Diagnostic Quality and Public Policy

The SIDM Policy Committee, a joint effort of the Society to Improve Diagnosis in Medicine and the Coalition to Improve Diagnosis, monitors the legislative and regulatory landscape for developments likely to impact diagnostic quality and safety and opportunities to move the diagnostic quality conversation forward. The committee made great strides in 2018 by reaching out to and educating policymakers about the need for greater federal investment in diagnostic quality and safety research, resulting in roughly $2 million in new funding to AHRQ to support grants to address diagnostic errors. On another front, the Policy Committee reports that several important new developments in the Medicare Physician Fee Schedule (PFS) have taken effect this year. PFS is a complete listing of payments and policies that Medicare uses to reimburse physicians and other providers working on a fee-for-service basis and is updated annually. The 2019 update took effect in January. It includes a number of long-sought changes in Medicare payment policy that the Centers for Medicaid and Medicare Services (CMS) says are intended to reflect modern practice and unburden physicians from paperwork, allowing them to spend more face-to-face time with their patients. Ideally, these provisions will work in support of a more safe and efficient diagnostic process.

Modernizing Medicare Payment Policy: Virtual Visits

Medicare payment policy generally states that, with a few exceptions, patient-provider interactions qualify for reimbursement only if they are face-to-face. Telephone “check-ins,” for example, by a patient who wants to know if a new symptom warrants an office visit, or by a clinician checking up on a patient’s response to a care plan, have not been reimbursable.

As of January 1, 2019, Medicare will reimburse physicians and other clinicians under two new billing codes that recognize “technology-enabled” physician-patient communications. The first establishes payment for a 5-to-10 minute “virtual check-in” between a provider and a patient using “communications-technology-based service” (e.g., telephone, video-chat). The second new code allows payment for asynchronous professional evaluation and 24-hour follow-up of video and/or images submitted or uploaded by a patient (“store-and-forward”).

With these new codes for “virtual” physician-patient communication, CMS aims both to align payment policy with current trends in medical practice and to improve efficiency. There should be less incentive for practices to require patients to show up for what may be unnecessary office visits for problems and concerns that could be handled through a call or other “technology-enabled” communication.

It bears noting that CMS also cautions that payment for “virtual” communication has significant potential for abuse, particularly since the agency does not require additional clinical documentation for the new codes. The agency will monitor the use of the new codes very carefully to learn how they are used and their impact on patient care.

Interprofessional Consultation

The 2019 PFS also implements a long-sought change in payment policy for clinical consultations. Consistent with a recommendation in the National Academy of Medicine’s report, Improving Diagnosis in Health Care, CMS has adopted new codes to reimburse clinicians for time spent referring and responding to requests for medical consultation. Until now, the clinician’s time and effort to request or provide clinical consultations for a patient were considered bundled into the payment for that patient’s office visit and not reimbursable as a distinct service.

The practical effect of that policy has been that referring physicians typically send patients to separate visits with consulting specialists. That results in significant added cost and inconvenience to patients and the system in cases where a simple phone or internet-based interaction between the treating clinician and the consultant would have been sufficient. And there was no guarantee that patients would actually follow up with specialists. The new codes allow payment for consultations through telephone, internet, or electronic medical records (EMR) directly between the treating clinician and a consulting clinician “with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to face contact.”

Beneficiaries are subject to regular cost-sharing provisions (copayment and deductibles) for these services so their consent for the virtual consult must be documented in the medical record.

Clinical Documentation Requirements

Physicians and other practitioners have been complaining for years that the work required to fulfill all the documentation requirements in electronic medical record templates siphons time away from the patient encounter and often results in obscuring the information most important to establishing a diagnosis. One of the biggest changes in the 2019 PFS and part of CMS’s broader “Patients Over Paperwork” initiative seeks to tackle this problem by simplifying clinical documentation requirements that were established before the widespread adoption of electronic medical records. This is one step in a longer-range initiative by CMS and the Office of the National Coordinator for HIT to address the burden associated with electronic records.

One major source of frustration for physicians — and a potential safety issue for patients — has been a requirement that for each patient visit, clinicians document in the medical record a patient’s chief complaint (CC), history of present illness, past family social history, and review of systems. In an EMR environment, this requirement has resulted in a tendency to “cut and paste” information already in the record into the current visit documentation, leading to vastly long and impenetrable clinical notes, or “note bloat.” Starting in 2019, for established patient office or outpatient visits, when relevant information about the required elements is already contained in the medical record, clinicians do not need to “redocument” that information at each visit. Rather, they can focus their visit documentation just on what has changed since the last visit, or on pertinent items that have not changed, so long as there is evidence that the clinician reviewed the previous information and updated it as needed.

In addition, for new and established patients, any part of the CC or history can be documented in the medical record by ancillary staff or even the patient, freeing the physician to focus attention on the patient. Clinicians still must review prior data, update as necessary, and indicate in the medical record that they have done so. (State laws regarding scope of practice will determine which ancillary staff are able to enter the initial documentation for approval by the billing clinician.)

CMS intends these changes to allow practitioners greater flexibility to exercise clinical judgment in documentation, “so they can focus on what is clinically relevant and medically necessary for the beneficiary.”

Finally, CMS proposed significant changes to the underlying structure of documentation and payment rates for Evaluation and Management codes but did not finalize those changes. While also intended to reduce provider burden, the proposed changes proved to be so controversial that CMS is delaying further action until 2021, giving stakeholders more time to influence policymaking. The Policy Committee and SIDM are engaging with CMS to ensure that any further proposed changes to clinical documentation support improvement in diagnostic quality and safety.

Questions about these and other policy developments? Please contact leslie.tucker@improvediagnosis.org.