EDITOR’S NOTE: The following article was originally published on the American College of Physician Advisors (ACPA) blog by the author.
I never really understood how my “square peg” of work as a geriatrician was supposed to fit into the “round hole” of evaluation and management (E&M) CPT® coding with its five levels each of new and follow up office visits and detailed lists of elements that had to be in the record to justify each level of billing.
Why did I have to count the number of questions I asked in the clinical history, social history, family history, and review of systems in order to be paid for a 45-minute appointment for the evaluation of a new 85-year old patient with dementia, hypertension, COPD, type 2 diabetes and congestive heart failure?
Sure, I had checklists that patients prepared before I saw them, but when so many items were checked off and each required some inquiry, it took time to cover all the issues, any one of which could indicate a serious disorder. There were “typical times” published for each level of office visit, but billing for time could only be invoked when at least half the appointment was dedicated to “counseling/ coordinating care”, whatever that is. The reimbursement offered was inadequate for the time required, anyway.
Now in the 2019 proposed “Revisions to Payment Policies Under the Physician Fee Schedule” the Centers for Medicare and Medicaid Services (the CMS) has proposed the collapse of levels 2 through 5 outpatient physician E&M billing codes (99212 through 99215 for existing patients and 99202 through 99205 for new ones) into one new code with a single payment, which will increase payment at the low end and slash it at the top.
According to the CMS’ “2019 PFS E&M Changes Chart” (https://tinyurl.com/yac7sakk) the new blended code will pay physicians $93 for any follow up visit. In comparison, the chart indicates that payments in 2018 under the current 5-level coding system were $45 for 99212, $74 for 99213, $109 for 99214, and $148 for the highest revisit, 99215. Do the math: That’s nearly a 15 percent reduction for a level 4 and a 37 percent cut for a level 5.
On the other hand, the CMS reports that 2018 new patients visits vary from $76 for a level 2 visit (99202,) up to $211 for level 5 (99205), with $167 for a level 4 (99204). The proposed payment would allow $135 for a new patient, 19 percent less than a level 4 and 36 percent less than a level 5!
Add-on G code for E&M Specialists
For certain specialists, the CMS proposes a new HCPCS G code, GCG0X to compensate for "visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care." This code, an add-on to the visit code, would result in adding 0.25 RVUs based on an anticipated additional physician work of 8.25 minutes, which the CMS proposes to value at approximately $14, or $1.70 per minute.
Primary care gets no R-E-S-P-E-C-T
For primary care physicians, there is another proposed add-on HCPCS G code, GPC1X, to compensate for “Visit Complexity Inherent to Primary Care Services”. In this case, however, the CMS has valued primary care visits at 0.07 RVUs or a “generous” 1.75 additional minutes to compensate for complexity. According to the CMS, “This proposed valuation accounts for the additional work resource costs associated with furnishing primary care that distinguishes E&M primary care visits from other types of E&M visits.” As a result of this adjustment, every primary care visit would have to be coded with 2 HCPCS codes: the new CPT code for the visit as well as the primary care G code. The CMS estimates that this will provide an additional $5 to the base payment for the proposed blended code. That’s $2.86 a minute.
But wait, the time required to see patients isn’t going to change so if the “typical time” for a level 4 follow up office visits is 25 minutes and the new payment for that time is $93, that’s $3.72 a minute and a level 5 is currently paid at $3.70 based on a typical time of 40 minutes.
So is this a fair adjustment? After acknowledging that primary care deserves payment above the new blended office visit payment, the CMS came to the conclusion that that added complexity can be dealt with in one and three-quarters minutes, or 105 seconds. The average speaking rate is 150 words per-minute, so the CMS is estimating that the complexity of primary care visits can be handled with 162 words. As I recall, my geriatric patients took that long just to tell me about their sleep habits! One could also ask why a primary care physician’s time has up until now been valued at about $3.70 a minute but the additional time needed to address complexity is worth 22.7 percent less.
