Wednesday, September 03, 2014

Alice in Wonderland had nothing on this CMS billing issue

Muriel Gillick provides a cogent description of some Medicare billing issues in nursing homes.  If you can provide an explanation for how this can exist side-by-side with federal rules that support extra payments to hospitals for proton beams and to doctors for use of femtosecond lasers for cataract surgery, you are eligible to become the next CMS administrator.

An excerpt:

It's thought to be perfectly reasonable for a physician to be paid $92 in 2015 for a nursing home visit for an acute medical problem such as a new pneumonia (code 99309). To merit this payment, the physician must provide documentation that he or she has taken 2 out of 3 possible steps: obtained a detailed history, performed a detailed physical exam, or engaged in “moderately complex” medical decision making. Only if the physician takes a comprehensive history, performs a comprehensive exam, and engages in highly complex medical decision-making can he or she bill with the code“99310,” earning the somewhat more generous sum of $136. For comparison, note that a gastroenterologist is paid on average $220 for performing a colonoscopy, a 20-minute procedure. 

No wonder physicians often respond to a call from the nursing home about a sick patient with an order to send the patient to the hospital for evaluation. Send a frail nursing home patient to the emergency room and he has, I would guess, about a 90% chance of being admitted. So instead of paying a physician an appropriate amount for making a visit to the nursing home and instituting on-site medical care, Medicare would fork out a minimum of $5774 (the base DRG payment) for a 5-day hospitalization, exposing the patient to the risk of iatrogenesis.


Barry Carol said...

The two issues here, I think, are how much should the doctor be paid for his time examining the patient and how much should he be compensated for time to travel from his home or office to the nursing home and back? The answer to the first question is likely more than he is paid now. The travel time is probably not compensated at all but should be in my opinion. Maybe CMS needs to move away from relative value units to compensate primary care while keeping them for procedures.

Unknown said...

Then add the roughly $400.00 payment to the ambulance company, each way, for the non emergent transport.

Keith said...

Now you know why we have no one choosing to join our ranks in the primary care fields. Day to day patient care gets short changed (not glitzy enough), while we spend enormous sums onmedical technology offering little improvement over the old technology.