By MATTHEW HOLT

Okay, I can’t do it any longer. As much as I tried to resist, it is time to write about ambient scribing. But I’m going to do it in a slightly odd way

If you have met me, you know that I have a strange English-American accent, and I speak in a garbled manner. Yet I’m using the inbuilt voice recognition that Google supplies to write this story now.

Side note: I dictated this whole thing on my phone while watching my kids water polo game, which has a fair amount of background noise. And I think you’ll be modestly amused about how terrible the original transcript was. But then I put that entire mess of a text  into ChatGPT and told it to fix the mistakes. it did an incredible job and the output required surprisingly little editing.

Now, it’s not perfect, but it’s a lot better than it used to be, and that is due to a couple of things. One is the vast improvement in acoustic recording, and the second is the combination of Natural Language Processing and artificial intelligence.

Which brings us to ambient listening now. It’s very common in all the applications we use in business, like Zoom and others like transcript creation from videos on Youtube. Of course, we have had something similar in the medical business for many years, particularly in terms of radiology and voice recognition. It has only been in the last few years that transcribing the toughest job of all–the clinical encounter–has gotten easier.

The problem is that doctors and other professionals are forced to write up the notes and history of all that has happened with their patients. The introduction of electronic medical records made this a major pain point. Doctors used to take notes mostly in shorthand, leaving the abstraction of these notes for coding and billing purposes to be done by some poor sap in the basement of the hospital.

Alternatively in the past, doctors used to dictate and then send tapes or voice files off to parts unknown, but then would have to get those notes back and put them into the record. Since the 2010s, when most American health care moved towards using  electronic records, most clinicians have had to type their notes. And this was a big problem for many of them. It has led to a lot of grumpy doctors not only typing in the exam room and ignoring their patients, but also having to type up their notes later in the day. And of course, that’s a major contributor to burnout.

To some extent, the issue of having to type has been mitigated by medical scribes–actual human beings wandering around behind doctors pushing a laptop on wheels and typing up everything that was said by doctors and their patients. And there have been other experiments. Augmedix started off using Google Glass, allowing scribes in remote locations like Bangladesh to listen and type directly into the EMR.

But the real breakthrough has been in the last few years. Companies like Suki, Abridge, and the late Robin started to promise doctors that they could capture the ambient conversation and turn it into proper SOAP notes. The biggest splash was made by the biggest dictation company, Nuance, which in the middle of this transformation got bought by one of the tech titans, Microsoft. Six years ago, they had a demonstration at HIMSS showing that ambient scribing technology was viable. I attended it, and I’m pretty sure that it was faked. Five years ago, I also used Abridge’s tool to try to capture a conversation I had with my doctor — at that time, they were offering a consumer-facing tool – and it was pretty dreadful.

Fast forward to today, and there are a bunch of companies with what seem to be really very good products.

Nuance’s DAX is in relatively wide use. Abridge has refocused itself on clinicians and has excellent reviews, (you can see my interview and demo with CEO Shiv Rao here) and Nabla has just published a really compelling review from its first big rollout with Kaiser Permanente, Northern California in the NEJM no less. (FD I am an advisor to Nabla although not involved in its KP work). And others like DeepScribe, Ambience, Augmedix and even newcomers Innovaccer and Sudoh.ai seem to be good options.

If you take a look at the results of the NEJM published study that was done in Northern California using Nabla’s tool, you’ll see that clinicians have adopted that very quickly, with high marks for both its accuracy, and the ability to deliver a SOAP note and patient summary very quickly. And it has returned a lot of time to the clinician’s day. (Worth noting that independent practice Carbon Health has built its own inhouse ambient scribe and used it on 500K visits so far)

The big gorilla on the EMR side, Epic, has integrated to some extent with Nuance and Abridge, but many of the other companies are both working to integrate with Epic and are inside other EMR competitors – for instance Nextgen is private-labeling Nabla. At the moment, for basically everyone integration really just means getting the note summary into the notes section of the EMR.

