Many primary care physicians do not believe that they can make a reasonable living caring for Medicare beneficiaries. Based on the belief that the fee-for-service model drives unnecessary utilization of services, Centers for Medicare & Medicaid Services (CMS) has developed new payment models. The upcoming implementation of these programs has led to a lot of confusion and fear amongst physicians. In many ways, this is nothing new. Fear is a major reason that physicians have struggled with Medicare for many years. Unfortunately, there has been little focus on addressing this fear. In fact, the attorney general and the Office of Inspector General (OIG) have tended to stoke these fears by focusing audits on physician coding.
In 2012, the U.S. attorney general and the Secretary of Health and Human Services (HHS) publicly questioned the gradual increase in the use of higher paying billing codes by primary care physicians. This type of scrutiny only serves to heighten the fear that has historically driven “undercoding” by physicians. The OIG recently announced that it will be auditing the use of the new transitional care and chronic care management codes in 2017. The unintended consequence of this focus could be that it casts a pall over the appropriate and necessary use of these important new codes.
I have often asked audiences of primary care physicians how frequently they spend at least forty minutes face-to-face with a complex frail older adult in their office. I invariably see the entire room raise their hands. I then ask how often they use the highest level CPT code for those visits. Most of the hands go down. Next, I ask if the majority of time spent during those visits are related to education and counseling of the patient. All of the hands go up again. This indicates that physicians are afraid to utilize the highest level code, even when it is appropriate. Andy Slavitt, the Acting Administrator at CMS, has repeatedly tweeted and blogged about the importance of primary care physicians spending time with their patients. I couldn’t agree more! Unfortunately, physicians do not feel that they are reimbursed appropriately when they spend more time. That’s actually not true; if they were to code appropriately for the visit, they would be paid fairly. If they undercode, their reimbursement is woefully inadequate.
In 2001, Dr. Don Murphy and I founded Senior Care of Colorado. We felt that the rules actually allowed primary care physicians, and geriatricians in particular, to spend whatever time was necessary to provide quality care to older adults. We studied the coding rules and educated our clinicians on appropriate coding. Our practice made significant use of time-based coding, and even the use of prolonged visit codes. It wasn’t long before we were under the scrutiny of the OIG. One of the first things this led to was a shift by our clinicians to undercode. This almost killed our practice, but we heightened our efforts to educate our clinicians and assure that they actually followed the coding rules. The OIG investigation led to multiple audits of our coding and billing practices.
In addition to regular education on the coding rules, we promoted the necessity to document the thought processes behind each visit and to explain what was being done when spending more time with our patients. The audits were revealing from other perspectives. One year, we received a subpoena for a number of charts of patients who we saw very regularly in the office. Many of them were my patients. I had a tendency to see my most frail patients every couple of weeks. One of those patients was a very frail older man with severe congestive heart failure. Over four years, I had seen him regularly every two weeks. He was not hospitalized a single time during those four years.
Our OIG investigation lasted 8 years. Whenever the government closed a big case, we would receive a subpoena for records, as if they kept our investigation handy for when they didn’t have anything else to do. Near the end of the eight years, a government agent (carrying a gun, no less) knocked on the door of a patient our practice cared for in a rural area. This patient was a diabetic with a foot ulcer, who had been receiving weekly home visits from one of our nurse practitioners. The patient called us in a panic, wondering why the government was interviewing. We were being targeted for doing weekly visits. When I found out about the interview I was furious. It was one thing to cause me and my clinicians stress from an audit, but it was another to add stress to a frail and vulnerable Medicare beneficiary. I called our attorney and suggested we go public with this unseemly episode. He contacted the supervisor of the agent pursuing our investigation and shared the incident. We never heard from the OIG or state attorney general’s office again. They clearly realized that they had gone too far.
Our practice invested significant resources in education. We ultimately spent over a quarter of a million dollars on attorney’s fees, learning how to deal with an OIG investigation. Most primary care practices do not have the wherewithal to do what we did. However, I encourage primary care doctors to learn the coding rules and to follow them with clear documentation. I also encourage them to resist bullying from intermediaries that question the appropriate use of higher level CPT codes. Primary care physicians must code without fear. We must strive to do what is best for our patients. Oftentimes, that means spending whatever time is necessary to deal with complex issues.
Ironically, spending time with complex frail older adults is one practice for which a fee-for-service reimbursement model actually can work. If physicians properly understand the appropriate use of time-based coding, they can be fairly reimbursed for spending the time needed for these complex patients. We desperately need CMS and the OIG to coordinate their efforts in support of the important work that primary care physicians can accomplish in caring for frail older adults. Primary care practices run on very narrow margins. Even a small amount of undercoding can be enough to sink a practice. CMS needs to realize that ignoring this issue, while focusing on 5-10% bonuses or penalties, risks missing the forest while focusing on a few trees. Physicians should not fear doing the right thing. CMS needs to let primary care physicians focus on the care of their patients, not on arbitrary coding rules.