Melissa Young, MD: An Endocrinologist's Perspective on E/M Changes in 2021

Endocrinologists and other physicians in “cognitive” specialities have long lamented that our healthcare system values physicians who work with their hands but not those who work with only their minds.

For example, a surgeon who performs one single-vessel coronary artery bypass graft gets paid the equivalent of about 20 moderately complex office visits. We can spend hours seeing patients, educating them, managing the intricacies of the social and behavioral aspects of their care, and try to keep them from needing surgery, and make infinitely less than our colleagues who perform procedures. Endocrinologists are, in fact, among the lowest-paid specialists.

The 2021 E&M changes were supposed to level the playing field a little. The rates for new patients are decreasing, but not by much for the more complex patients that endocrinologists typically see. The reimbursement of each outpatient follow-up visit, however, is going up.

There is a snag there however. In addition to changing the reimbursement for each code, they are also changing the criteria necessary to reach each level. This change was allegedly made to decrease the administrative burden of documentation in each note. Gone are the points necessary in the physical exam and review of systems. Great. Sort of. I’m still going to perform a comprehensive exam and ask for an extensive review of systems.

My patients have disorders that affect every organ system, so I’m still going to examine and ask about symptoms relating to the nervous, cardiovascular, gastrointestinal, urinary systems. I’m still going to have to ask about smoking and drinking. And quite honestly, with an electronic medical record, clicking on those boxes is easy. And because my patients have multiple related medical issues (for example those who have diabetes almost invariably have hypertension and hyperlipidemia), and they need labs and tests and meds and specialist referrals, the visits quite commonly reached the highest level of complexity, a 99215.

With the new criteria, these same visits may not make the cut for a level 5. It might be doable if we consider insulin a drug that requires monitoring for toxicity. In my mind, it absolutely is. After all, insulin accounts for over 100,000 ER visits a year and 9% of all ER visits due to drug-reactions. And yet the AMA singled out insulin specifically in its description of an exclusion, stating that “monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern). That is just absurd.

Ah, but we were being consoled because to offset this problem, there was an add-on code, G2211. This was to be tacked on to a bill for “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or medical care services that are part of ongoing care related to a patient’s single serious condition or complex condition”.

This was supposed to provide an additional payment to reflect the time, intensity and practice expense required to build longitudinal relationships with patients and to provide care for them over an extended period of time. Endocrinologists and many other non-procedure based specialists, as well as primary care and family physicians, could have used this code on the majority of our visits, finally giving some value to the “in-between visit” work we do every day.

Why past tense? Why “could have”? Because in a last minute decision, use of this code has been delayed for 3 years. Why? Because the changes in coding and reimbursement are made within a structure that keeps the overall budget neutral. What does that mean?

It means they need to rob Peter to pay Paul. So, when these changes were proposed, the organizations and societies of the “cerebral” specialists supported it, but those of surgical specialties did not, as their reimbursement was likely to decrease.. And in the end, once again, the surgical Peters won and us Pauls lost.

The alleged decrease in administrative burden is unlikely to be tangible, and certainly unlikely to increase productivity. And as such, while the expense of running a practice in 2021 will continue to increase, reimbursement will almost certainly decrease. As one colleague put it “I feel like endocrinology is a dying field. I can’t keep going like this”.