But there is definitely more to come. For many years, NLP companies like Apixio, Talix, Health Equity and more (all seemingly bought by Edifecs) have been working on EMR notes to aid coders in billing, and it’s an easy leap to assume that will happen more and more with ambient scribing. And of course, the same thing is going to be true for clinical decision support and pretty soon integration with orders and workflow. In other words, when a doctor says to a patient, “We are going to start you on this new drug,” not only will it appear in the SOAP note, but the prescription or the lab order will just be magically done.

But is it reasonable to suppose that we are just paving the cowpath here? Ambient scribing is just making the physician office visit data more accessible. It’s not making it go away, which is what we should be trying to do. But I can’t blame the ambient scribing companies for that. And as I have (at length!) pointed out, we are still stuck in a fee-for-transaction system in which the health services operators in this country make money by doing stuff, writing it up, and charging for it. That is not going away anytime soon.

But given that’s where we are, I think we can still see how the ambient scribing battle will play out. 

Nuance’s DAX has the advantage of a huge client base, but frankly, Nuance has not been an innovative company. One former employee told me that they have never invented anything. And indeed, the DAX system was massively enhanced by the tech Nuance acquired when purchasing a company called Saykara in 2021, some years after that unconvincing demo back at HIMSS 2018.

So innovation matters, but the other issue is the cost of ambient scribing, which in some cases is nearing the cost of a real scribe. Nuance’s DAX, Suki, and even new entries like Sunoh seem to be around the $400 to $600 a month per physician level. Sunoh is offered by eClinicalworks and has some co-ownership with that EMR vendor. What’s amazing is that at the price quoted at HIMSS of $1.25 per encounter the ambient scribing tool would cost a busy family practice doc seeing 25 patients a day as much as the EMR subscription, around $600 a month.

Abridge has been quoted at roughly $250 a month, and Nabla seems to be considerably less expensive, around $120. But realistically, the whole market will have to compress to about that level because the switching costs are going to be very trivial. Right now, with most of them requiring a paste and copy into the EMR, it’s almost zero.

Which then leads to some more technical issues. How good will these systems become? (Noting that they are already very good, according to reviews on the Elion site). And what will happen to the way they store data. Most of them are currently moving the data back to their cloud for processing. But this may not be acceptable for health systems that like to keep data within their firewalls. For what it’s worth, Nabla, being from the EU and very conscious of GDPR, has been pushing the fact that its process stays on the physician’s local machine – although I’m not sure how much difference that makes in the market.

The other technical issue is the reliance on the large LLMs like OpenAI, Google, etc., compared to companies that are using their own LLM. Again, this may just remain a technical issue that no one cares much about. On the other hand, accuracy and lack of anonymization will continue to be a big issue if more generic LLMs are used. Now the fascination with the initial ChatGPT type LLM is wearing off, there’s going to be a lot more concern about how AI is using health care as a whole–particularly its tendency to “hallucinate” or get stuff wrong. That will obviously impact ambient scribing, even if mistakes may not be as serious as perhaps patient diagnosis or treatment suggestions.

So it’s too early to know exactly how this plays out, but it’s not much too early. In some ways, it’s very refreshing to see the speed at which this new technology is being adopted. As it is, the number of American doctors using ambient scribing is probably below 10%. But it’s highly likely that number goes up to 70%+ in very short order.

The problem that it is fixing for doctors is one that has been around for thousands of years and also one that has been particularly acute for the last twenty years or so. It’s almost like we’re in a period where the doctor suffering with having to  type up their notes in Epic–written up so eloquently by Bob Wachter in his book, “The Digital Doctor,”– is going to be a historical artifact that lasted for fifteen years or so. Maybe it’s going to be talked about nostalgically, like those of us who reminisce about having to get online with dial-up modems.

I’m pretty sure that the winners will be apparent in a couple of years, and that somebody, possibly Microsoft, or possibly the investors in big rounds at 2021 style valuations for Abridge or Ambience, may be regretting what happened in a couple of years. Alternatively, one of them may be a monopoly winner that soon starts printing money.

