Steve

Dr. ehscott,

Yes, agreed that initial consultation in which most specialists are asked to render an opinion are billable as an E&M code. However, note, that at least in my practice (vascular surgery) NONE of the referral doctors dictate or even suggest whether or not I proceed with a procedure (many diagnoses do not even require a procedure). I am responsible for the appropriate decision, workup and plan (hence the term ‘consultation’). I am sorry for the status of the ‘proceduralists’ where you practice and understand your position if this is so.

Note though that any E&M code proceeding to surgery within 24 hours and for 90 days after is not billable. For me at least, this includes between .5 and 25 hours of direct patient care PER procedure which is compensated for in the procedural code.

But as Dr. Fischer offers, how exactly do we establish the cognitive complexity of anything we do in a fair and reproducible manner, and tie it to compensation? What about those who put a lot of cognitive effort into complex problems yet have poor outcomes? Be assured that if payment were to reflect ‘complexity’ for E&M, we will see a tremendous increase in ‘complex’ problems and diagnoses, no different than multiple procedures or add-on codes or self-owned imaging studies that run afoul. Current volume-based systems are ripe for being ‘gamed’, unfortunately.

Still no one here has yet to lay-out a realistic alternative. I will ask again, how should we consider on-call and available hours, bedside time for inpatients, liability etc.? These represent true ‘costs’ beyond cognitive complexity. It would be interesting to see the primary care response to this given (at least where I am) primary care docs turnoff their phones at 5pm and take no night-weekend call, don’t go to the hospital, have 1/2 of the training debt I do, and malpractice rates that are 1/8th of mine. Bundled payment for sure is coming, in agreement with Dale, and could ease cost and the reimbursement gap.

In this month’s HBR, the time-based cost analysis of Kaplan and Porter ( http://hbr.org/2011/09/how-to-solve-the-cost-crisis-in-health-care/ar/1 ) may hold some merit Simply accept that some will deal with more complexity, some with less, some do procedures some don’t, but adjust reimbursement to reflect the true ‘cost’ of time, overhead etc. regardless of ‘number’ of procedures or specialty.

Dr Motew, this is crappola. Proceduralists also bill for E&M, so they get paid for preparing/discussion/educating (even thought it is usually their PA or FNP who does that). As far as “diagnosing”, their patients have already been diagnosed — by the person that referred them to the proceduralist in the first place. Proceduralists are much less concerned with a diagnosis than they are with an indication. You need an indication to do a test, that is what they are looking for. Chest pain is an indication for a cardiac workup to a cardiologist, even though the chest pain is atypical for heart disease and more typical for GERD

As I have posted time and again, the faults of the current system are not contended, yet the incessant ‘whining’ from primary care seems to be getting nowhere. I am all for a fair system, one that takes into account all of the aspects Dr. Fischer mentions, but also does not ignore: on-call hours, malpractice risk, job stress, time, unassigned care coverage, quality….Where is a balanced recommendation? The lack of a cohesive approach to a fix is exactly why the current system is maintained by CMS….there is simply no ‘better’ solution that has been proposed here.

To Matt, where is some editorial oversight to these continual one-sided postings/whine session?

The devaluation of cognitive services is so deeply imbedded in our current payment system that even most docs don’t see it.