Let me stipulate that health care is not as good as it could be in the US and we on the provider side can do a lot to put our houses in order to achieve better outcomes and reduce costs. Let me suggest that the major impediment has nothing to do with intelligence, professionalism or work ethic.
As I've noted repeatedly in the past, high performing health systems share a solid foundation of effective primary care. Primary care is effective when it provides good access to care, solid relationship over time, comprehensive services and care coordination.
The current payment policies of government and private insurers, coupled with the financial models of hospitals and health systems combine to form an environment that works against effective primary care at every turn. With funding that covers only a fraction of the work, primary care is demoralized and worked at a pace beyond the ability to provide adequate access, relationship, comprehensive services or care coordination.
Intending to cut costs, payers lay on a crushing load of additional policy that accelerates the negative effects of inadequate primary care funding.
The dawning recognition of this problem has lead very smart and well intended folks to rush to the aid of primary care so that we can get better outcomes for our patients and reduce costs. Adding a "case management fee" to the mix provides payment for previously uncovered services. This is just the ticket: primary care gets paid for a key element: care coordination.
I'm going to paste at the bottom of this the rule set from CMS so you can see how a good idea morphs into a continuing nightmare. A colleague found this rule set on line after a lively discussion focused on "how in the world does anyone get paid for doing this work?" The initial doctor had her claims denied multiple times - adding to her office costs, adding to CMS costs, adding costs throughout out dying system.
Who wins in the coding wars? Insurers might posit that they are able to keep costs down as they expand fronts to include formulary restrictions and prior authorization. Doctors purchase EMRs so that they can flood the chart auditing engines that equate word counts with burden of work and thus reap more $$ for their Dickensian encounter notes. Neither side is winning this war. Costs continue to spiral out of control and outcomes are no better than in the past.
We have to stop the coding wars. We have lost too many good doctors to this war and our nation cannot sustain these losses. We need an entirely new paradigm of payment that does not rest on a foundation of mind numbing bureaucracy and complexity.
Here's a peek at one skirmish nestled in a battlefront of the coding wars:
Jurisdiction 1 Part B
Care Plan Oversight Services
Care Plan Oversight (CPO) is physician supervision of patients under either the home health or hospice benefit where the patient requires complex or multi-disciplinary care requiring ongoing physician involvement. Medicare does not pay for care plan oversight services for nursing facility or skilled nursing facility patients.
Separate payment is allowed for the services involved in physician certification/re-certification and development of a plan of care for Medicare covered home health services.
HCPCS code G0179 is to be used for re-certification after a patient has received services for at least 60 days (or one certification period). HCPCS code G0179 will be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode.
HCPCS code G0180 is to be used when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service HCPCS codes (G0181 or G0182).
G0179: MD re-certification HHA PT
G0180: MD certification HHA patient
G0181: Home health care supervision
G0182: Hospice care supervision
How to submit a claim
Physicians must submit the six-character Medicare provider number for the HHA or hospice rendering covered Medicare services during the period the care planning was furnished. The physician is responsible for obtaining the Medicare provider number for the HHA or hospice that is responsible for the plan of care he/she has signed for the beneficiary and that is providing Medicare-covered services to the beneficiary.
For paper claims, the six-character Medicare provider number of the HHA or hospice must be entered in Item 23 of the CMS-1500
For claims submitted electronically, the six-character number must be in loop 2310D/REF/LU/02 (NM1/01=FA) or 2420C/REF/LU/02 (MN1/01=FA)
Claims submitted for care plan oversight services with an invalid or missing HHA or hospice Medicare provider number will be rejected as unprocessable and must be refiled as a new claim, but not submitted as a review
Note: There is no place on the HIPAA standard ASC X12N 837 professional format to specifically include the HHA or hospice provider number required for a care plan oversight claim. For this reason, the requirement to include the HHA or hospice provider number on a care plan oversight claim is temporarily waived until a new version of this electronic standard format is adopted under HIPAA and includes a place to provide the HHA and hospice provider numbers for care plan oversight claims.
Claims for care plan oversight services will be denied when:
Review of beneficiary claims history files fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service
Only use CPT codes 99201-99263 and 99281-99357 for face-to-face meeting encounters.
Dates of service entered on the claim form:
HCPCS codes G0181 or G0182 must be the first and last date during which documented care planning services were actually provided during the calendar month. They should not be the first and last calendar date of the month in which the claim is submitted.
Medical records for those dates must document:
30 minutes or more were spent by the physician for countable care planning activities
The specific service furnished including the date and length of time
Claims submitted without the first and last date will be rejected as unprocessable
The physician must:
Report care plan oversight services on the claim
Not submit the claim until after the end of the month in which the service is performed
Report care planning only once per calendar month
Report only one month's services per line item