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.

Wednesday, January 13, 2010

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.


At Wed Jan 13, 05:04:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I'm not sure we entirely disagree on this, Dino.

I completely agree that we need to get back on track with primary care. I also think that the RVU system is not well done, and that we need to change the way docs are compensated so that time spent with patients matters.

What I object to is the villifying of speicalists and the pitting of us docs against each other, primary care vs specialists.

Calling consult codes "overused" is one way of changing the conversation from "how do we fix healthcare " into " it's all the fault of the doctors".

Those who are making the most profit out of healthcare love it when we docs start fighting amongst ourselves - it leaves them free to go after the real money.

Love ya'


At Wed Jan 13, 05:30:00 PM, Anonymous medrecgal said...

I must say I was hip-hopping happy to see that the consult codes have gone by the wayside; they were nothing but a pain in the posterior. No more pre-op "consults" for us...

What I'd have to say about Medicare isn't nearly nice enough to post on a lovely blog such as yours; but if the change helps the pitiful payment rates for cognitive services, perhaps the field would be a little more level between the primaries and the specialists. That would be good for patients, and probably for primary care docs, too, as long as the change didn't result in terribly higher prices all the way around the system.

At Wed Jan 13, 11:39:00 PM, Anonymous Anonymous said...

Do you really think this will make an impact to correct the profound disparity that is apparent between specialities and primary care( Dr.Rich rightly says we should stop calling primary and instead call it 'advanced care'). I think taking care of 6-10 problem list while making sure mammo, colon screen, med recon etc etc is as challenging or more than focussing on a single organ. THE whole problem is because AMA is adamant is keeping the RUC process opaque and only 5 out 23 member board belong to primary care( I mean advanced care) and they give reimbursement advice to medicare. No wonder specialites are reaping huge $$ as they dominate this reimbursement board. WTF... why is ACP, family practice taking this SHIT for so long that is so wrong!!! We need grass root efforts and education to enlighten internists, hospitalists, FP, palliative etc about his abusive skewed system that has been rigged totally.

At Thu Jan 14, 07:59:00 AM, Blogger #1 Dinosaur said...

Geez, Anon; tell us what you really think.

As it happens, many of us office FPs agree that we've been thrown under the bus by our "organized medicine" representatives. The universal problem is that we're too busy in our offices to "get out and do something about it." The other commonality is that we FPs seem to be more willing to go the extra mile for our patients than many of the specialists. I had a guy with Medicaid and a broken hand who needed surgery. After the local ortho LIED to his face (told him he didn't need surgery, casting it was fine; then dictated a letter to me IN THE PATIENT'S PRESENCE that he'd recommended surgery but the patient refused) I couldn't get the primo Main Line group to see him for cash. I guess making a half mil a year is just too close to the poverty line to risk taking on patients who might not pay.

At Thu Jan 14, 08:32:00 AM, Anonymous Anonymous said...

In the Netherlands we have the system you describe. You can't go to a specialist without seeing your FP first. Works almost perfectly.

At Thu Jan 14, 09:12:00 AM, Blogger #1 Dinosaur said...

Dutch Anon: It works because patients are willing to accept the FP's opinion, and you have enough FPs.

At Thu Jan 14, 09:24:00 AM, Anonymous ndenunz said...

What irked me was when I would get a letter from a specialist saying "So and so was referred for such and such" when it was a pt who made his own appointment or it was clearly a follow up visit for an ongoing problem. I guess it was this kind of fraud and abuse that killed the consult code. I, too, say good riddance.

At Thu Jan 14, 10:34:00 AM, Anonymous Anonymous said...


Or specialists who REFUSE to let patients established with their practices call in and schedule their own appointments without a referral from us. Good riddance indeed!

And, Dino, "thrown under the bus" is the perfect description of what to AAFP has done to family docs. It's impossible to imagine how they could have done a worse job of representing their membership over the past 15 years.

At Thu Jan 14, 02:48:00 PM, Blogger Midwife with a Knife said...

Excuse me, but I do think that there is a place for consultants and consultation codes. I practice a very specialized form of medicine, and my "physical exam" is usually an ultrasound. I see patients for 30-90 minutes at a time and have to sort out a plan for their pregnancies and articulate it in a way that their obstetricians and fps feel comfortable putting it in place. I spent 3 years in fellowship (with a total of 7 years in training, more than twice that of a family practicioner), all of which delayed paying off student loans and comes at a significant opportunity cost.

I accept patients who other people wont take, not because they're beyond their scope of care (although many of them are), but also because the referring physician considers them to be malpractice nightmares.

Given all of this, I think that my time might be reimbursable at a higher rate than for the average general fp or general ob/gyn.

I don't abuse the consult codes, and they do have certain requirements (a referral and communication back to the referring doc). If I'm going to keep a patient, I bill as an OBV (it all falls under the global pregnancy compensation).

I don't understand why you have a big beef against specialists, dino, but I don't think that it's fair to say that I didn't deserve the compensation I was getting.

At Thu Jan 14, 03:07:00 PM, Blogger #1 Dinosaur said...

MWAK, I agree that you function as a true consultant, for which you are certainly entitled to greater compensation. It's a far cry from what you do, to the cardiologist who insists on seeing the guy with controlled hypertension every year (billing it as a full consult each time) because the patient once had chest pain.

I also agree that your greater training entitles you to greater compensation, but if you trained twice as long as I did, why should you get six times the money? It's still a question of proportionality.

