For the next several weeks, I’ll try to explain to non-physician readers why the Center for Medicare and Medicaid Services (CMS) billing rules create the horrid lack of primary care patients experience when they simply want to find a personal physician. My conclusions are based on recent research on the topic.
This task is actually somewhat difficult because part of the problem is that the documentation rules are so unnecessarily complex it’s hard to explain the details to physicians, much less everyone else. This matters to you because it is the source of doctors spending time on paperwork instead of caring for you. I’ll try to explain this concept further later. For now I’ll start with some preliminary problems.
For today I want to focus on the American Medical Association. One of the foundational problems with the CMS rules is that they depend on the AMA procedure codes. In the AMA code book, there is an Appendix C that gives clinical examples for the few coding options included in its system. This section defines “medically necessary” for many payers, not just CMS.
The most complex family medicine situation in the AMA book is a 70-year-old patient with diabetes, high blood pressure, confusion, agitation, and memory loss. I think this is really 3 separate issues, not 5, but let’s say there are 5. It’s not even clear if the issues are new or old, stable or worsening, all of which make a big impact on how much work the family doc will have to do.
Other studies of family physicians at work calculate that family physicians address an average 4.5 issues in each diabetic patient visit; 6 issues on average in geriatric visits. These are AVERAGE numbers. This means that family docs routinely deal with a wider variety of issues than the AMA codes allow us to tell a computer. I’ve followed private practice family docs and have seen visits where 11 separate issues were addressed in one visit.
The other problem for family docs is if they start billing a lot of the highest allowable codes, the CMS and insurance computers recognize this pattern and start denying claims or threatening the physicians with investigations.
Realistically, there are only 3 basic codes for established patients with concerns that the AMA has given us to tell the payers what we did to care for out patients. This is a gross under-representation of the tremendous breadth of services we can provide out patients.