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My CMS Proposal to Improve the E/M Documentation, Coding, and Billing System for Family Medicine

September 17, 2012

I’m back from my final CMS Innovation Advisors meeting in Baltimore. I was one of the speakers for this final gathering where I shared my proposals to create a fairer and better payment system for family medicine. A lot of people have asked me what I propose. I provide a general outline here.

My system is a blend of fee-for-service (FFS) and global fees, but is weighted on the FFS side. I chose the route for at least 2 reasons: First, I wanted to incentivize family physicians to care for the most complicated patients with multiple chronic diseases. A flat fee per visit or fee per patient system would incentivize the opposite. Second, the majority of family physicians we interviewed on this topic last year as part of a research project stated they wanted to be paid a little bit for a short, quick, and easy visit; but they wanted to be paid more for a complex visit. My system accomplishes this.

Other features of my proposals include:

  • Get rid of most of the bullet counting in the current documentation rules
  • Improve how we document chronic disease care
  • Get rid of the insulting requirements that we document past medical information in each clinic note for our personal patients we’ve known for years.
  • Get rid of the CPT system for primary care. This is replaced by what I call Issue Addressed codes. If the family physicians deals with one issue, he bills for one issue; 10 issues, he bills for 10 issues. The billing amount for each issue depends on how thoroughly the physician addressed the issue, with a built-in incentive to promote thoroughness.
  • Extra time codes for the unusual visits where a visit takes longer than a standard visit. This could be caused by either physician needs to spend more time explaining something or talking about options, or it could be driven by a patient who has 20 questions she wants answered. An example is when a long discussion about resuscitation and end-of-life plans is in order. The physician is allowed to bill for the extra time required over a standard clinic visit.
  • Codes to pay for non-face-to-face time such as email communications and phone calls. I have rules describing which of these is allowed to be billed extra and which aren’t.
  • Fees to encourage family physicians to provide care in the evenings and weekends.
  • Fees to encourage family physicians to provide a full complement of cognitive and procedural services, take care of their hospitalized patients, and provide some convenient lab and x-ray services.
  • Fees to discourage over-testing and over-treating.

A copy of my Power Point presentation I gave at CMS is attached. It includes background justification information on my proposals, examples of some of my proposals, and two sample bills a patient would receive under my system: one for a quick simple visit and one for a complex multi-organ visit.

Young Group 4 IAP projects 9-12

Please feel free to share these slides with anyone who may be interested in them. And please let me know if you have any questions.

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