Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, July 31, 2009

Medicare Micromanaging

The latest kerfuffle drawn from the double-ream of paper that is the new Congressional health care reform bill stems from the provision about allowing payment for a discussion of end-of-life care every five years. (What if the patient develops a new life-threatening condition four and a half years after the last discussion? Sorry, dude. You should have either thought of that four and a half years ago, or waited six more months to get sick.) Several other bloggers have already weighed in, mostly in an effort to debunk the deceptive misreading by right wingnuts claiming that the provision calls for euthanasia (which it of course does not).

The fact of the matter is that the provision is unnecessary, and is just another example of governmental attempts to micromanage medical care. This is an assertion I can actually prove.

In the first place, Medicare already pays for counseling. As long as more than half the face-to-face time of the visit consists of "counseling and/or care coordination," Medicare pays the visit based on the elapsed time of the encounter. Please note that there are no limitations on the topics discussed for the visit to qualify for payment. I can and do frequently bring elderly patients into the office and spend the entire visit discussing issues such as end of life care. I document and bill it accordingly, and no one blinks an eye. Nor should they; this is a completely legitimate medical encounter. It doesn't matter whether it happens once a year, once every two months or once every five years; whatever is appropriate for a particular patient is what I do.

That is why this new provision adds nothing of value to Medicare patients. On the surface it may sound like a good idea, but I have an example of something else that started out making sense that, once the government got ahold of it, perverted it completely out of any semblance of usefulness. I am speaking of the "Welcome to Medicare" physical.

It turns out that the way the original legislation was written, Medicare is legally forbidden to pay for preventive care. Various specific work-arounds have been legislated over the years to allow payment for specific items such as flu shots and pneumococcal vaccination, and a few years ago Congress decided to explicitly include a single preventive care service. Because this service was only eligible for payment during a patient's first six months (more recently extended to twelve months) on Medicare, it became known as the "Welcome to Medicare" physical.

"Wonderful!" I thought when I first heard about it. Finally, Medicare would pay for at least one preventive visit actually so labeled, as opposed to a more extended evaluation once a year that I usually do for my patients with multiple problems that I think of as a "physical" in my head, but never dare write down on paper. Ah, but then the devilish details came out.

Apparently Medicare didn't trust my version of what constitutes an appropriate preventive care visit. Instead, they promulgated detailed regulations about what the encounter had to include:
  • Height
  • Weight
  • Blood pressure
  • Visual acuity
  • Electrocardiogram
  • Depression screening
  • Functional ability/safety screen
  • Counseling and referral [note: NOT performance] of other preventive services, including:
    • vaccines
    • mammogram
    • pap and pelvic exams
    • prostate cancer screening
    • colorectal cancer screening
    • diabetes screening tests (and self-management training for patients who already have it)
    • medical nutritional therapy for diabetes or renal disease
    • cardiovascular screening blood tests (lipids)
    • bone mass measurements
    • glaucoma screening
    • abdominal aortic aneurysm screening sonogram
Note that these are minimums. I can do anything else I feel is appropriate for a preventive care visit above and beyond these things, though I don't get paid anything extra. The result is predictable: the "Medicare Initial Preventive Physical Examination Encounter" has become more trouble than it's worth. I tried it a few times. Basically, it turns into a generalized risk assessment for things like falls and depression, along with a most cursory exam. Frankly, once I'd finished covering all the "required" bullet points, there wasn't really any time left for my version of a physical (including an actual history, where one listens to the patient, as opposed to ticking off yes/no boxes to satisfy Medicare's documentation guidelines for the MIPPEE). It doesn't even pay all that well. Nowadays I'll do one if a patient requests it, but it's not something I'm pushing, as it doesn't add any value to the medical care I provide.

My fear is that CMS will promulgate a specific new code that must be used to bill these quinquennial visits for discussion of end-of-life issues, and that certain specific topics must be discussed (and documented) in order for the visit to be paid. And unless that particular code pays significantly more than a corresponding evaluation/management (regular office visit) code, I'm not going to bother. Oh, I'll continue to have discussions with my patients about end of life care and other issues on a regular basis, but all the sturm und drang about this provision will have been nothing but a giant waste of neurotransmitters and electrons.


At Fri Jul 31, 08:29:00 PM, Anonymous medrecgal said...

Nice timing, Dr. Dino...I was just tearing my hair out in absolute frustration today trying to code one of those blasted "Welcome to Medicare" IPPEs. (Glad I don't see many of them...) There are so many criteria it's like you practically have to write a novel in the pt's medical record...and what a headache it is to code, too; if 27 different criteria aren't met, it can't be coded as an IPPE and the poor provider is stuck bringing the pt.back in to complete the missing elements. (And of course there are 87 special codes they demand you use. No "99397" for them, please!) I don't know how you guys feel about Medicare as providers, but as a coder I think that a lot of the time it's a royal pain in the gluteus maximus (glutei maximi?), just because you have to jump through so many hoops to ensure the "right" documentation and you're made to feel like you're bugging the docs all the time. (We don't mean to, honest!)Sometimes Medicare is a shining example of your fourth law....give me your standard E/M levels any day over the Gs, Qs, and all that other insanity. Micromanaging, indeed! (Love the waste of neurotransmitters thought, too!)

At Sat Aug 01, 09:37:00 AM, Anonymous Anonymous said...

"(What if the patient develops a new life-threatening condition four and a half years after the last discussion? Sorry, dude. You should have either thought of that four and a half years ago, or waited six more months to get sick.)"

