Family physicians offered medical services that was not explicitly reportable with available CPT codes in more than 60% of office visits, according to findings recently published in the Journal of the American Board of Family Medicine.
There are no examples in the CPT book or CMS evaluation and management guidelines that explain how to code certain patients, such as those with three chronic conditions in poor control, or those with three new symptoms and three chronic diseases and three new symptoms, according to researchers.
“This issue is important because 1) previous observational studies of [family practitioners] found that they actually manage a mean of 2.5 to 3.1 diagnoses, 3.9 to 6 for elderly patients and 4.6 for patients with diabetes per clinic visit; 2) some insurance forms only permit four diagnoses lines for any single CPT charge code; and 3) CPT codes are directly tied to relative value units, which are commonly used by practice groups to guide compensation,” Richard A. Young, MD, of the department of family medicine at JPS Health Network in Fort Worth, Texas and colleagues wrote.
Researchers collected data using a tool modeled on the National Ambulatory Medical Care Survey. Trained assistants watched 982 family physician-patient visits and noted every issue addressed by the physician (including care barriers related to social determinants and health care systems), patient concern and treatment ordered. A visit had work not specifically reportable if the number or nature of issues discussed surpassed the definitions or examples for 99214 + 99354 or 99205/99215 codes or a preventive service code, included a family member’s care, or a physician discussing social determinant or health care system issues.
Young and colleagues found that in 60.3% of the encounters, the family physician did work that was not explicitly reportable with available CPT codes either by the type of problem addressed or by being higher than the CPT example number of diagnoses per code. In addition, 59.3% of the visits addressed more issues than could specifically be reportable; 6.5% discussed system barriers; and 1.3% discussed concerns for other family members. In addition, patients raised a mean of 5.4 different reasons per visit and family physicians discussed a mean of 3.7 issues per visit. Also, there were a mean of 4.6 total medications managed and 3.9 chronic medications continued per visit, and there were 11 devices, 18 supplements and 425 different medications managed across all visits.
Researchers wrote that their findings largely aligned with earlier research using National Ambulatory Medical Care Survey data that likened the “complexity” of primary care with psychiatry and cardiology and previous studies that examined the number of issues addressed per visit in higher risk elderly and diabetic populations.
“Because the highest-cost Medicare and Medicaid patients are those with multiple chronic diseases, creating a payment system that encourages thorough primary care for these patients would be desirable, which our study suggests is not the current situation,” Young and colleagues wrote. “Our findings also show the limitations of using our current system to account for the work performed by [family practitioners]. This concern is in addition to the observation that [relative value units] (based on CPT coding with examples) preferentially reward procedural work over cognitive work.” – by Janel Miller
Young reports being the sole owner of Sentire LLC, a company developing a novel method for family physicians to document, code and bill for their work. Healio Family Medicine was unable to determine the other authors’ relevant financial disclosures.