At Thu Jan 14, 08:28:00 PM, Anonymous JPB said...

Then there is the patient who is in for a general check-up with no symptoms who is subjected to the annual "fishing expedition." Where does this come in for the usual chain of events?

At Fri Jan 15, 12:10:00 AM, Blogger Midwife with a Knife said...

Dino: I don't actually make 6x what you do, if I did, you'd be living below the poverty line and making less than a resident, which I assume you're not. I probably don't make anything near 6x what you do. I actually doubt I make 2x what you do (although I will conceed that I make more than you do).

My malpractice insurance alone might actually be more than 10x yours, although I don't really worry about it because I am employed by the hospital. Interesting fact about perinatology: even in the current pricing structure, we generally aren't self sufficient (the cost of the technology to keep us going is pretty prohibitive), so most perinatologists (at least those who accept medicaid/medicare pts) are sort of loss-leaders for the hospital because our services allow the NICU to function and us combined with an NICU draw general ob-gyns who draw patients.

As an aside, those jobs you see advertised for perinatologists that pay 400000-750000 either don't really pay that much or come with almost unliveable lifestyles (or in unattractive parts of the country)

My subspecialty is primarily cognitive (even the babies I deliver are paid under the global fee for pregnancy, and I don't deliver many babies), and my only procedure is the amniocentesis (ok, there are rare intrauterine transfusions and shunts and cerclages, but you add all of those up, and it's still a single digit per year, they're so rare).

You have truly fallen for the attempt of CMS to pit physicians against each other, and it actually isn't fair to make assumptions about what other people actually make. Many specialties/subspecialties are primarily cognitive, probably most of them (endocrine, neurology, MFM, etc.). The 3-4 extra years of training need to count for something (at least if you want to have endocrinologists/MFMs/etc) available for your patients. And while generalists do very well for most of the patient population, they actually don't do a very good job at managing medically complicated pregnancies, and why should they have to?

We already have a nationwide shortage of MFMs and cutting back the pay is only going to make it harder for you to find docs to refer your patients to.

I'm hospital employed which has several benefits (I never worry about patient ability to pay, for example, because the hospital is a non-profit with a strong commitment to serving the underserved), and one of those benefits is that I'm salaried rather than revenue-based income. These cuts are unlikely to directly effect me. However, I think that the overall disdain and dislike you showed for specialists in this post is unkind and generally unlike you.

At Fri Jan 15, 06:11:00 AM, Blogger #1 Dinosaur said...

MWAK: It isn't disdain for specialists so much as it is my profound frustration at my inability to support myself in my chosen career. That's right; if it weren't for DS, I would not be able to continue my practice in its current form. I would have to go to work for someone else, where I too would be a loss leader.

What really needs to happen is increase payment for all cognitive services, perhaps with a multiplier for specialists based on years of training. The real thing keeping students out of primary care is that twice the training far more than doubles the income. The arithmetic is straightforward, and students aren't stupid.

As I concluded in the post, perhaps this is what we -- primaries and specialists -- need to come together and demand appropriate payment for all of us.

At Fri Jan 15, 10:31:00 AM, Anonymous Anonymous said...

"You have truly fallen for the attempt of CMS to pit physicians against each other"

Don't blame this on CMS. The AMA has been waging an intentional and very effective war on the "cognitionists" for the past 15 years. Look at which speciality and sub-specialty groups spend the big lobbying bucks.

At Fri Jan 15, 10:47:00 PM, Blogger Lockup Doc said...

As a psychiatrist, I'm not in the procedural/surgical pay range, but right now I think we need more solidarity among all of us physicians. I totally respect where you are coming from regarding the consult codes (I've used them myself)and pay disparities that exist, but right now I'm much more concerned about the fact that Medicare payments (especially with upcoming cuts that have not yet been put on hold again) do not cover the cost of providing services for hospital or physician visits. Our health care system is going to collapse if our medical system eventually must rely only on government reimbursements.

At Tue Jan 19, 06:39:00 PM, Anonymous Anonymous said...

(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.)

Except when you actually are in need of a specialist, know it, know whom you need and see no good reason to spend time and money at a gate-keeper for a referral! Good grief, some of us actually do understand what is wrong and know whom to seek out - and guess what, it's less costly and time consuming to skip the primary and go to the specialist!

Case in point - I'd developed drop foot for no apparent reason, I could wait two weeks to get into my primary, all the while the peronial nerve gets more damaged each day that goes by, or I could get myself into a neurologist immediately for tests on the nerve, a script for a brace, and six weeks in it so I do not develop a permanent gimp! Guess what I did - I went to the neurologist - no way was I goint to wait to see the primary first - neurologist confirmed what I suspected and was able to take care of it same day and my foot and leg nerves were actually back to normal within a week or so too!

At Thu Jan 21, 12:50:00 AM, Anonymous Burn Belly Fat said...

I see now the problem, specialists are more numerous compare to primaries. Quite alarming!

At Wed Mar 10, 04:23:00 PM, Anonymous Anonymous said...

Consult codes got axed because most of the specialists were using them wrong. Every specialist I talked to (dozens), said well THEY were using them correctly. I talked to three coding experts in the field and asked them what percentage of consult codes are billed to Medicare are billed incorrectly (not a consult at all) and the answers were 70+%,85% and 90+%. That would be by far, most of the specialist gaming the system. So if you're a specialist and you're pissed off about this then look in the mirror dumbass.


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