The Centers for Medicare and Medicaid Services (CMS) has issued a Proposed Rule to “blend” payments for higher-level office visits, while decreasing the documentation requirements, as part of its Patients over Paperwork initiative. CMS claims this will save clinicians 51 hours per year—likely a gross underestimate—while critics protest that doctors will get paid the same for treating sniffles and cancer, notes the Association of American Physicians and Surgeons (AAPS).
The Rule is “budget neutral,” which means that it is a zero-sum game with winners and losers. The payment for any type of office visit of more than minimal complexity (level 2 through 5) will be between the current amounts for a level 3 and level 4.
“CMS observes that the Evaluation and Management (E/M) Documentation Guidelines have not been updated since 1997,” reports AAPS executive director Jane M. Orient. M.D. “They have a history that is worth recalling.”
“In 1997, the AMA released the 1997 update to its 1995 guidelines, with its copyright notice on every page. It was monstrously complex, with all kinds of ‘bullet points’ for different body systems and aspects of care that would have to be documented, repeatedly, on every visit, to claim higher levels of payment. There was so much outrage among physicians that the AMA held a “fly-in” in Chicago on April 27, 1998, so that physician representatives from the AMA’s federation of medical societies could ‘vent.’
“Participants stated that the new guidelines increased transcription time by 20 percent, were a ‘complete waste,’ and increased gaming of the system.
“In her closing statement, president-elect Nancy Dickey, M.D., said that the 1997 guidelines were on the ‘scrap heap,’ although physicians could use them if they chose.”
The Health Care Financing Administration (HCFA, renamed CMS) agreed to work for changes to avoid imposing an “undue burden” and to delay implementation—apparently until the energy for protesting died down, Dr. Orient observed.
Twenty years have now passed. “It is long past time for CMS to scrap these oppressive, time-devouring ‘guidelines,’ which are used to subject doctors to draconian civil and criminal penalties,” stated Dr. Orient.
The issue of payment for complex visits is being addressed by add-on codes for increased visit time, as CMS has explained in panel discussions. “Apparently, time is to be a proxy for massive cutting-and-pasting, and easier to audit because the number of hours in a day is limited,” Dr. Orient explained.
“The basic problem is the Byzantine system of Medicare price controls, with CMS using the AMA’s Resource-based Relative Value Scale to set prices for every Medicare encounter, instead of relying on free-market competition.”
The Association of American Physicians and Surgeons (AAPS) is a national organization representing physicians in all specialties, founded in 1943.