So I'll ask, but I don't think there's a logical answer.
I believe that CMS valuing the added complexity of primary care visits, which can cover a broad range of clinical and social issues, at $5 is unfair and no less than insulting. It perpetuates the steep divide in income between primary care physicians and their subspecialist colleagues.
The CMS is soliciting feedback on the definition and valuation of the proposed HCPCS G codes.
And for the Most Prolonged Visits…
There’s one more adjustment of approximately $67 for unusually prolonged visits, but it doesn’t kick in until a visit exceeds the “allocated” time by 30 minutes. (The CMS is here valuing the primary care physician’s time at $2.33 a minute.) But if the physician is billing based on time and we are abandoning the time frames imbedded in the CPT office visit codes, we don’t yet know how long a visit has to be to generate the 30 additional minute prolonged visit payment. And now we’re up to 3 codes to bill for prolonged geriatric visits and physicians will need to have stopwatches in their examining rooms to track time spent with each patient. I don’t think that will add to patient satisfaction.
The bottom line: Pain for Geriatrics
For a family medicine or internal medicine practice that sees a large number of patients quickly, the collapsing of codes and the proposed payment rate could represent a significant raise for high volume low acuity primary care practices, but for geriatricians, who hardly know what a level 2 visit is, the reduction on payment for more complex visits could be a disaster.
Frank Cohen, MPA, MBB did an analysis of the impact of the new blended codes on physicians' income. It was published by RACmonitor on Aug. 2 (https://tinyurl.com/ycv3ad42). He found that some specialties, e.g., podiatry, dermatology, and orthopedic surgery will get the most benefit from the new coding rule; physicians in cardiology, internal medicine, neurology, and hematology/oncology, will see the biggest cuts. While he didn’t break out geriatrics from internal medicine, my experience tells me that geriatricians, who see the most complex primary care patients, will be hurt the most.
Where are the Geriatricians?
According to the New York Times (“As Population Ages, Where Are the Geriatricians?” Jan. 25, 2016) “Geriatrics is one of the few medical specialties in the United States that is contracting even as the need increases, ranking at the bottom of the list of specialties that internal medicine residents choose to pursue…[B]y the year 2030, roughly 31 million Americans will be older than 75, the largest such population in American history. There are about 7,000 geriatricians in practice today in the United States. The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.”
Physicians are not choosing geriatrics. Why is this? Well one reason is the fact that geriatricians make a lot less than most of their physician colleagues. In fact, the Times reported that the average geriatrician makes $20,000 per year less than general internists even though specialty certification in geriatrics now requires an additional two-year fellowship for new entrants. (Cardiologists’ income, by the way, is twice that of geriatricians.)
The CMS has taken a step in the right direction by addressing the irrational billing criteria created by the American Medical Association’s (AMA’s) CPT coding system for outpatient physician visits. But I believe the economic disincentive to pursuing a career in geriatric medicine will only be exacerbated by the collapse in coding the CMS has proposed and I fear it will contribute to the death of geriatrics.
So What Alternative do I Propose?
If geriatrics is to remain a viable specialty and geriatric physicians allowed to make a living commensurate with other specialists while treating the elderly and chronically ill, let’s pay geriatricians fairly for the time and skill required to handle complex geriatric visits by providing higher payment for visits that address multiple systems as well as the many issues that are so common in geriatrics, including, among other things, family and social needs, psychological support, increasing frailty, and limitations on the ability to live unassisted.
This could be accomplished by an additional payment when the record identifies non-clinical issues addressed and increases with the patient’s age blended with their principal diagnoses and the number of active comorbidities treated. It would require documentation supporting complexity, but I think it makes more sense to pay physicians for the actual work they do rather than according to an insufficient flat rate for all visits.
The AMA came up with CPT, an unrealistic unworkable system for coding E&M services that has plagued us for decades. It’s time they went back to the white board with their dry markers and gave us a system that fairly compensates physicians for complex care and which saves geriatrics from extinction as a specialty.