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Friday, February 19, 2010

Performance measurement: Curiouser and curiouser

In response to the pressures of health care cost inflation, the Centers for Medicare & Medicaid Services (CMS) and other payers have been investigating "value-based purchasing" initiatives.  These initiatives, including pay-for-performance, assume that the entities from which payers buy health care have a sufficiently large number of patients with specific conditions to support statistically valid comparative measurement. 

However, the reality is that many primary care physicians provide a wide variety of services to different patients.  Consequently, they do not see enough eligible patients in any given category to produce statistically reliable performance measurements.  In essence, individual primary care physicians are often as indistinguishable as Tweedle-Dee and Tweedle-Dum for performance measurement purposes. 

For proponents of accountable care organizations and similar arrangements, the answer to this conundrum is primary care physician aggregation.  That is, if you put enough primary care physicians together and measure their collective performance at the practice in which they work, you can overcome the sampling problem posed at the level of the individual primary care physician. 

That may be true, but unfortunately, you have to do a whole lot of aggregating to get to that point, and most practices aren't that big.  This point was driven home to me in a study by Nyweide et al in the Dec. 9, 2009, edition of the Journal of the American Medical Association.  They concluded that relatively few primary care practices are large enough to reliably measure even 10 percent relative differences in common measures of quality and cost performance (at least among Medicare fee-for-service patients).  For instance, the authors calculated that it would take a caseload of 2,526 Medicare fee-for-service patients to detect a 10 percent difference in ambulatory costs.  However, only practices with 11 or more primary care physicians are likely to reach that threshold, and the percent of practices with that many primary care physicians is less than 2 percent. 

According to the study, no groups had enough patients to detect 10 percent differences in preventable hospitalizations or congestive heart failure readmissions.  This implies that a group of Tweedle-Dees is as indistinguishable from a group of Tweedle-Dums as the individuals are from each other. 

Does this mean that CMS and other payers are likely to abandon pay-for-performance, tiering and steering, and other efforts to grade physicians relative to each other?  I would suggest that you would be Mad as a Hatter to think so.  As for the payers, they're not saying, just grinning like a Cheshire Cat. 

Tuesday, February 2, 2010

No crosswalking!

As the dust settles following the removal of the consultation codes from the 2010 Medicare fee schedule, a lot of questions remain. Unfortunately, some of the people trying to answer those questions are not providing sound coding advice. Most concerning is the idea that the outpatient consultation codes crosswalk directly to the office or other outpatient service codes.

The very first cross in this walk should raise questions. Could a 99241 service with key components of a problem focused history and exam and straightforward medical decision making realistically cross to a 99211 nursing visit? No. This service is much more likely going to meet the key components of a 99212 service. The difference is significant. The national average Medicare fee schedule amount for a 99211 is $19.12 while the national average amount for a 99212 is $38.97. By using someone's idea of a time-saving crosswalk rather than selecting the code that your documentation support, you could lose half the revenue your practice earned for this service.

Physicians should also be aware that hospital or nursing facility consultations that meet the key components of 99251 or 99252 do not satisfy the key components for 99221 or 99304, which require higher levels of history and examination.

The bottom line is that services should be assigned the code that the documentation supports. You should not cut corners by crosswalking the codes. This may be especially important to consider if you are billing a patient's private payer plan first and Medicare second. You may be able to bill the private plan for a 99251 service but you cannot bill that same code to Medicare for the secondary payment. In this case, you must determine whether your Medicare contractor will accept a subsequent hospital care code even though this was the physician's first inpatient encounter with the patient. They may require you to submit code 99499 for an unlisted E/M service instead, leaving them decide what level of service was rendered.

This move by Medicare to eliminate consultation codes from the fee schedule has shown just how complex E/M coding has become.Let's hope we can move toward a simpler system where physician work (i.e. level of history, exam, medical decision making, counseling and coordination of care) is fully valued with or without a request for advice or opinion. Now if there could be a closer look at all those E/M services valued into the global fees for surgery...

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The views expressed here do not necessarily reflect the opinion of FPM or the AAFP. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. See Terms of Use.

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