The Math of E/M Coding: When Does 5=1?

Paul M. Fischer

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 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.

About Brian Klepper

Brian Klepper is a health care analyst and the Chief Development Officer of WeCare TLC onsite clinics.
This entry was posted in Analytics, Medical Management, Physicians, Policy/Law/Regulation, Quality, Reform and tagged , , , , , . Bookmark the permalink.

One Response to The Math of E/M Coding: When Does 5=1?

  1. a family doc says:

    Yup, in the past I tried to be efficient and cover at least 3 chronic problems at my geriatric patients’ appointments. That works out to be a 99214. Due to the quirks of E&M coding, any problems addressed beyond that are usually done for free.

    I’ve learned to only cover 1 or 2 chronic problems per visit as the “oh by the ways…” inevitably fill the rest of the appointment and then some.

    Third party payment is the wrong, clumsy tool for routine primary care visits.

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