PCPs should be paid for coordinating outside care, proposal says

Chronically ill patients take far more of your time than a regular office visit, but a regular office visit often is the only service for which you receive payment.

Addressing that perennial complaint of primary care physicians, the American Medical Association (AMA) recently recommended that Medicare pay doctors for time spent coordinating care for patients.

The letter from Barbara Levy, MD, chairwoman of the AMA/Specialty Society Relative Value Scale Update Committee (RUC), to Donald Berwick, MD, administrator of the Centers for Medicare and Medicaid Services (CMS), advocated payments for four kinds of coordination starting next year: anticoagulant management, patient education and training, medical team coordination meetings held in the patient’s absence, and telephone calls made 7 or more days after an office visit and more than 24 hours before an in-person visit.

All four services have existing current procedural terminology (CPT) codes and relative values published by CMS. Currently, CMS does not pay separately for these services, instead considering them part of an evaluation and management (E/M) bundle. Lori Heim, MD, chairwoman of the American Academy of Family Physicians (AAFP)  recommended that CMS institute payment for the four currently “non-covered services” in her letter to Berwick in August. 

Levy estimated that payment for anticoagulant management would be $41 per month for the first 90 days and $14 per month for each subsequent 90 days. Patient education and training by a nonphysician health professional such as a nurse or registered dietitian “are clearly separate and distinct from E/M” and require 30 minutes of clinical staff time that cannot be separately billed today. Similarly, medical team conferences cannot be billed by nonphysicians and cannot be billed by a physician in the patient’s absence.

“Not only will payment for these services save Medicare money in unnecessary office and emergency room visits, potential savings in Medicare Parts A and D will also offset upfront payment for non-face-to-face-services,” Levy says.

The AMA recommendations arose in response to CMS’s proposed 2012 Medicare physician fee schedule. In that proposal, CMS requested “the AMA RUC conduct a comprehensive review of all E/M codes” to identify potential undervaluation. To ensure prioritization of this task, CMS asked the RUC to complete the review of 91 E/M codes in 2012 and 2013. The AMA created a chronic care coordination workgroup of CPT editorial panel and RUC members to “consider specific alternatives to a re-review of the valuation” of the E/M codes.

The AAFP also would like an alternative to a review of the E/M code values by the RUC.
“We believe that it would not be productive to ask the RUC to revalue evaluation and management services under the same structure, procedures, and methodology that it used to establish the current values,” Heim wrote. The AAFP has created an alternate task force to value primary care payments.

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