In the 1970s, there were presentations to the Sacramento Society of Internal Medicine (SSIM) indicating that we as internists and medical specialists were not being fairly rewarded for our cognitive skills. Some of the more “enlightened” members spent a great deal of time and effort in order to come up with a Resourced Based RVS to recognize this discrepancy. But in order to get paid for it we had to come up with a way to document our thinking processes. Thus the simple RVS gave way to the more detailed RB-RVS which in turn was further codified by complicated Clinical and Procedure Terminology (CPT) codes. These had to be further defined by Evaluation and Management Guidelines which have been evolving to document the time spent.
Since it has now been 25 years since the 1974 RVS codes were published, it is appropriate to make an objective appraisal. Did we do the right thing? I think not.
Medical writers tell me that they may spend many hours, sometimes days, to record a simple dialog so that the words will accurately describe what is actually taking place. How can we record a nebulous, changing symptom story from a patient in 10, or 20, or even 30 minutes of dialog that will pass legal scrutiny? Especially when the legal requirement is also a nebulously changing document. In a two-page pulmonary section of the CPT codes, 20% of the codes are new, or revised, or the text is new or revised. I understand there are 600 code changes now in transition. How can we as physicians, keep up with the advances in medicine, and learn hundreds of new rules that have nothing to do with taking care of patients? If we miss, we can face being prosecuted as felons.
The 1974 RVS codes haven’t died and after 25 years are still being used. Last week I received a fee schedule from an insurance company giving the conversion factor for the 1974 RVS codes. The last edition of the workers compensation fee schedule that I have still uses the 1974 RVS codes. The RVS codes had simple one line descriptions of the evaluations we did, e.g. Brief (xxx40), Limited (xxx50), or Extended (xxx70) office or hospital examination. (xxx60 was effectively eliminated by a reimbursement value that was less than the xxx40). These were used by family physicians, internists, and subspecialists respectively. The “Relative Value” in this particular schedule was listed as 3.5, 5.2, and 8.7 units which, on a $12 conversion factor used at that time, translated into $40 for the family physician who scheduled 6 patients an hour, $60 for the internist who scheduled 4 patients an hour, and $80 for the subspecialist who may have scheduled 3 patients an hour. Thus our specialty, training, and mode of practice would quite well define the type of service we rendered. There was no need for Medicare to hire 400 ex-FBI officers with guns (the Medicare conference in this area made a point that their investigators were armed) to invade our offices and check our records as to how much we documented when arriving at a diagnosis. In fact, as far as Medicare and the FBI agents are concerned, the diagnosis is totally irrelevant. They are only interested in the documentation of the time spent and the billing code. The practice of medicine and service to patients is totally irrelevant.
The lawyers that our professional organizations hire to put this subterfuge together, of course, can only think in terms of time spent. However, medicine is at the opposite extreme. We are result-oriented. We are interested in saving lives, improving health, and giving realistic prognostications, not in taking hours to utilize time to no end. In fact, the best doctors take the least amount of time to do the best work. My cardiologist is worth far more than Blue Shield pays him for examining my heart and doing an exercise ECHO. But after what seems like only 15 or 20 minutes, he assures me that my cardiac function is perfectly normal and I have no myocardium at risk. He tells me to see him again in four years, that my chances of having an infarct during that time is less than 2%. But that information and prognostication is worth more than money can buy, certainly more than a 90070 code (or a xxx14, xxx15), or $80 that a twenty minute code suggests for that amount of time. And it can’t be bought for any price in 95% of the world. It can’t even be bought in countries with universal coverage because they don’t come close to universal access. Canada now has a watch dog organization to document how many people have to wait more than 48 hours in an emergency room before being seen. Organizations that naively believe that lawmakers can provide universal access will continue to lose members. HCFA’s guidelines state that my cardiologist requires decision making of only “moderate” complexity, whereas a decision to terminate treatment is of “high” complexity. This was further exemplified when Linda W Wilson, MD, in Culver City, CA, was told by Occidental Life Insurance that since she is a specialist, complex medical decision-making is not warranted because it is easy for a specialist to make complex medical decisions by virtue of the fact that they are specialists.
In staff room discussions, more physicians have told me that this splitting of hairs in order to get a few dollars more for time spent with one patient (CPT code xxx15) and sacrificing a few dollars for less time spent with another patient (CPT code xxx13) ends up costing more non-professional time, which is money, than if our office visits were simply averaged for the usual time spent. Hence, for an internist, if all our office visits were an RVS 90050 (rather than a CPT xxx12, or xxx13, or xxx14, or xxx15,) and our hospital visits were an RVS 90250, (rather than a CPT xxx21, xxx22, xxx23, xxx24, xxx25 etc) we would be better off, the time would be averaged, and the entire issue of Medicare fraud for not having the time to document in detail what we did, and the need for 400 Ex-FBI investigators to police us, would all disappear. We could no longer be the scapegoats for Medicare’s fiscal problems.
The fraud in Medicare may be huge but it’s seldom from physicians. Yesterday there was a report that a health facility paid $4 million in Medicare fines for billing Medicare for lottery tickets, vacations, condos, and other nonmedical items. Physician fraud doesn’t come close to such egregious items. In physician fraud, except when physicians become non-practicing businessmen and thus no longer clinicians, the physician still sees the patient and provides the service, but someone takes issue with a variance in their understanding of our service. A conscientious physician could spend hours trying to satisfy the legalese that the AMA & HCFA have put together, and still go to jail despite his or her competence. Since physicians comprise less than 20% of the health care dollar, eliminating all physician reimbursements entirely would not solve the Medicare short fall and eventual bankruptcy.
The RB-RVS, CPT codes, and E & M guidelines were grievous errors which are now the undoing of the practice of medicine which in turn is unraveling our professional organizations. Our profession must come to terms with it soon. It looks like now is the time to dump the whole RB-RVS, HCFA, AMA mess which has made potential criminals of all of us. I know it will be hard for the AMA to be more loyal to the dues paying members who provide $69 million of income rather than the business interests, such as the publishing of the changing CPT code book, which bring in $120 million. The AMA’s publisher felt the AMA was too demanding in royalties for the CPT code book. So the AMA and the publisher have sued each other. It may have back fired. The Circuit Court of Appeals ruled that the AMA could not own a copyright of a code book that was required by law. If the code book is required, it has to made available on the same cost or free basis that any other code or statute. The AMA appealed and the Supreme Court had agreed to rule during this year’s session. Millions of business revenues may be declared illegal. We are a dues-paying professional organization and if we don’t provide service to our dues paying professionals, then when the business dealings disappear, there will be no AMA.
The old 1974 RVS could be simplified even further and serve us better. We’ve heard about going “back to the future.” This may be a case of where we should “move forward to the past.” If organized medicine doesn’t proceed along these lines soon, it will cease to exist. Then we will have to start over. So why don’t we just get the job done now and tell our leaders and administrators what we expect to happen and how soon? How about a Y2K-RVS revision and living within our dues paying revenue. The old KISS plan.