Cognitive Care

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One of the docs I was working with called me into a room because a patient of hers was going into anaphylactic shock.  His tongue was swollen and his pressure and oxygen dropped big time.   We were able to stabilize him with O2, epinephrine, prednisone and the works and then the ambulance finally came.  The code for this will be a level 4 which is the same as a simple bronchitis.   Insane.   Do you know that physicians who perform procedural care, such as screening colonoscopy and cataract extractions, are reimbursed by Medicare at a rate that several hundred times that of cognitive care?  I am trying to rip my colleagues in different specialties here.   I, myself, do a lot of procedures and that is what bumped my wRVUs in my last job.  The problem is that if this disparity is not lessened there will be no primary care doctors left.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  8 comments for “Cognitive Care

  1. Dave F
    January 29, 2014 at 11:16 am

    Others have beaten me to it, but this deserves being billed as critical care time…there’s may be a lot of stuff that you do in the office that you may consider routine because the patient doesn’t seem as sick or is not in as much extremis as the example anaphalaxis. Think of tuning up an active wheezer in mild respiratory distress with nebs, etc., treating someone with active chest pain while waiting for the EMS to arrive… Both of these cases have an actual or *potential* impairment to one or more critical organ systems, and you are applying high level MDM and intervention to prevent deterioration…that is critical care by the definition.

    Depending on how long the patient was in the office before you handed care off to EMS, you may not actually reach the required 30 min of time required for the first level of critical care billing, but even if you can claim 20 min of time, this certainly solidifies a level 5…

  2. Russell B
    January 29, 2014 at 10:23 am

    Did you know that you can charge for critical care time in the outpatient setting? Check this out.

    https://www.mc.vanderbilt.edu/documents/CAPNAH/files/Modules/Prolonged%20Service%20Coding.pdf

  3. Private doc
    January 26, 2014 at 11:36 am

    Do you really think that patients stop having COPD, CHF, DM and all their other ailments when they go into the OR? That’s what it sounds like when you attempt to say there is no “cognitive care” in the OR. I am a general surgeon in a rural area and I have to do some primary care whether I want to or not and it is actually less cognitive than surgery. Now I 100% agree that the reimbursement for it socks but you get more than I do for it because in order to get the full fee schedule for interventions they dock your reimbursement for office visits. Then on top of that they claim all kinds of unrelated things are included in the global fee. It’s to the point now they are saying they don’t want to pay for my ER exam at 2 am for appendicitis and that it should be included in the fee for the appendectomy. Do I bring in more per year than my primary care friends? Yes per year but they make more per hour (9-5 vs 100 hours per week).

  4. JRDO
    January 26, 2014 at 10:22 am

    Are you suggesting PCPs are underpaid or that procedurists are overpaid? What do you think is a reasonable income for a PCP who sees 75-90 patients per week in a 40 hour work week with no hospital duties? That is the scenario for most employed PCP in my area. The private PCPs often add to their income by doing hospital work as well.

    • Doug Farrago
      January 26, 2014 at 10:28 am

      How long are the hours for a dermatologist? Should a radiologist get paid 4 x more money than a PCP and have 16 weeks off a year? A surgeon working 70 hours a week and killing herself on call deserves all she gets. But there are low hanging fruit out there and I am NOT even saying PCPs should be paid the same but CLOSE the gap or there will be no PCPs left. As I clean up the mess of a NP, a practice I needed to take over per the administrators, I reminded how much training and education mean.

    • Robert
      January 28, 2014 at 12:15 pm

      Right, I forgot about all those PCPs getting rich by spending two hours every morning rounding on three Medicare patients.

  5. Jason V
    January 26, 2014 at 7:21 am

    That’s a level 5 visit. You need to learn how to code better.

    You have High Complexity medical decision making and clearly the patient isn’t stable enough to answer a 14 point review of systems.

    • Doug Farrago
      January 26, 2014 at 9:21 am

      You may have a point there. That kind of case is rare and it was my partner’s code. Let’s use an 84 you with tons of complaints as an example then.

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