By PAUL FISCHER, MD

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.