-cell cancers that could have been easily removed with a simple excision?

The biggest brouhaha in medical coding at the moment is the indignation of radiology for being subject to the MPPR at all, since they are accustomed to being paid the full price for each and every scan they read, no matter how many are on the same patient on the same day. In a letter from the American Society of Neuroradiology to Don Berwick, head of CMS (“We are the preeminent society concerned with the diagnostic imaging and image-guided intervention of diseases of the brain, spine, and head and neck.”), the outraged radiologists claim that the reduction “represents a drastic departure from data-driven reimbursement policy.”

Maybe I missed something, but I don’t think you can accuse CMS of being data-driven on anything! The coding process is political with both rigged codes and rigged relative value. For radiologists, 1 = 1. For me, 1 = 5 or more.

The national unemployment rate is over 9%, spiraling health care costs have bankrupted the US Post Office, and the country has no primary care doctors for the 32,000,000 soon-to-be insured.  So, to the 4,300 physicians specializing in neuroradiology, I say “suck it up.” A double-dip recession is looming.

Paul Fischer MD is a primary care physician at the Center for Primary Care in Augusta, GA. With 5 other primary care colleagues, he recently filed a suit in Maryland Federal Court challenging CMS’ refusal to require the AMA’s Relative Value Scale Update Committee (RUC) to adhere to the requirements of the Federal Advisory Committee Act, even though that panel has been CMS’ near sole advisor of medical services valuation for nearly 20 years.

6 replies »

  1. That patient with 10 problems? The proceduralist needs to care for that patient at 4:00 in the morning, while they are bleeding and/or septic. If we ignore those 10 problems, the pt dies. The proceduralist does cognitive work, plus the procedure. Ok, only 9, we dont talk about fish oil.


  2. Dr. ehscott,

    Yes, agreed that initial consultation in which most specialists are asked to render an opinion are billable as an E&M code. However, note, that at least in my practice (vascular surgery) NONE of the referral doctors dictate or even suggest whether or not I proceed with a procedure (many diagnoses do not even require a procedure). I am responsible for the appropriate decision, workup and plan (hence the term ‘consultation’). I am sorry for the status of the ‘proceduralists’ where you practice and understand your position if this is so.

    Note though that any E&M code proceeding to surgery within 24 hours and for 90 days after is not billable. For me at least, this includes between .5 and 25 hours of direct patient care PER procedure which is compensated for in the procedural code.

    But as Dr. Fischer offers, how exactly do we establish the cognitive complexity of anything we do in a fair and reproducible manner, and tie it to compensation? What about those who put a lot of cognitive effort into complex problems yet have poor outcomes? Be assured that if payment were to reflect ‘complexity’ for E&M, we will see a tremendous increase in ‘complex’ problems and diagnoses, no different than multiple procedures or add-on codes or self-owned imaging studies that run afoul. Current volume-based systems are ripe for being ‘gamed’, unfortunately.

    Still no one here has yet to lay-out a realistic alternative. I will ask again, how should we consider on-call and available hours, bedside time for inpatients, liability etc.? These represent true ‘costs’ beyond cognitive complexity. It would be interesting to see the primary care response to this given (at least where I am) primary care docs turnoff their phones at 5pm and take no night-weekend call, don’t go to the hospital, have 1/2 of the training debt I do, and malpractice rates that are 1/8th of mine. Bundled payment for sure is coming, in agreement with Dale, and could ease cost and the reimbursement gap.

    In this month’s HBR, the time-based cost analysis of Kaplan and Porter ( http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/1 ) may hold some merit Simply accept that some will deal with more complexity, some with less, some do procedures some don’t, but adjust reimbursement to reflect the true ‘cost’ of time, overhead etc. regardless of ‘number’ of procedures or specialty.

  3. Dr Motew, this is crappola. Proceduralists also bill for E&M, so they get paid for preparing/discussion/educating (even thought it is usually their PA or FNP who does that). As far as “diagnosing”, their patients have already been diagnosed — by the person that referred them to the proceduralist in the first place. Proceduralists are much less concerned with a diagnosis than they are with an indication. You need an indication to do a test, that is what they are looking for. Chest pain is an indication for a cardiac workup to a cardiologist, even though the chest pain is atypical for heart disease and more typical for GERD

  4. Your posts have quickly become one of my favorites…nicely done again. The granular, CPT-driven reimbursement model has limited days of life remaining. Employers are going to force the change to fixed-fee, bundled payments on private payers, regardless of CMS. The only question I have is, will primary docs continue to be among the most underpaid professionals in terms of their value to society– the way of fireman, teachers, and policeman– or will employers force a leveling of salaries– primary care docs get an increase and specialists a decrease. I’m betting that the latter is going to happen.

  5. Is Dr. Fischer implying that since proceduralists are compensated too much for multiple procedures, primary care docs should be as well? Let’s be clear that procedures include not only the work associated with the procedure but ALSO the cognitive aspects of diagnosing, preparing, discussion, educating as well. How should this be accounted for?

    As I have posted time and again, the faults of the current system are not contended, yet the incessant ‘whining’ from primary care seems to be getting nowhere. I am all for a fair system, one that takes into account all of the aspects Dr. Fischer mentions, but also does not ignore: on-call hours, malpractice risk, job stress, time, unassigned care coverage, quality….Where is a balanced recommendation? The lack of a cohesive approach to a fix is exactly why the current system is maintained by CMS….there is simply no ‘better’ solution that has been proposed here.

    To Matt, where is some editorial oversight to these continual one-sided postings/whine session?

  6. Good post.

    The devaluation of cognitive services is so deeply imbedded in our current payment system that even most docs don’t see it.