Getting Paid: Wrestling With the System
Fam Pract Manag. 2002 Feb;9(2):12.
Don’t you just hate coding? I have to think you do – especially coding for evaluation and management (E/M) services. After all, articles on E/M coding are among the most popular FPM publishes.
Granted, you might read the articles because you enjoy the CPT game and dream about cutting strokes off your handicap, so to speak. But I don’t hear many family physicians talk about how much they love the challenge of getting that code just right. Quite the contrary, most of the physicians I talk to see CPT coding as an unnecessarily complex arrangement that adds no value to the clinical encounter, invites gaming the system, hides pitfalls of fraud and abuse, is often perverted by payers, and offers small and shrinking rewards even to those who play the game well.
I agree with them. In saying that, I hasten to add that I mean no disrespect to all the dedicated physicians and others who have put in countless hours of thought and discussion trying to make CPT the best coding system for the purpose, to make physician-friendly, livable E/M documentation guidelines and so on. Many of them are members or staff of the AAFP whom I respect deeply. They labor to make the system as useful and as manageable as possible –and, like FPM, they try to equip you to use the system well. (For FPM’s latest effort, see “Test Your Coding Skills,” page 41.)
Coding and reimbursement don’t mix
Actually, the fundamental problem is not CPT itself; it’s the connection between CPT and reimbursement. Disconnect the two, and CPT becomes a useful, reasonably well-structured system for collecting data on how physicians provide care. But when dollars hang on a one-digit difference between two codes, the system gets vicious. Whether it ever entered your head to go for that higher code just to get paid more, there are payers ready to assume that you will. Look through any loophole in the coding system, and you will surely see a battle between payers and physician payees. Worse, I suspect that it’s impossible to close all loopholes. And even if it’s theoretically possible, every loophole closed adds to the administrative burden of all concerned – mostly you.
Think about the evolution of the E/M documentation guidelines. Before 1995, the CPT manual gave only anecdotal clarification of the differences between various levels of E/M services. Coding was easier, but payers were nervous. The 1995 guidelines were a step toward giving payers and physicians a common language to describe E/M services, but they still left gaping holes in the description of the exam and of medical decision making. And even with the loopholes, they exacted a significant price: The precise words of the chart note suddenly became important financially as well as clinically. The difference between two codes became, at best, the presence or absence of a couple of words. At worst, it remained an unreconcilable difference of opinion between a physician and an auditor.
And while the 1997 guidelines closed some loopholes, particularly in the areas of history and exam, the price was a fusillade of bullet-points and a significant increase in the financial importance of individual words in the note. The outcry over the extra burden was so great that the Health Care Financing Administration (HCFA) went back to the drawing board. And now the Centers for Medicare & Medicaid Services (CMS), as the organization is called today, has virtually thrown up its hands. Instead, the CPT Editorial Panel of the AMA is contemplating a complete reworking of the E/M codes.
A dead end
While I wish the Panel the very best of luck in its endeavor, I’m afraid it can’t succeed, at least in the context of the current system, any more than it could develop workable documentation guidelines – because the system itself is unworkable. In the catch phrase of the Age of Managed Care (may it rest in peace), the current system does not align incentives. Where incentives aren’t aligned, the letter of the law is all we can live by – and as St. Paul says, the letter kills.
We need a whole new system of tracking and paying for medical care. What that system is, we can’t see yet, but today’s crescendo of dissatisfaction with the current system may mean that it’s around the corner. For the moment, FPM will continue to help you play the game better, but we should all keep our eyes open for a better game.
Copyright © 2002 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact email@example.com for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions