CMS Still Doesn't Know What Doctors Do


How will the newly proposed Centers for Medicare & Medicaid Services fee schedule impact your practice? One physician explains. 

CMS, Doctor, Medicare Medicaid


The 2019 proposed Medicare fee schedule has many endocrinologists concerned, along with primary care physicians and other specialists who see patients with complex problems.

Under the proposed fee schedule, there would be 1 fee for what are now considered levels 2 through 5 follow-up visits. Proponents in favor of the change state that under this new schedule, documentation requirements will be decreased. Well, that’s all well and good, but that does not decrease the time and effort needed to care for patients with multiple chronic complex diseases.

There is a difference between seeing a patient for hypothyroidism who has been on the same dose of medication for the last 5 years and who comes only once or twice a year and a patient with type 1 diabetes on an insulin pump who has retinopathy, hypertension, and hyperlipidemia. The pertinent questions and appropriate physical examination are very different for these 2 patients. It seems only right that physicians be compensated more for seeing the complicated case.

There are those that argue, “Well, then use the prolonged visit code.” Except that I can’t.

You can only use that code if you exceed 30 minutes beyond the “typical time” of the base code. I can’t start lengthening patient visits so I can get paid more. If I do that, I won’t be able to accommodate all the patients that need to be seen. If endocrinologists start prolonging their appointment slots, it will create an even greater backlog of patient visits. As it is, patients wait from 3 to 6 months for appointments due to the shortage of endocrinologists. If we prolong visits, we’ll end up seeing fewer patients each day, which in turn means patients will be seen less often and revenue will decline due to reduced patient volume.

Another argument says, “Well, there’s a code for E&M visits for endocrinology.” Yes there is, but it doesn’t make the proposed fee (for level 2-5) equal to a current level 5.

Another position holds that, well, we’ll just have to address one problem at a time and have the patient come back for another visit to address other things. I think that is unfair to the patient and puts additional burden on them. Also, put them where on the schedule? The calendar is already full for the next 3 months. This strategy brings us back to the problem of patient backlog and lack of endocrinologists.

It has long been an issue that our healthcare system does not value specialties that are based on providing advice and education. Physicians do not get paid for teaching, for counselling, or for listening. Physicians get paid if they do procedures.

This proposed demotion of all visits to a single level is just more evidence that CMS underestimates how difficult this work is.

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