Behind the Scenes: Medicare Coding Changes...

Starting January 1, 2010, Medicare implemented a dramatic change to how doctors, and specifically specialists, code your visit to their office, specifically referred to as E & M codes, or Evaluation and Management codes. Up till now, if your primary care doctor or internist referred you to a specialist, he would be required to send a letter requesting the consult and fax your medical chart with his notes to the specialist so he would have them to review when you were seen. After your visit, the specialist would send a letter to the referring doctor explaining his recommendation and plan for you, the patient. These higher level, or "consult codes", reimbursed the specialist a higher amount than the lower level "new patient codes". A patient who came to a specialist's office for a visit but who was not referred by another doctor, would be coded using a "new patient" code, (which has 4 levels), with the level of the visit being determined using multiple factors Medicare has developed. There is no communication required between the specialist and a 'new patient''s other doctors. He does not send his chart notes to any of the physician's you list on your information sheet. This only happens if a specific doctor has requested you see a specialist, usually of his own choosing.

So here is the change....Medicare is not accepting any more consult coded visits. All visits must be coded as a 'new patient visit'. Here is what this means to Medicare.....Medicare can get the same work out of the doctors but pay them less. As medical professionals, the majority of doctors will practice as trained, doing whatever necessitates the appropriate care required for their patients i.e. communicating to the referring physicians. The continued administrative costs associated with corresponding with each other and time required to process a consulting physicians notes will not change, in fact they continue to increase.

Here is what it means to you the patient....there will be doctors who forego communicating with the referring doctor because they are not getting paid for it. Already there are patients and families who are frustrated when they don't get answers. Think about the ramifications when confusion is built into the process because one doctor doesn't know what the other is doing (this already happens sometimes right?) With the elimination of the consult structure, which had been built into the Medicare reimbursement schedule, the incentive for some doctors to communicate with each other will be eliminated. Many of the costs associated with communication between doctors will continue to exist and actually increase. The fact they aren't being compensated for those costs will be enough to propagate practicing medicine in a shoddy way - reduced communication between referring physicians. Bottom line: the quality of healthcare we receive will continue to be eroded, little by little, and most people won't be able to connect the dots. (Where have I heard that before?) But because you are reading this blog, you will! :) Doesn't that make you feel better??

Entering the Fray....

The frustration of sitting on the side lines while politicians, celebrity cable news channel hosts and their station heads shape public perception and understanding of health care has finally pushed me over the edge and into the realm of the "blogosphere". My agenda is simply to provide a forum to clarify the information and correct misinformation that is spreading through editorials and miscellaneous news articles appearing in journals and major newspapers, as well as television media reporting. Consumers of health care, which we all are, need to understand what system our politicians are trying to reform in order to best evaluate whether proposed legislation and policy will actually accomplish the change we are all looking for.

So, what do I bring to the table? In addition to my fifteen years in the business administration of medical practices in both multi-doctor groups and solo practices, my husband is a practicing surgical subspecialist. We have been able to experience and observe how the medical field and the business of medicine function in the private marketplace (as opposed to academic centers and our government VA hospitals)in a variety of areas: twelve years in a major metropolitan area, and currently for four years in a rural area of the U.S. We also had the opportunity to live overseas in New Zealand where he practiced within a nationlized system of healthcare. These experiences have given me a unique overview of how the business of medicine functions. And the business of medicine is what has shaped our current system of health care,and will continue to influence and redefine the practice of medicine.

The industry as a whole is convoluted and multi-faceted. I can only comment on those areas in which I have direct knowledge or experience, which is limited to physicians and hospitals, and health insurance - and this admittedly is only one piece of the health care puzzle.


How medicine is practiced, how it is accessed, and how it is compensated is complex and confusing. It is my hope that by way of referencing current news and journal articles in order to validate or refute assertions by offering constructive and helpful explanation in layman's terms, we can all be more educated about what is most definitely a convoluted and confusing maze of business practices unique to the business of medicine.

Please feel free to offer your insight, experience or correction to my analysis of different commentary's, articles, etc that I will post here. And please send me links to articles that you may have read that you would like to be reviewed.