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CMS Billing Rules Subjugate Family Medicine – Inadequate Payment for Complex Care

June 16, 2014
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I’m continuing my series on the reasons there are so few family physicians in the U.S. and why the Center for Medicare and Medicaid Services (CMS) is a root cause of this deficit. My conclusions are based on recent research on the topic.

In my last post, I showed how the American Medical Association’s billing codes that CMS uses limits family physicians’ options for telling a computer the work they did. CMS has provided no other codes to allow a family physician to tell their professional story.

This is a huge problem, because the average number of issues a family physician thinks about in an office visit is 2.5 to 3 for an average risk population, about 4.5 per visit for diabetics, and 6 per visit for geriatric patients (where Medicare, a CMS product, is the only payer essentially).

CMS only pays us for 2 issues per visit at a maximum.

Some CMS supporters might argue with this number. There is not an explicit rule that says this, but it’s a reality that is created by the extraordinarily complicated rules CMS created in the mid 1990s. The rules are just too hard to explain to a lay audience without absolutely boring you to tears. In fact, the VAST majority of physicians don’t know the details of the documentation and billing rules.

The CMS rules are too onerous for every physician, but they kind of make sense if the doctor only cares for one body part. For example, a patient with very stable angina who just needs medicines refilled would be a simple visit, a patient with a few mild anginal symptoms a low complexity visit, a patient with more impactful symptoms that require medication adjustment a moderate complexity visit, and a patient with a severe case of unstable angina a high complexity visit, which is the highest allowable code for a physician to bill for evaluation and management services (doctor thinking work).

But the family physician also in the same visit cares for the patient’s diabetes, headaches, eczema, and depression. There are literally no codes in the CMS or AMA system or no examples of this kind of visit in the AMA list of clinical examples that look like this very typical visit for us. I’m convinced the leaders of these organizations have absolutely no idea what we do in an office visit.

Therefore, the family physician is caught in this awful conundrum. Do I care for just one problem my patient is concerned about or do I deal with all the other issues even though I’m not paid a dime for it?

Since family physicians tend to be altruistic and just plain nice, they often elect to give away their expertise for free, and not tell a patient to come back to deal with the other issues. However, other research shows that they survive these situations by being sloppy and quick with items #3 and beyond. Now I hope you have a better idea why your family physician looks so rushed when you get to item number 4 on the list you pulled out of your purse.

You are asking your personal physician to work for free, and this innocent unknowing request is made by another dozen or so patients per day in the office. You can thank CMS and the AMA for this.

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