Consult Codes: Goodbye and Good Riddance

Consult codes have just gone the way of the dinosaur! And none too soon, I might add.

For all you non-medicos with no idea what I'm talking about, allow me to enlighten you:

Medical care comes in two flavors. The first kind, so-called cognitive services, involves the doctor talking to you, examining you, perhaps ordering some blood tests or imaging studies, figuring out what's wrong with you and what to do about it. The other variety, "procedural services," is when the doctor does something to you, like cutting something off of you or out of you. There's plenty of overlap, of course. The most important part of any procedure is deciding whether or not it needs to be done (which usually involves thinking), and procedures of some kind are required to establish many diagnoses. The problem is that procedures pay far more than cognitive services.

It began about 25 years ago, some Harvard economists came up with the idea of quantifying the amount of "work" in a medical encounter. This allowed them to calculate a Relative Value Scale of everything a doctor does (cognitive and procedural). Add some geographic fudge factors (to make it "resource-based") and a "conversion factor" (a dollar amount) to turn it into a fee and you have the Resource-Based Relative Value Scale, the infamous RBRVS. Leaving aside the subsequent actions of the specialist (read: those who do procedures)-heavy RBRVS Update Committee (RUC) that have made procedures more and more lucrative than cognitive services, I have a problem with the idea that the amount of "work" can be quantified for any given medical procedure, cognitive or procedural.

Take the so-called Level 3 (of 5) Office Visit. This has an actual definition:

Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity. Counseling and coodination of care with other providers or agenies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

Here's my take on that: NOT ALL LEVEL 3 VISITS ARE CREATED EQUAL. Believe me, 15 minutes reviewing three chronic problems, performing a brief physical, and renewing ten prescriptions for a pleasant, informed, cooperative patient is a very different 15 minutes from those spent with a cranky, demanding, loudmouth who has no idea what meds he's taking, much less whether any of them need refilling, and who insists that I order an MRI because he had a headache last night. In fact, that I can manage to accomplish what each of these patients need (not counting a swift kick to the behind in the case of the second patient, but I have a bum foot) in only 15 minutes is a testament to my skill, tact, and efficiency. Nevertheless, I still believe that for cognitive services -- the so-called Evaluation and Management, or E/M services -- the most logical and equitable proxy for "work" is TIME. By and large, the 20 minute visit is generally twice the work of the 10 minute one.

But I digress.

It turns out that specialists have another mechanism to increase their take set of codes they can use for what are essentially E/M services: Consultations.

Here's the way the system is supposed to work: everyone sees their family doctors for all their concerns. Family doctors are perfectly able to take care of 90% or more of the problems they see. The remaining 10% are either too complex or severe for our skill set. Those we refer to the specialists, who, by virtue of their longer and more detailed training, are better equipped to deal with this small proportion of the general public. For this (a specific request from another physician who was unable to handle the problem) it is generally accepted that specialists deserve greater compensation. The purpose of Consultation codes was originally to identify this specific service, to distinguish it from any old garden-variety E/M visit. Logical; fair; economical.

Two things are necessary for this system to work as designed, though:

1. Everyone has to go to their primaries first, and
2. There have to be more primaries than specialists.

Instead of having the accepted ratio of 70/30 specialist to primary care, this country has exactly the opposite. This is only part of the reason why people don't go to their primaries first; in too many cases, the too-few doctors are too busy. Then again, Americans are notorious for demanding "the BEST." In the case of medical care, this usually means the specialists. (The really sad thing about this situation is that for the unselected, self-referred patient, the specialist's approach is much more expensive than it needs to be, and subjects the patient to all kinds of inappropriate interventions.)

So when you have 70% of physicians using codes intended for 30% of them, to care for medical conditions that do not require their full expertise, you're going to be spending far more money than necessary.

This is why the Centers for Medicare Services (CMS, ie, "Medicare") decided to stop paying for Consultations. Weep bitter tears for the poor specialists who are now stuck with the same paltry selection of E/M codes as we Primaries. If nothing else, maybe it will help them work together with us to increase compensation for cognitive services.


h/t to my good friend TBTAM, with whose post on this topic I respectfully disagree.