I suspect, though, that ambient scribing will essentially become a close-to-free product for all different types of business and that clinical care will not be much of an exception. That suggests that a company like Anthropic or OpenAI with close connections to the tech titans, Amazon and Microsoft, will end up becoming more of a feature for the tech giants. My guess is that they will be delivering that product for free probably also into much of clinical care, including ambient scribing. Of course, Epic may decide that it wants to do the same thing, which may leave its partners including Microsoft in the lurch.

It’s reasonable to expect that all aspects of life, including education, general business, consumer activity, and more, will find note-taking, summaries, and decision support a natural part of the next round of computing. For instance, anyone who has had a conversation with their contractor when renovating a house would probably love to have the notes, to-dos and agreements automatically recorded. It’ll be a whole new way of “keeping people honest”. Same thing for health care, I suspect.

But to be fair, we are not there yet. My dictation tool took this whole thing while watching a water polo game on Sunday. And I think you’ll be modestly amused about how terrible the original transcript was. But then I put that entire mess of a text  into ChatGPT and told it to fix the mistakes. it did an incredible job and the output required surprisingly little editing.

AI is getting very smart at working on incomplete information, and health care (as well as clinicians and patients) will benefit.

Matthew Holt is the publisher of The Health Care Blog and one upon a time ran the Health 2.0 Conference

My life changed dramatically 18 months ago when I started my new practice.  The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new.  That’s a tough thing to do with four kids, three of whom were in college last fall.  OK, that’s a stupid thing to do, but my stupidity has already been well-established.

Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.

• I am no longer focused only on patients in my office.
• I am no longer focused on ICD and CPT codes.
• Saving patients money has become one of my top priorities.
• I feel like my patients trust me more, and see me as an ally.
• Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
• I focus far more on preventing problems or keeping them small.
• I laugh with my patients far more.
• I no longer feel like a Zombie at the end of the day (and I no longer eat brains)

What is most interesting to me about all of this is what is at the center of all of these changes: I changed the way I am paid for my work.  Instead of being paid largely by third-party payors, I am paid by my patients, and instead of being paid more for sickness and procedures, I am rewarded for having healthy and well-informed patients.  (For those who don’t know, patients pay me between $30 and $60 per month for my services, and there is no copay for office visits).

Since all of these positive changes stem from the incentives created by this different payment system, I’ve seen even clearer the reasons for all of the problems in our health care system: it’s all about the payment system, or the basic transaction of healthcare.  From this transaction flow all of the bad things about our system, the waste, the impersonal nature of care, the physician burn-out, the spending without consideration of cost, and the blatant profiteering by companies associated with healthcare.  Changing our system for the better, therefore, can’t happen without a basic change in the financial transaction at its center.

A business transaction involves two main participants: the buyer and the seller.  The buyer gets a product or service they want from the seller in exchange for money.

What about the transaction of healthcare? Who are the participants in this transaction, and what is the product sold?

• The Seller:  It’s pretty clear that healthcare providers, doctors, hospitals, and ancillary care facilities, are the seller in this transaction.
• The Buyer:  It would seem that the patient, the one getting the “care” is the buyer here, but this ignores an important fact: providers get almost all of their money from third-party payors (insurance companies and government organizations).  I think it’s pretty clear that doctors and hospitals are selling their “product” to these third-parties, not to the patients.
• The Product:  Again, it would seem that the care given by the provider is the thing buyers are paying for, but this clearly isn’t the case.  Reimbursement for health services is based on two main things: codes (CPT and ICD), and the documentation required to support these codes.

So, the basic transaction of healthcare is this:

The healthcare provider is paid by third parties for codes and documentation.

The codes, which are the most valuable commodity for a provider, are two types: problem codes (ICD) and procedure codes (CPT, E/M).  The payment is actually only given for procedures, not problems, but the problem codes are the immediate justification of those procedures, and failure to justify will reduce or eliminate payment.  So, the provider is motivated to find the best paying procedures and find problems to justify their submission.

