It’s complicated

A 7% fee increase for Family Physicians?  I’ll believe it when I see it.”

The 2013 Proposed Physician Fee Schedule released in early July 2012 included a CMS estimate of an increase in payments to FP of 7% and Internists of 5%.  But one doctor I know greeted the news with skepticism.  “I’ll believe it when the check clears.”

CMS has signaled that it wants to increase payments for primary care services and has done so under the Primary Care Incentive Program (PCIP) and plans to do so under a Medicaid parity rule in 2013-2014, which will match Medicaid payments to the Medicare rate for two years.  The initiative announced in the 2013 Proposed Rule is for a new benefit for a non-face-to-face service provided by a community PCP to transition moderate to highly complex patients after a facility discharge back into the community.  This correlates with their goal to decrease re-admissions.  This benefit is not, as the song says, “money for nothing.”  It’s a new code that describes a distinct set of services.

CMS is proposing (it won’t be finalized until November, and if finalized the code will be released with an effective date of 1-1-13) to pay for this service after discharge from an inpatient medical or psychiatric facility or nursing home.  The community physician reviews the admission and discharge and works for a smooth transition.

The requirements for the service as proposed are:

  • Direct or phone or email contact within two business days of the discharge from the hospital
  • A face-to-face E/M service either 30 days before or 14 days after the discharge
  • Assuming responsibility for care with no gap
  • Establishing or adjusting the plan of care
  • An assessment of the patient and caregiver understanding of the plan, education and assessment of need
  • Communicating with other health care professionals
  • Assessment of need for community services
  • Assistance in scheduling care

So, indeed, CMS is proposing a service that will result in an increase in revenue for some community based primary care clinicians.  It is a service that many are doing already but not getting paid for.  It has specific and defined elements that must be documented.  Stay tuned: I’ll write about this again in November.

Less is more

“My medical assistant populates the past medical, family and social history in every note.”

Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation.  I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we implored physicians to add detail to their notes, describe their clinical thinking more fully and in general, produce more words.  But, that was before Electronic Medical Records.

Using an EMR to document an office visit or hospital admission produces pages of information that no one reads or wants.  I know: EMR notes aren’t meant to be printed and sent, but the dirty secret is that since medical practices don’t all use the same EMR, many notes are printed or faxed to another physician.  And, looking at the visit documentation within the EMR is often the same as looking at a long, flat document.  Filled with information that no one else wants or reads.  And, yet, physicians complain that the notes they receive from other physicians hide critical information.

Over the coming months, I’ll write in more detail about what I think would improve the quality of EMR notes.  When I audit records, this is my gold standard:  can I tell why the patient was seen that day, what happened during the visit and what the medical provider recommended.  Or, in other words, could a covering provider use the note to treat the patient?

I often question, do we really need the medical assistant to load family and social history for every follow up visit?  How often is the treating physician really reviewing that information with the patient?  Is it relevant to today’s visit?  If the answers to those questions is it’s not needed, it’s not reviewed and it’s not relevant: leave it out.  Less is more.