Keep the codes   (December 6, 2009)

As an endocrinologist in private practice, many of the patients that I cared for, both in my office and in the hospital settings, were patients who were also under the care of other physicians. These patients needed specialized care greater than the primary physician was comfortable with providing, hence the request for review of the case and assistance with care. Such a situation, when there is a request from one physician to another physician to provide advice and assist with the care of a patient, is called a consultation.

Consultations are particularly common in diabetes, as busy general physicians or internists may not have the time, knowledge, or resources needed to educate and care for the person with diabetes. Hence, in private practice in the office setting, it is frequent to have patients arrive whose diabetes is out of control despite the best efforts of the referring physician, and it is our job as specialists (physicians, nurse educators, and dietitians) to review the present care plan and make recommendations for adjustments. We also are routinely consulted to help patients newly diagnosed with diabetes get started "on the right foot" -- teaching survival skills, meal planning, and blood glucose monitoring, as well as initiating drug therapy as needed.

Diabetes consultations are also frequent for endocrinologists in the hospital setting, as a patient's diabetes control may disappear under the super-stresses of acute illness and/or surgery. Hence it is common to be asked for advice to get an insulin intravenous drip going to control blood glucose, or to switch a patient who is usually on diabetes pills to insulin to control the temporary but sometimes humongous hyperglycemia associated with illness.

As these office visits and hospital visits are consultations, there are specific billing codes that are used to identify these services for appropriate reimbursement, and to differentiate them from routine office visits (such as when a patient visits their primary physician for a cough and cold) or routine hospital daily visits by the attending physician.

I would think that none of this discussion would be a particular surprise to folks reading this essay. But apparently it is a total surprise to government bureaucrats, who plan to eliminate Medicare consultation codes in 2010.

This has upset quite a few endocrinologists, according to a poll conducted by the American Association of Clinical Endocrinologists. An AACE survey released last week indicates that four out of five AACE members will be forced to reduce or eliminate service to Medicare patients as a result of the new consultation code policy. The new policy, according to AACE, "threatens to marginalize the critical role of the clinical endocrinologist as a consultant--at a time when our nation is facing a diabetes epidemic and is striving to improve the quality of patient care."

AACE is starting a grassroots campaign to reverse (or at least delay?) the implementation of the new consultation code policy; they are calling the campaign the "Keep the Codes", and have started a website to encourage physicians and patients to learn more, and sign a petition and write Congresspersons. The website is at www.keepthecodes.com. Please take a look at their website, and sign the petition -- I did! [Editor's Note: As of March, 2012, this website is not available.]

Full disclosure: I have been a dues-paying member of AACE since it was founded in 1991.