Using this, the transaction of healthcare becomes this:

The provider is rewarded for finding the best-paying procedure code to match the most severe problem codes.

Documentation is done after the fact as a bookkeeping tool to prove the validity of the problem and procedure codes.

Where is the patient in all of this?  Patients are the raw materials used for the product.  They are a source of problem and procedure codes.   What about the actual patient care?  It is a byproduct of this transaction.  Care is presumed to be encompassed in the procedure codes (a presumptuous presumption, as many would attest).

Let that sink in: patients are raw materials, and patient care is a byproduct.  That’s pretty damning.  It’s also fact, not opinion.  It flows from the basic transaction of healthcare.

So let’s translate this to an office visit:

• The patient is nearly always required to come to the office for all “care” because this is the only place where payable “procedures” are done.  For a PCP, the main “procedure” is the office visit itself.
• The patient history is done to find problems to which procedures can be applied.
• The bigger the problems, the better the reimbursement for procedures for the doctor.
• The main task of the office visit is to find problem and procedure codes, and to document those codes.
• “Customer service” in healthcare is not something that applies to patients, since patients are raw materials, not customers.  Doctors are motivated to treat patients only well enough that they will continue to come and supply codes (much as a farmer would treat his/her cow who produces milk).
• True “customer service” from doctors applies to how quickly and accurately they produce codes for the customer: the payor.

Pretty brutal, isn’t it?  This gets worse when you consider some of the corollaries that come from these facts:

• Solving patient problems is bad for business.
• Priority is given to patients with the best-paying payors.  Conversely, lowest priority is given to those with the worst payors (i.e. Medicare and Medicaid).
• The best paid physicians are those who are the most skilled at finding the most well-paying codes for the least amount of effort.

When explaining my practice to people, I often take a slightly different take on the transaction:

You are employed by whoever pays you.

The reality of my former practice, and those of most of my colleagues, is that they are employed by the third-party payors, and so will spend most of their time doing the job required by their employer.  In my new practice, on the other hand, I am employed by my patients because I am paid by them.  They are no longer a cow from which I can milk codes. They are no longer a well from which I can draw procedures. They are the one I am hell-bent on keeping happy so that they’ll continue to pay for the care I give.

Finally, the care I give is no longer a byproduct of codes; it is the product for which I am paid.  My kind of practice is the ultimate accountable care organization because we are accountable to our patients for the quality and value of what we do for them.  If they don’t like the product we sell, they leave.  The end result is more time devoted to assuring the quality of care our patients see.

More time for patients?  That’s something I had to get used to when I started this practice.  It’s also something my patients are still getting used to.

Surely there’s a catch.

No, I work for them, and that makes all the difference.

For any solution to have a real effect, this core problem must be addressed.  The basic incentive has to change from sickness to health.  Doctors need to be rewarded for preventing disease and treating it early. Rewards for unnecessary tests, procedures, and medications need to be minimized or eliminated.  This can only happen if it is financially beneficial to doctors for their patients to be healthy.

What a coincidence!  That’s what my new practice does!  Who’d have thought it? The healthier my patients are, the less of me they need and the larger my patient panel can get.  I am motivated to keep problems small, to avoid complexity, and to think in terms of true prevention rather than the invention of diseases.

Obviously, the system still must address the inevitable/unpreventable medical problems that arise despite my best efforts to prevent them.  This is where the high-deductible plans come in: covering problems that the patient cannot afford.

Yet my job will aways be to prevent patients from spending that deductible, wherever possible, avoiding unnecessary tests, medications, or ER visits.  Why?  Because in doing so I justify the monthly payment.  It turns out that this is not very hard.

This is a win/win/win, as patients are healthier, I make more money, and insurance companies don’t have to pay for nearly as much.

The Bottom Line

Any significant change, whatever the means, won’t happen until there is an even more basic shift, a shift in the very center of health care: we must focus again on people.  The patient (or the person trying to avoid becoming a patient) has moved from the center of the health care transaction and has become the raw-materials for what we call “health care.”

