Use Additional Codes to Cope With Pay for Performance


FORT LAUDERDALE, FLA. — Pay-for-performance evaluations of physicians will require additional reimbursement codes to justify the provision of some services.

Medicare and private insurers historically have used coding for financial reimbursement, but the government and insurers began “profiling” all physicians based on claims data about 5 years ago, Dr. Barbara Levy said at a meeting on hysterectomy sponsored by the Cleveland Clinic.

“We are designing additional ICD-9 codes because of pay for performance,” said Dr. Levy, a member of the Code and Nomenclature Committee of the American College of Obstetricians and Gynecologists.

For example, one of the quality measures from HEDIS (the Healthcare Effectiveness Data and Information Set) promotes regular pap smears for cervical cancer screening, except for patients who had a hysterectomy for benign disease. “We did not have an ICD-9 code for this until this year: 'Patient no longer has organ.' So now the payers will know that we did not do a pap smear for a good reason. And they are extrapolating this information to judge our quality,” said Dr. Levy, also the medical director of the Women's Health and Breast Center, Franciscan Health System, Federal Way, Wash.

Ob.gyns. should begin collecting their own case data, including outcomes, instead of waiting for the government or others to do it, Dr. Levy said. “We need to learn to be stewards of our resources and pay attention to what things cost.” She calculated a $4,800 overall cost per case for laparoscopic supracervical hysterectomy at her institution, for example. The cost per case for a vaginal hysterectomy is less than $1,000. “We need to think about those things … If we don't do this, someone else will.”

Watch for inequities in physician ratings as pay for performance is implemented, Dr. Levy said. The typical measure of physician efficiency is a ratio of actual resource use to expected resource use, given an equivalent quality of care in a particular geographic area. “My practice is primarily gynecologic surgery, so my patients are typically 15 years older than the average ob.gyn. patient in my area,” she said.

A physician who uses more resources per patient during a period of time will be paid less, according to the program's efficiency measures. Also, if particular physicians are labeled as higher-cost doctors, a patient might have to pay a higher copay to see them, Dr. Levy said.

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