Why doctors won’t use the new end-of-life Medicare counseling codes

Poor bored government. So much time on their hands; so little real work that needs to get done, all they can do is micromanage poor physicians like me to death. Well, they can try.

For its first forty-five years, Medicare was (in)famous for the very narrow limits on things it covered. It would pay for medical care when you were sick or injured, and that was basically it. No preventive care. No shots. Counseling, coming under the rubric of psychiatric care, was paid at 65 percent of the “medical” rate. On the flip side, all you had to do to get paid was bill for it. Somehow way back then, physicians were considered professional enough to be trusted only to bill for what they did.

Of course, they gamed the system some. (Some would say a lot.) I remember happily billing for physicals as long as a patient had any possible “medical” diagnosis I could use as a primary code. Hypertension, diabetes; even just “elevated blood pressure, no diagnosis of hypertension” or “impaired fasting glucose” would work. “Fatigue” was also a great catchall. Who wasn’t tired all the time? I had no ethical problem with it, because I felt that once a year my hypertension and diabetes patients deserved a longer, more complete evaluation. It was simply a matter of getting paid for doing the right thing for my patients.

Then along came coverage for preventive care. Now I could provide that annual wellness visit without having to fudge a diagnosis. Great, right?

Not so fast. Turns out that once the proposal had made it through the sausage-making machinery of CMS, the only way to get paid was by jumping through a slew of hoops requiring the documentation of all kinds of irrelevant minutiae that converted the visit into nothing even remotely resembling what you or I or any rational being would consider a “physical.” Then again, because it pays pretty well, and because some of the services waive patient deductibles and co-insurances, I used a template designed to capture all the picayune crap they want, and actually use the codes.

A shining example of getting paid for doing the right thing for my patients.

Next stop on the CMS runaway Medicare train was paying for “chronic care management.” You know; recapturing at least some of the uncompensated time spent on the phone coordinating care for patients with multiple chronic conditions. Again, something that sounds like a good idea in practice didn’t quite turn out that way. Gee, I wonder why? Because of the micromanagement of required documentation, in short.

And now CMS, the bumbling, fix-what’s-not-broken, great and powerful has deigned to begin paying for two new codes (though not until January 1, 2016) specifically for covering discussion of end of life issues. I haven’t yet seen any documentation parameters regarding the codes (99497 for the first 30 minutes; 99498 for subsequent 30 minutes) though if the wellness visits and chronic care management codes are any gauge, I shudder to think what they could come up with.

Unless these new codes pay significantly more than what CMS already pays for a level 4 visit, I will not be using them. Here’s why.

I already have these conversations with my patients, and have for years. I also get paid for them, and it’s completely legitimate. Quoting myself:

Medicare and other payment systems have a provision for time-based billing. When more than half of the face-to-face time is spent counseling the patient, reviewing treatment options, etc. then the total time spent in the encounter can be used as the determining factor for payment. News flash: The topics discussed are not regulated. “Death panels” (i.e., the proposed payment once every five years to discuss end of life issues) aside, I can and do (and always have) bill specifically for those visits.

That was from a post five years ago.

I use time-based billing to cover visits for psychiatric problems, chronic care management, end of life discussions, and much more. I document appropriately, sleep soundly, and cannot fathom why the big hullabaloo over this new policy.

People have been dying for years, and I have it on good authority that they will continue to do so. On the one hand, perhaps the existence of these new codes will encourage more doctors and patients to have these difficult conversations. Then again, human nature being what it is, I have my doubts. We need to do much more than just create new medical billing codes in order to overcome our deeply ingrained cultural aversion to all things death.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

Image credit: Shutterstock.com

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