The doctor/hospital needs the patient to generate the codes necessary to be paid by the payor, which is the bottom-line reason for our problems.  A system that has incentives to create disease and procedures, will be satisfied (and even happy) with a lack of health.  But a system which rewards health will be radically different.

Changing the focus of care to this is more than just emotional idealism, it is good business.  Care should not be about codes, procedures, medications, tests, or interventions, but instead about helping people live their lives with as few problems as possible.  We need an economy that thrives when the patient costs the system less.

Any attempt to reform without this change will ultimately fail.

Rob Lamberts, MD (@doc_rob) is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared. 

Mrs. B was washing dishes in the kitchen when she heard a thump where her twelve-month-old son was asleep. She ran to him and found her son had fallen from a chair (code: e884.2). He was crying (code: 780.92) and visibly shaken, but did not have overt signs of bleeding, bruising, or trauma. She picked him up and immediately brought him to the emergency room. There, he was triaged by the nurse (nursing report #1) and vitals were taken (nursing report #2). Shortly after the mother and son pair settled into the pediatric emergency room, he vomited once (code 787.03).

The emergency medicine residents came by an hour later to conduct a focused interview, and performed a comprehensive physical exam (code: 89.03). He took care to ask at least four elements of the history of present illness that included location, quality severity, duration, timing, context, or associated symptoms from the event. He performed a complete review of at least 10 organ systems and surveyed the patient’s social history (code: 99223). It was decided that the boy was to be observed in the ED for the next few hours for signs of brain injury or concussion.

No labs or imaging studies were ordered. The nurses were instructed to check for vital signs every hour (nursing reports #3,4,5,6). During the observation period, the boy was found to be active, interacting well with mom, hungry, without signs of lethargy or focal neurologic deficits. When the attending physician came by to evaluate and assess the patient, he agreed with the resident’s report and signed the discharge note. The mother was given discharge paperwork and instructions for returning to the hospital if she noticed any new, alarming symptoms.

This is what Kelly, an emergency department medical coder, gathers while reading an ED admission note.  She turns to me and explains that the few lines of attending attestation are the only way the patient can get billed. Kelly types in “959.01” into her software because she memorized the diagnosis code for “head injury, unspecified.” She has been doing this for the last 18 years.

As I listened, she explained that a head injury in a twelve-month-old infant is automatically a level three, so long as the resident documents a review of ten systems, past medical history, and a physical exam. These levels indicate the complexity and severity of the patient’s disease/injury. “It’s all about the documentation,” she says. “If just 9 organ systems instead of 10 are documented,  even a critically ill patient could be down-coded to a level 4.”

In this case, the resident did not order any additional labs or imaging studies, keeping him at a level three.  Kelly then counts the number of nursing reports that were filed for this patient and enters the number. There are no specific codes for procedures performed by the nursing staff. So, the only indication of level of nursing care is the number of nursing reports written.

During my morning with Kelly, I learned about how patient charts are medically coded and about which services contributed most to the costs of care. How are medical supplies accounted for? How do hospitals bill for the amount of time spent on each visit? As a medical student and prior to my morning with Kelly, these concepts were foreign to me. There is little in the medical education curriculum that prepares students in a way that my visit with Kelly did.

I learned that first of all, coding and billing are two separate procedures, done by two different people, trained individually, working miles apart. The coders see only what is documented on paper while billers see only a column of numbers of which to assign monetary value. I learned that there are two parts to coding: hospital services and physician services.  The bill that results from these codes can contribute to the large bill that the patient or insurance company receives. These charges are the basis for what is negotiated with insurance companies, who use an algorithm to determine actual reimbursement rates for each patient based on risk factors. As you can see, this is a complicated business that involves many different stakeholders.

Everything documented in a physician’s note contributes to determining the level of care of the patient and in turn determines what charges get submitted to the insurance company and to the patient. It is crucial that physicians not only understand the importance of clear documentation but the effect these procedures and tests in the documentation have  on the increased costs passed on to the patient and payer.

