ORLANDO – With Medicare seeing a sharp spike in payments for evaluation and management services, a proposed overhaul of Current Procedural Terminology E&M codes could force physicians to provide substantially more documentation of their medical decision making.
The American Medical Association’s CPT editorial panel is scheduled to vote in mid-May on a recommendation to make such changes to E&M codes.
Dr. Robert Wergin
If the CPT panel’s changes are substantial enough, it’s even possible that the Centers for Medicare and Medicaid Services may embark on a revaluation of all the E&M codes, said Dr. Glenn Littenberg, a past member of the CPT editorial panel and a current CPT adviser to the American Society for Gastrointestinal Endoscopy.
If CMS decided to do so, revaluation potentially could be a good thing – if it results in a higher valuation for decision making, said Dr. Robert Wergin, president-elect of the American Academy of Family Physicians. But "if the motivation is to put up a barrier to code appropriately for the level of complexity of visits, it’s another step to undervalue the cognitive area," he said.
The federal government has been taking a closer look at coding, with the concern that electronic health records are making it easier to upcode.
A report in 2012 by the U.S. Department of Health & Human Services (HHS) inspector general found that between 2001 and 2010, physicians had increased their billing for higher-level E&M codes. Medicare payments for E&M services increased by 48% during the same period, from $22.7 billion to $33.5 billion. The Office of Inspector General labeled E&M services as "vulnerable to fraud and abuse."
Coding is a physician’s lifeblood, said Dr. Wergin. The AAFP is waiting to get more details on the CPT panel’s recommendations before it can say whether it supports the changes, he said.
The American College of Physicians said its officials could not comment, citing confidentiality agreements for ACP members who are on the CPT panel.
Detail your decision making
According to Dr. Littenberg, the CPT panel is proposing much more detailed documentation of decision making, including describing the number and complexity of problems. Medical decision making will be one of the two requirements to qualify for moderate to extensive E&M services for an office visit, an established patient, or follow-up hospital care.
The proposal is more prescriptive than current requirements, "and harder to grasp and keep in mind during an encounter," said Dr. Littenberg, who is also a gastroenterologist in Pasadena, Calif. He said he is "concerned about the impact of this," adding, "there are things about this proposal I don’t like, and I’ve said as much at CPT."
Decision making "is critical at arriving at a diagnosis and treatment plan," Dr. Wergin said, but the AAFP believes that it needs to be better defined by the CPT. "Let’s define medical decision making in a more meaningful way that makes sense to people like me," said Dr. Wergin, who added, "I have a lot of complicated patients."
If the focus is only on the presenting problem, it tends to undervalue the decision making that goes into evaluating a patient who may have multiple comorbidities and perhaps social issues as well, Dr. Wergin explained. To truly evaluate a patient, decision making should look at that individual as a whole, not as one issue, he said.
It appears that the panel is moving in that direction, Dr. Littenberg observed, but it will also require clear documentation that "reflects our thought process."
Note the basics
Physicians should be thinking more in terms of what would be required in documentation to defend an audit, he cautioned. The history, physical, and what led to decisions about diagnosis and treatment – the basic thinking behind what happened on that particular day – need to be within the notes.
That kind of documentation "is actually not that complicated, and yet we fail to do it a large percentage of the time," said Dr. Littenberg.
"It can’t just be a recap of a problem list and continue the same therapy and ‘See you next year,’ " he said. "That’s not ever going to pass a high-level audit."
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