Not to worry; section 3(B) states:
"An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, lifelimiting disease, a life-threatening or terminal diagnosis or lifethreatening injury, or upon admission to a skilled nursing facility, a
long-term care facility (as defined by the Secretary), or a hospice program."

At Sat Aug 01, 09:06:00 PM, Anonymous Anonymous said...

1) DON'T do welcome to medicare exams, just code to the dx, and for straight medicare, I DON'T CHARGE for the physical (yep, just don't, not worth it) -- just like Dr Dino

2) Don't bill a dx of "counselling end of life" as a dx, yep, just don't do it.

Also most of my 70+ yo's have 3 or more chronic probs, so that's 99214 anyway.

Good thing, too, as I'm outpt primary care too.

Dr Matt in Western PA

At Sun Aug 02, 12:28:00 AM, Blogger drcharles said...

A very good post. The whole 99214 versus 99213 debate and the CPT criteria in general have made a mockery of the doctor-patient interaction. We follow the rules that are dictated to us in so many bureaucratic ways. I have a colleague who claims to do 95% of his coding based only on time documentation. Not sure how that goes in an audit, but the main point is that you can't fit the complexity of every encounter into a nice tidy box.

At Sun Aug 02, 12:37:00 AM, Anonymous medrecgal said...

Right on, Dr Matt...I was just saying the other day that in lieu of this IPPE craziness, the overwhelming majority of Medicare records will code to a 99214. I never did understand why the docs bother doing PEs on Medicare pts, particularly those over 65, since they are a "nonpayable service" by definition and the pt. gets stuck with the bill. Doesn't seem quite right to me; what can possibly be preventive about an office visit for a pt. when the doc is already managing at least three (and sometimes I've even seen problem lists into the teens) chronic problems? Oh, well, that's the government for you...make as much paperwork (or electronic work in the case of an EMR) as possible without really benefiting anyone.

At Sun Aug 02, 12:51:00 AM, Anonymous medrecgal said...


I have to admit I completely agree. We have a few providers in our practice that always try to bill on time-based criteria, but most of the time the necessary documentation is lacking. I have regularly had queries from physicians and their extenders that fall along the lines of "but how can this be a (pick any E/M level) when I spent over an hour with this patient?" E/M levels are based upon documentation, and if there isn't any documentation to indicate what services were provided, we can't give proper credit. Certainly the situation where a doc spends an unusual amount of time with a patient warrants consideration, but if there isn't the right kind of documentation there's always the chance the bill will be returned as nonpayable or we would be accused of some kind of fraud.
(The usual result of this sort of statement in a record is a request for further documentation from the provider, and sometimes the response is either lacking or unhappy.)

Perhaps the problem is that there aren't enough CPT E/M levels to reflect all possible office encounters, but then we'd get into the matter of having to deal with just that many more codes. It's kind of a no-win situation. But really, we're all on the same page, trying to work in a terrifically imperfect system.

At Mon Aug 03, 10:05:00 AM, Anonymous Anonymous said...

"In the first place, Medicare already pays for counseling."

Well, not exactly. Try spending 90 minutes with a patient and using the correct diagnosis code of V62.9(counseling for unspecified psychosocial circumstance). You'll be paid zero dollars and zero cents.

Instead, we ALL engage in that delightful game called "Coding for Dollars." We'll put down dxs such as hypertension, diabetes, etc., even though those were not the point of the visit.


At Mon Aug 03, 10:13:00 AM, Blogger #1 Dinosaur said...

@Robert: Medicare pays for counseling regarding medical conditions. I agree that psychotherapy is terribly compensated, but it is perfectly legitimate to code for diabetes when >50% of the face-to-face time is spent counseling the patient about its management.

(But of course we are all experts at playing "Coding for Dollar$".)

At Mon Aug 03, 10:44:00 AM, Anonymous Anonymous said...

My point is that Medicare currently does not pay for end-of-life counseling (unrelated to a specific medical diagnosis) unless we do some creative coding.



At Tue Aug 04, 07:30:00 AM, Anonymous A Cancer Doc said...

Yes, the guidelines in the new bill do suggest that one can readdress the of advanced care planning if the patient is diagnosed with a terminal progressive condition (or something like that). However, what if....a healthy patient has his counseling at age 70. He's healthy, manages a ranch and thinks he will live forever. He wants EVERYTHING done. That is documented. One year later, Cousin Joe dies after a CVA. His death is a long protracted thing: after PEG placement he develops aspiration pneumonias, ends up on a ventilator, goes into renal failure and has HD. Your patient suddenly realizes what doing everything means. He returns to amend the document; however, since he is healthy he is very concerned that people will "just give up on him" if he declares himself DNR. This counseling session takes far longer than the first. In fact, it takes multiple visits because after talking for a while, he realizes that he isn't certain what he wants so goes away to talk to family. Family, being concerned, accompanies him at the next visit so now there is a family conference. Because the doctor documented advanced care planning only 12 months ago, all of this goes uncompensated? I do not understand the need to legislate frequency, and I think it highly inappropriate. This suggests that like much of medicine, the "rules" of provision are made by people who do not understand what it means to actually practice medicine.

In the next section after advanced care planning, there is "a proposed set of measures" that shall be published as "quality measures" with the possibility of "data submission." Like much of the rest of legislated medicine, it sounds like physicians will be compelled to potentially have to document a set of "measures" to satisfy medicare and then submit that data....more busy work detracting for the real care and counseling of patient. Perhaps I am being a little too cynical this early in the morning.

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