After my experience with Kelly learning about medical coding, I am now much more aware of the information conveyed in my progress notes. The medical chart is a physician’s way of communicating the severity of the patient’s health and the amount of effort invested in the patient’s care. It is also a potential channel for documenting exams that were not performed. This process has shown me, in real time, how a plethora of unnecessary tests and imaging could increase a bill exponentially. Most importantly, there is no medical code for good or bad outcomes and there is no reward for physicians who are conscious of medical resources to cut costs of care. On the contrary, physicians are incentivized to order more tests and provide critical care measures that may be unnecessary.

I believe all medical students and residents should take a class that outlines the lessons I learned with Kelly that morning- that billing, coding, and every decision can contribute directly to the exponentially rising health costs in America.

Jessica Jou is currently a fourth year medical student at Tufts University. She is interested in promoting medical student education on cost-awareness of healthcare.

It seems both ironic and inevitable: I won’t be getting any more “meaningful use” checks. It’s not that I didn’t qualify for the money; I saw plenty of patients on Medicare and met all of the requirements. I was paid for my first year money without much hassle. The problem I am facing is this: I am probably going to be “opting out” of Medicare, and once I do that I will cease to exist as far as HHS is concerned, and they are the ones who write the “meaningful use” checks. No existence equals no money.

This is ironic because I have gotten famous for how well I’ve used electronic medical records, have written advice for physicians trying to qualify for “meaningful use,” and am esteemed enough to be often asked for my opinion on the subject (culminating in a presentation last year for CDC public health Grand Rounds).  I have spent much of the past 16 years disproving the myths that small practices couldn’t afford EMR, that EMR decreases profitability, or that they reduce quality of care.  We not only could afford EMR, we flourished, using it as a tool to increase both productivity and profitability.  Not to overstate the issue, but my practice (and others like it) paved the way for the existence of “meaningful use.”  I don’t know if that’s a good or a bad thing.

But, as fate would have it, I am leaving the practice in which I did all of this work and am starting a new practice with a different payment system.  Instead of charging for office visits or tests done in my office, I am charging a monthly “subscription” fee for access to my care and to the other resources I offer.  But there isn’t a Medicare code for a monthly subscription fee, and the rules of Medicare are such that, as far as I can tell, I cannot have the practice I intend to build and be listed as a Medicare provider.  This is the case even if I never charge Medicare for any of my services.

Regarding my status as a Medicare provider, there are three options:

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

Innovative thinkers and influential healthcare leaders aren’t relying on the decisions coming out of HHS to determine their strategy.  Despite the fact that many healthcare organizations were on target to transition from ICD-9 to ICD-10, Health and Human Services (HHS) announced it would initiate a process to postpone the date by which certain healthcare entities have to comply with ICD-10.

The details of the delay have not been revealed, but industry experts are speculating that a one-two year delay is in the works.  With only 20 months remaining to the Oct. 1, 2013 deadline, this leaves many organizations in limbo.  Do they continue down the path of ICD-10 adoption, revise plans based on speculation about a new timeline or completely put the initiative on hold?

The leaders in healthcare never limited their thinking to a coding mandate.  They were aligning their ICD-10 efforts with quality of care initiatives- EMR adoption and improved clinical documentation.  They won’t hesitate, they won’t miss a step, and they will focus on providing exceptional care through improved processes, many of which will prepare them for a successful transition to ICD-10 and ICD-11.

The following areas of focus will improve quality of care, reporting and accuracy of reimbursement.

–        Lead with purpose- understand the long-term impact of a coding mandate and help providers understand the alignment of greater specificity in coding with quality reporting, improved clinical documentation and clinical decision support.

–        Take this time to improve clinical documentation– develop processes and feedback to improve how physicians and other providers document care.  This effort will reap financial benefits and directly impact quality of care and reporting.

–        Invest in educating coders– coders will benefit from increased knowledge in anatomy and physiology under any coding system.  Introduce the changes in coding structure that will come with ICD-10 and ICD-11.

