As I've explained before, we've always had reimbursement for end of life counseling. I've availed myself of it many times in my career. Before we ponder the inscrutable question of what the measure would add it might be useful to take a closer look at the counseling provisions already in place. First a direct quote from the 1995 and the 1997 Medicare coding guidelines:
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.
If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.
What this means (Happy Hospitalist explains here) is that if you spend enough time counseling, about end of life or other issues relevant to a person's care (and it doesn't have to take very long) you can code a level 3 visit without even taking a history or laying a stethoscope on the patient. No history, no exam, no complexity required. Any time you counsel a patient in any detail at all it makes coding level 3 a breeze.
From discussions I've had with other docs this seems to be a well kept secret, but in the many coding seminars I've attended, whenever I pin the experts down about this they tell me it's true.
So why, then was the new provision felt to be necessary and what would it have added? We were never told. The policy wonks refuse to talk about it. To me that leaves three possible explanations. 1) It was purely symbolic. 2) There was a hidden agenda. 3) The policy makers and politicians were showing their ignorance of the regs already in place.
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Here's how end of life counseling happens in the hospital at 2 am when grandma looks "kind of sick"
Happy: Grandma, if someone walked in and you weren't breathing or your heart had stopped and in order to keep you alive we had to bang on your chest (do a chest compression motion" and put you on a breathing machine, would you want us to do that?
Patient: I think so. I'm not sure.
Happy: Full code it is.
And it's on to the next patient or it's back to sleep.
Perhaps this is the kind of counseling our government desires.
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