–        Appeal to the provider’s intellect- roles and responsibilities continue to evolve in healthcare.  Help the provider understand their role in clinical documentation and responsibility for greater specificity in describing care.

Lead an effort focused on improved clinical documentation, not on coding.  Healthcare leaders who develop a purpose greater than a mandate path will be the clear winners from a quality reporting and reimbursement perspective.  Those who use the delay as another reason to “wait” put their organizations at financial risk and will lag behind the industry leaders with or without a delay.

My typical Medicare patient expects me to deal with 5 or more problems in a single routine visit.  There are usually around 3 old ones (e.g., diabetes, hypertension, hyperlipidemia) and at least 2 new ones (e.g., low back pain, fatigue).  For those who come with handwritten lists, there may be as many as 10, including every health question that has come to mind over the past 6 months (Should I take a holiday off of Fosamax? Should I add fish oil? Do I need another colonoscopy? Is the shingles shot any good?).

Physicians who do procedures get paid for each one done to a single patient on a particular day. Medicare’s rule for this – the Multiple Procedure Payment Reduction Rule (MPPR) – says doctors should be paid 100% for the first procedure and 50% for each subsequent procedure up to 5. However, for those of us whose work is primarily cognitive rather than procedural, there is an important exclusion:  the multiple-payment rule does not apply to E/M codes.  In fact, the definitions of 99213 and 99214 unambiguously state, “Usually the presenting problem(s) are of . . . complexity.” Note the “(s)”! It clearly creates a double standard that favors doing procedures and places thoughtful solving of patients’ problems at a disadvantage.

So in my case, 5 or 10 or more separate patient problems equal one payment. The “(s)” in the AMA’s CPT book is the most outrageous injustice to primary care of this generation.  Because of it, the AMA’s CPT committee is accountable for even more damage to primary care than is their RUC!  Think how different life in primary care would be if the “(s)” were removed and you were paid 50% for each additional patient problem you addressed in a single office visit!

The AMA’s CPT committee is quite sophisticated in dealing with multiple procedures and regularly adjusts its coding to reward proceduralist physicians with targeted CPT codes.  For example, there are unique CPT codes for 1,2,3,4,5, and 6 coronary artery bypass grafts. For podiatrists, there are individual codes for nail debridement of 1 to 5 toes and a separate one for 6 or more toes. Dermatology has become a rich field by taking advantage of this coding tactic. The most recent example is CPT coding for Mohs surgery, for which the AMA has awarded a separate procedural code for each slice up to 5.  Is it any wonder that my patients are now presenting with 5-slice Mohs (never 6) on simple basal-cell cancers that could have been easily removed with a simple excision?

The biggest brouhaha in medical coding at the moment is the indignation of radiology for being subject to the MPPR at all, since they are accustomed to being paid the full price for each and every scan they read, no matter how many are on the same patient on the same day. In a letter from the American Society of Neuroradiology to Don Berwick, head of CMS (“We are the preeminent society concerned with the diagnostic imaging and image-guided intervention of diseases of the brain, spine, and head and neck.”), the outraged radiologists claim that the reduction “represents a drastic departure from data-driven reimbursement policy.”

Maybe I missed something, but I don’t think you can accuse CMS of being data-driven on anything! The coding process is political with both rigged codes and rigged relative value. For radiologists, 1 = 1. For me, 1 = 5 or more.

The national unemployment rate is over 9%, spiraling health care costs have bankrupted the US Post Office, and the country has no primary care doctors for the 32,000,000 soon-to-be insured.  So, to the 4,300 physicians specializing in neuroradiology, I say “suck it up.” A double-dip recession is looming.

Paul Fischer MD is a primary care physician at the Center for Primary Care in Augusta, GA. With 5 other primary care colleagues, he recently filed a suit in Maryland Federal Court challenging CMS’ refusal to require the AMA’s Relative Value Scale Update Committee (RUC) to adhere to the requirements of the Federal Advisory Committee Act, even though that panel has been CMS’ near sole advisor of medical services valuation for nearly 20 years.

In a recent Wall Street Journal article, Barbara Levy, Chairwoman of the Relative Value Scale Update Committee (RUC), commented on the American Medical Association’s (AMA’s) decision to have minimal primary care participation on the RUC, saying the committee is an “expert panel” and not meant to be representative.  Since the committee is made up of 27 specialists, one family doc, and a pediatrician, the AMA apparently believes it requires little in the way of primary care expertise but lots of experts from every minute surgical specialty.

This is, of course, reflected in the AMA’s coding system.  Most of primary care is condensed into four Evaluation and Management (E/M) codes: a “focused” encounter, an “expanded” encounter, a “detailed” encounter, and a “comprehensive” encounter (99212-99215).  It does not matter whether the problem is a cold or an acute myocardial infarction.  It does not matter if you worked with just the patient or the entire family spanning three generations.  It does not matter if the problem was simple and common (eg, essential hypertension) or rare and complex (eg, pheochromocytoma).  It does not matter whether you completed everything in a single visit or spent hours fighting with an insurance company for payment.  And it does not matter whether you dealt with a couple of well-established problems or a dozen new ones.  It is clear that the AMA has little expertise in this area.  What is amazing is that they think they have enough!

In contrast, there are 400 pages in the CPT book to help proceduralists get maximum pay for their work.  In general, procedure coding follows a scheme based on the part of the body, the number of times you repeat a procedure, how fancy the equipment is, and how many different names you can come up with to do the same work (eg, vein ablation, injection, sclerosing, ligation, interruption, excision, or stripping).  This is obviously a boon for many physicians’ income.

In a letter to Dr. Roy Poses, Levy also warns physicians against “attempting to drive a wedge between cognitive and proceduralist specialties,” which could weaken the physician lobby.  To that end, I propose that the 400 pages of CPT procedure codes be replaced by a simpler system that is more in line with the one used for payment in primary care.

This system would follow the E/M strategy with a Procedure and Follow up (P/F) coding scheme.  There would be four codes that categorize procedures as “easy,” “not too easy,” “hard,” and “very hard” (P/F codes 99912-99915).  An easy procedure would be something like skin biopsy, cataract removal, or PEG tube placement.  Very hard procedures would be paid more and would include such things as excision of a brain tumor and replacement of a heart valve.  RUC would obviously need to validate each CPT-coded procedure and fit it into the appropriate reimbursement level. It would also need to validate the work involved in each of the four codes to inform CMS how it should be reimbursed.  Should an easy procedure be paid $51.43 or $52.66?

Some will argue that this is an absurd scheme and not based on the multifaceted contributions proceduralists provide to the public.  An alternative scheme to consider would incorporate details of the actual physician work.  In this scheme, you would have one code for “taking something bad out.”  This could include removing pus in a skin abscess, cholecystectomy (out with the bad gall bladder), or removing a brain tumor.  The second code would be for “putting something good in.”  This could include total knee replacement, hernia repair with graft, or breast augmentation.  Next would be “opening something that is blocked.”  These procedures would include transurethral resection of the prostate (TURP), cardiac stent placement, and esophageal dilation.  Finally, there would be a code for “looking but not doing much.” This would be the code for most things that involve a scope, as well as radiology and pathology services.  Again, (delete?) The brilliance of this plan is that all procedures would be compressed into four payment codes, greatly simplifying the system and minimizing fraud and abuse.

Some may argue that these schemes do not take into account “training” as a component of physician work.  It takes six or seven years to be able to destroy varicose veins and get paid for it.  To those, I argue that consideration of training time for any given procedure must be based on the efficiency of the training. It probably does take six years to learn how to care for a patient undergoing coronary bypass grafting, but how many months does it take to learn how to destroy a varicose vein?  Medicare should not be in the business of paying more to physicians who choose inefficient medical education pathways.

I am eager to present these ideas at the next RUC meeting and look forward to receiving an invitation to attend.

Paul Fischer MD is a family doc at the Center for Primary Care in Augusta, Georgia.